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© 2009 McGraw-Hill Higher Education. All rights reserved.

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


Anatomy of the Thigh


Figure 21-1


Figure 21-2


Nerve and Blood Supply

• Tibial and common peroneal are given rise from the sacral plexus which form the largest nerve in the body the sciatic nerve complex

• The main arteries of the thigh are the deep circumflex femoral, deep femoral, and femoral artery

• The two main veins are the superficial great saphenous and the femoral vein


Fascia

• The fascia lata femoris is part of the deep fascia that invests the thigh musculature

• Thick anteriorly, laterally and posteriorly but thin on the medial side

• Iliotibial track (IT-band) is located laterally serving as the attachment for the tensor fascia lata and greater aspect of the gluteus maximum


Functional Anatomy of the Thigh

• Quadriceps insert in a common tendon to the proximal patella

• Rectus femoris is the only quad muscle that crosses the hip– Extends knee and flexes the hip

• Important to distinguish between hip flexors relative to injury for both treatment and rehab programs


• Hamstrings cross the knee joint posteriorly and all except the short of head of the biceps crosses the hip

• Bi-articulate muscles produce forces dependent upon position of both knee and hip

• Position of the knee and hip during movement and MOI play important roles and provide information to utilize w/ rehab and prevention of hamstring injuries


Assessment of the Thigh• History

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

location?

• Observation– Symmetry?– Size, deformity, swelling, discoloration?– Skin color and texture?– Is patient in obvious pain?– Is the patient willing to move the thigh?


•Palpation: Bony and Soft Tissue

• Medial and lateral femoral condyles

• Greater trochanter• Lesser trochanter• Anterior superior

iliac spine (ASIS)• Sartorius• Rectus femoris• Vastus lateralis

• Vastus medialis• Vastus intermedius• Semimembranosus• Semitendinosus• Biceps femoris• Adductor brevis,

longus and magnus• Gracilis• Sartorius


•Palpation: Soft Tissue (continued)

• Pectineus• Iliotibial Band (IT-band)• Gluteus medius• Tensor fasciae latae


• Special Tests– If a fracture is suspected the following tests are not

performed

– Beginning in extension, the knee is passively flexed • A normal muscle will elicit full range of motion pain free

(one w/ swelling or spasm will have restricted motion)

– Active movement from flexion to extension • Strong and painful may indicate muscle strain• Weak and pain free may indicate 3rd degree or partial

rupture

– Muscle weakness against an isometric resistance may indicate nerve injury


Prevention of Thigh, Hip, Groin & Pelvic Injuries

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

• While muscle function is critical to perform dynamic activities, also critical in providing a base of support with pelvis for whole body motion– Due to demands of both dynamic force

production and core stability, this region is vulnerable to injury


• Maintaining strength and flexibility in this region is critical– Concentrate on dynamic stretching of

quadriceps, hamstrings, groin muscles

– Well designed strengthening program is also critical• Would include squats, lunges, leg presses

and core stability work


Recognition and Management of Thigh

Injuries • Quadriceps Contusions

– Etiology• Constantly exposed to traumatic blunt blow• Contusions usually develop as a result of severe

impact• Extent of force and degree of thigh relaxation

determine depth and functional disruption that occurs

– Signs and Symptoms• Pain, transitory loss of function, immediate effusion

with palpable swollen area• Graded 1-4 = superficial to deep with increasing loss

of function (decreased ROM, strength)


Quad Contusio

n

Figure 21-3


• Management– RICE, NSAID’s and

analgesics– Crutches for more severe

cases– Aspiration of hematoma is

possible– Following exercise or re-

injury, continued use of ice– Follow-up care consists of

ROM, and PRE w/in pain free range

– Heat, massage and ultrasound to prevent myositis ossificans

Figure 21-4


– General rehab should be conservative– Ice w/ gentle stretching w/ a gradual transition to

heat following acute stages– Elastic wrap should be used for support– Exercises should be graduated from stretching to

swimming and then jogging and running– Restrict exercise if pain occurs– May require surgery of herniated muscle or

aspiration– Once an patient has sustained a severe contusion,

great care must be taken to avoid another


• Myositis Ossificans Traumatica– Etiology

• Formation of ectopic bone following repeated blunt trauma (disruption of muscle fibers, capillaries, fibrous connective tissue, and periosteum)

• Gradual deposit of calcium and bone formation• May be the result of improper thigh contusion treatment (too

aggressive)

