Unit 21: The Thigh, Hip, Groin, and Pelvis

Anatomy of the Pelvis, Thigh, and Hip

Bony Anatomy

Pelvic Girdle Ilium

Iliac crest Anterior superior iliac spine Posterior superior iliac spine Anterior inferior iliac spine

Ischium Ischial tuberosity Hamstring or bursa problems Should sit on this area of pelvis

Pubis Pubic symphysis

Acetabulum

Femur Head Neck Greater trochanter Lesser trochanter Shaft Medial condyle Lateral condyle

Ligaments - Major source of strength

Ligamentum teres-head of femur Iliofemoral ligament

Y ligament Strongest in the body Prevents hyperextension, external rotation, abduction

Pubofemoral ligament Prevents abduction

Ischiofemoral ligament Prevents medial rotation

Bursa

18 in hipIschial bursaGreater trochanteric bursa

Found at attachment of gluteus maximus and IT band

Iliopsoas

Muscles

Flexors Iliopsoas Rectus femoris (quad) Sartorius

Anterior thigh (quads) Vastus medialis Vastus lateralis Vastus intermedialis

Extensors Gluteus maximus Semitendonosis (hamstring) Semimembranosis (hamstring) Biceps femoris (hamstring)

Abductors Gluteus medius Gluteus minimus Tensor fascia latae (Iliotibial band)

Adductors Adductor magnus Adductor brevis Adductor longus Pectineus Gracilis

External Rotators Oburator externus Obturator internus Quadratus femoris Piriformis – sciatic nerve goes through it. Gamellus superior Gamellus inferior Gluteus maximus

Internal Rotators Gluteus minimus Tensor fascia Latae Gluteus medius

Assessment of the Thigh

History Onset (sudden or slow?) Previous history? Mechanism of injury? Pain description, intensity, quality, duration, type

and location?

ObservationPostural symmetry?Size, deformity, swelling,

discoloration?Skin color and texture?Is athlete in obvious pain?Is the athlete willing to move the

thigh?

Palpation Soft tissue of the thigh (anterior, posterior,

medial, lateral) should be palpated for pain and tenderness

Bony palpation should also be performed to locate areas of pain/discomfort

Utilize palpation to assess body symmetry

Special Tests Thomas test

Test for hip contractures Straight Leg Raise

Test for hip extensor tightness Can also be used to assess low back

or SI joint dysfunctionThomas Test

Trendelenburg Test Gluteus medius

Ober’s/Noble Test IT Band

Fulcrum

Prevention of Thigh Injuries

Thigh must have maximum strength, endurance, and extensibility to withstand strain

Dynamic stretching programs may aid in muscle preparation for activity

Strengthen programs can also help in preventing injuries

Thigh Injuries

Quadriceps Contusions Cause of Injury

Constantly exposed to traumatic blows Signs of Injury

Pain, transitory loss of function, immediate bleeding of affected muscles

Early detection and avoidance of internal bleeding are vital – increases recovery rate and prevents muscle scarring

Quad Contusion

Care RICE and NSAID’s Crutches for more severe cases Isometric quadriceps

contractions should begin as soon as tolerated

Heat, massage and ultrasound to prevent myositis ossificans

Padding may be worn for additional protection upon return to play

Myositis Ossificans Traumatica Cause of Injury

Formation of ectopic bone following repeated blunt trauma

Signs of Injury X-ray shows calcium deposit 2-6 weeks following

injury Pain, weakness, swelling, decreased ROM Tissue tension and point tenderness If condition is recurrent it may indicate problem

with blood clotting

Care Treatment must be conservative May require surgical removal if too painful and restricts

motion (after one year - remove too early and it may come back)

Quadriceps Muscle Strain Cause of Injury

Sudden stretch-falls on bent knee or experiences sudden contraction

Weakness or over constricted muscle Signs of Injury

Peripheral tear causes fewer sx than deeper tear Pain, pt tenderness, spasm, loss of function and little

discoloration Complete tear may leave athlete w/ little

disability/discomfort but with some deformity

Care RICE to control internal bleeding Determine extent of injury early Neoprene sleeve may provide some added support

Hamstring Muscle Strains Cause of Injury

Multiple theories of injury Hamstring and quad contract together Change in role from hip extender to knee flexor Fatigue, posture, leg length discrepancy, lack of

flexibility, strength imbalances Grade 2 - partial tear, identified by sharp snap or

tear, severe pain, and loss of function

Signs of Injury Muscle belly or point of attachment pain Capillary hemorrhage, pain, loss of function, and possible

discoloration Grade 1 - soreness during movement and point

tenderness Grade 2 – increase pain, swelling, palpable

swelling/defect? Grade 3 - Rupturing of tendinous or muscular tissue,

involving major hemorrhage and disability, edema, loss of function, ecchymosis, palpable mass or gap