– Signs and Symptoms• X-ray shows calcium deposit 2-6 weeks following injury• Pain, weakness, swelling, decreased ROM• Tissue tension and point tenderness w/

– Management• Treatment must be conservative• May require surgical removal due to pain and decreased ROM


• Quadriceps Muscle Strain– Etiology

• Sudden stretch, violent forceful contraction of hip and knee into flexion

• Overstretching of quadriceps• Can be very disabling

– Signs and Symptoms• Peripheral tear causes fewer symptoms than deeper tear• Pain, point tenderness, spasm, loss of function

(decreased knee flexion) and little discoloration• Complete tear may leave patient w/ little disability and

discomfort but with some deformity


– Signs & Symptoms• Grade 1: Complain of tightness in front of thigh;

near normal ambulation; swelling may be limited; mild discomfort during palpation

• Grade 2: Abnormal gait cycle; may be splinted in extension; swelling may be noticeable with pain on palpation; possible defect in muscle; resistive knee extension will reproduce pain

• Grade 3: Possibly unable to ambulate; pain with palpation; may be unable to perform knee extension; isometric contractions may produce defect or bulging in muscle belly


– Management• RICE, NSAID’s and analgesics• Manage swelling, compression, crutches• With increased healing, progress to isometrics and

stretching• Grade 1: Neoprene sleeve may provide some added

support• Grade 2: Ice and compression for 3-5 days with gradual

increase in isometric exercises and pain free knee ROM exercises

– Limit passive stretching until later phases

• Grade 3: Crutch use for 7-14 days; restore normal gait; compression for support; may require 12 weeks until returning to full activity


• Hamstring Muscle Strains(most common thigh injury)– Etiology

• 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,

– Signs and Symptoms• Muscle belly or point of attachment pain• Capillary hemorrhage, pain, loss of function and possible discoloration• Grade 1 - soreness during movement and point tenderness (<20% of

fibers torn)• Grade 2 - partial tear, identified by sharp snap or tear, severe pain,

and loss of function (<70% of fiber torn)


– Signs and Symptoms (continued)• Grade 3 - Rupturing of tendinous or muscular tissue,

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

• >70% muscle fiber tearing

– Management• RICE, NSAID’s and analgesics• Grade I - don’t resume full activity until complete function

restored• Grade 2 and 3 should be treated conservatively w/

gradual return to stretching and strengthening in later stages of healing


– Management (continued)• Modalities and isometrics need to gradually

be introduced during healing process• When soreness is eliminated, isotonic leg

curls can be introduced (focus on eccentrics)

• Recovery may require months to a full year• Greater scaring = greater recurrence of

injury


• Acute Femoral Fractures– Etiology

• Generally involving shaft and requiring a great deal of force

• Occurs in middle third due to structure and point of contact

– Signs and Symptoms• Pain, swelling, deformity• Muscle guarding, hip is adducted and ER• Leg with fx may also be shorter

– Management• Treat for shock, verify neurovascular status,

splint before moving, reduce following X-ray• Analgesics and ice• Extensive soft tissue damage will also occur

as bones will displace due to muscle force


• Femoral Stress Fractures– Etiology

• Overuse (10-25% of all stress fractures)• Excessive downhill running or jumping activities• Often seen in endurance athletes

– Signs and Symptoms• Persistent pain in thigh/groin• X-ray or bone scan will reveal fracture• Walk with antalgic gait (abduction lurch)• Positive Trendelenburg’s sign

– Management• Prognosis will vary depending on location • Fx lateral to femoral neck tend to be more

complicated• Shaft and medially located fractures tend to heal

well with conservative management


Anatomy of the Hip, Groin and Pelvic Region


Figure 21-10


Figure 21-11


Figure 21-12 A & B


Figure 21-13


Figure 21-14 A


Figure 21-14 B & C


Functional Anatomy

• Pelvis moves in three planes through muscle function– Anterior tilting changes degree of lumbar

lordosis, lateral tilting changes degree of hip abduction

• Hip is a true ball and socket joint w/ intrinsic stability

• Hip also moves in all three planes, particularly during gait (body’s relative center of gravity)


• Tremendous forces occur at the hip during varying degrees of locomotion

• Muscles are most commonly injured in this region

• Numerous muscles attach in this region and therefore injury to one can be very disabling and difficult to distinguish


Assessment of the Hip and Pelvis


• Body’s center of gravity is located just anterior to the sacrum

• Injuries to the hip or pelvis cause major disability in the lower limbs, trunk or both

• Low back may also become involved due to proximity

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

location?