Care RICE Restrict activity until soreness has subsided Ballistic stretching and explosive sprinting should

be avoided initially

Acute Femoral Fractures Cause of Injury

Generally involves shaft, requires great force Occurs in middle 1/3 due to structure and point of

contact Signs of Injury

Shock, pain, swelling, deformity Must be aware of bone displacement and gross

deformity Loss of function

Care Treat for shock, verify

neurovascular status, splint before moving, reduce following X-ray

Secure immediate emergency assistance and medical referral

8 foot fall

Femoral Stress Fractures Cause of Injury

Overuse Females who are amenorrheic are more vulnerable to

stress fx Signs of Injury

Persistent pain in thigh X-ray or bone scan Commonly seen in femoral neck

Management Analgesics, NSAID’s RICE ROM and PRE exercises are carried out w/ pain free ROM Rest, limited weight bearing

Hip, Groin, and Pelvic Injuries

Groin Strain Cause of Injury

One of the more difficult problems to diagnose Early part of season due to poor strength and

flexibility Running, jumping, twisting w/ hip external rotation

or severe stretch

Signs of Injury Sudden twinge or tearing during active movement Produce pain, weakness, and internal hemorrhaging

Care RICE, NSAID’s and analgesics for 48-72 hours Determine exact muscle or muscles involved Rest is critical Restore normal ROM and strength -- provide support w/

wrap Refer to physician if severe groin pain is experienced

Sprains of the Hip Joint Cause of Injury

Result of violent twist due to forceful contact Force from opponent/object or trunk forced over

planted foot in opposite direction Signs of Injury

Signs of acute injury and inability to circumduct hip Pain in hip region, w/ hip rotation increasing pain

Care X-rays or MRI should be performed to rule out fx RICE, NSAID’s and analgesics Depending on severity, crutches may be required ROM and PRE are delayed until hip is pain-free

Dislocated Hip Cause of Injury

Rarely occurs in sport Result of traumatic force directed along the long axis

of the femur Signs of Injury

Flexed, adducted and internally rotated hip Palpation reveals displaced femoral head, posteriorly Serious pathology

Soft tissue, neurological damage and possible fx

Care Immediate medical care (blood and nerve supply may be

compromised) Contractures may further complicate reduction 2 weeks immobilization and crutch use for at least one

month

7 y/o posterior hip dislocationskate board fall

Posterior Hip Dislocation

injury footage

Anterior Hip Dislocation

Notice leg position

Hip Problems in the Young Athlete

Legg-Perthes Disease (Coxa Plana) Cause of Condition

Avascular necrosis of femoral head: children 4-10 y/o Articular cartilage becomes necrotic, flattens

Signs of Condition Pain in groin, can refer to abdomen or knee Limping is also typical Varying onsets and may exhibit limited ROM

•Legg-Perthes Disease (continued)

Care Bed rest-reduce chance of chronic condition Brace to avoid direct weight bearing Early treatment-head may reossify and

revascularize

Complication If not treated early, will result in ill-shaping and

osteoarthritis in later life

Slipped Capital Femoral Epiphysis Cause of Condition

May be growth hormone related 25% of cases are seen in both hips

Signs of Condition Pain in groin over weeks or months Hip/knee pain during PROM,AROM; limited abd, flex,med.

rotation and limp Management

W/ minor slippage, rest and non-weight bearing may prevent further slippage

Major displacement requires surgery If undetected/surgery fails severe problems

Iliac Crest Contusion (hip pointer) Cause of Injury

Contusion of iliac crest or abdominal musculature Result of direct blow

Signs of Injury Pain, spasm, and transitory paralysis of soft

structures Decreased rotation of trunk or thigh/hip flexion due

to pain

Care RICE for at least 48

hours, NSAID’s, Bed rest 1-2 days in

severe cases Referral must be made,

X-ray

Osteitis Pubis Cause of Injury

Seen in distance runners Repetitive stress on pubic symphysis and adjacent

muscles Signs of Injury

Chronic pain, inflam. of groin Pt tenderness on pubic tubercle Pain w/ running, sit-ups and squats

Management Rest, NSAID’s and gradual RTP

Acute Fracture of Pelvis Cause of Injury

Result of direct blow or blunt trauma Signs of Injury

Severe pain, loss of function, shock Care

Immediately treat for shock Refer to physician Seriousness of injury dependent on extent of shock

and possibility of internal injury

Stress Fractures Cause of injury

Repetitive abnormal overused forces Signs of Injury

Groin pain, w/ aching sensation in thigh that increases w/ activity and decreases w/ rest

Discomfort increases with activity and subsides during rest

Care Refer to physician for assessment and X-ray Rest for 2-5 months

Avulsion FracturesCause of Injury

Avulsions seen in sports w/ sudden accelerations and decelerations

What muscles can cause avulsion fx?Signs of Injury

Sudden localized pain w/ limited movement

Pain, swelling, point tenderness Care

Rest, limited activity and graduated exercise