• Observation– Symmetry- hips, pelvis tilt (anterior/posterior)

• Lordosis or flat back

– Lower limb alignment • Knees, patella, feet

– Pelvic landmarks (ASIS, PSIS, iliac crest)– Standing on one leg

• Pubic symphysis pain or drop on one side

– Ambulation• Walking, sitting - pain will result in movement

distortion


•Palpation: Bony

• Iliac crest• Anterior superior

iliac spine (ASIS)• Anterior inferior

iliac spin (AIIS)• Posterior superior

iliac spine (PSIS)

• Pubic symphysis• Ischial tuberosity• Greater

trochanter• Femoral neck• Poster inferior

iliac spine


•Palpation: Soft Tissue

• Rectus femoris• Sartorius• Iliopsoas• Inguinal ligament• Gracilis• Adductor magnus,

longus & brevis• Pectineus

• Gluteus maximus, medius & minimus

• Piriformis• Hamstrings• Tensor fasciae

latae• Iliotibial Band

- Major regions of concern are the groin, femoral triangle, sciatic nerve, lymph nodes


•Special Tests

• Functional Evaluation– ROM, strength tests– Hip adduction, abduction, flexion,

extension, internal and external rotation

• Tests for Hip Flexor Tightness– Kendall test

• Test for rectus femoris tightness

– Thomas test• Test for hip contractures


Kendall’s Test

Figure 21-15


Thomas Test

Figure 21-16


Femoral Anteversion (A) and Retroversion (B)

– Relationship between neck and shaft of femur

– Normal angle is 15 degrees anterior to the long axis of the femur and condyles

– Internal rotation in excess of 35 degrees is indicative of anteversion, 45 degrees of external rotation is an indicator of retroversion

Figure 21-18 A&B


Figure 21-18 A, C, D


•Test for Hip and Sacroiliac Joint

• Patrick Test (FABER)– Detects

pathological conditions of the hip and SI joint

– Pain may be felt in the hip or SI joint

Figure 21-19


• Gaenslen’s Test– Test works to

push SI joint into extension

– Test is positive if hyperextension on affected side increases pain

Figure 21-20 A&B


Testing the Tensor Fasciae Latae and Iliotibial Band

• Renne’s test– Athlete stands w/

knee bent at 30-40 degrees

– Positive response of TFL tightness occurs when pain is felt at lateral femoral condyle

Figure 21-21


• Nobel’s Test– Lying supine the

athlete’s knee is flexed to 90 degrees

– Pressure is applied to lateral femoral condyle while knee is extended

– Pain at 30 degrees at lateral femoral condyle indicates a positive test

Figure 21-22


• Ober’s Test– Used to

determine presence of contracted TFL or IT-band

– Thigh will remain in abducted position, not falling into adduction

Figure 21-23


Trendelenburg’s Test- Iliac crest on unaffected side should be higher when standing on one leg- Test is positive when affected side is higher indicating weak abductors (glut medius)

Figure 21-24 A & B


• Piriformis Test– Hip is internally

rotated– Tightness or pain

is indicative of piriformis tightness

Figure 21-25


• Ely’s Test– Used to assess tightness of rectus femoris– Patient is prone, w/ pelvis stabilized and knee on the

affected side is flexed– If hip on that side extends as the knee is flexed, rectus

femoris is tight

• Measuring Leg Length Discrepancy– With inactive individual, difference of more that 1” may

produce symptoms– Active individuals may experience problems w/ as little

3mm (1/8”) difference– Can cause cumulative stresses to lower limbs, hips, pelvis or

low back


– True or anatomical • Shortening may be equal throughout limb

or localized w/in femur or lower leg• Measurement taken from medial

malleolus to ASIS

– Apparent or functional• Result of lateral pelvic tilt or from a

flexion or adduction deformity• Measurement is taken from umbilicus to

medial malleolus


Leg Length Discrepancy Measures

Figures 21-27 A-C


Recognition and Management of Specific Hip,

Groin, and Pelvic Injuries• Adductor/Hip Flexor (Groin) Strain

– Etiology• One of the more difficult problems to diagnose• Injury to one of the muscles in the regions

(generally adductor longus)• Occurs from running , jumping, twisting w/ hip

external rotation or severe stretch

– Signs and Symptoms• Sudden twinge or tearing during active movement• Produce pain, weakness, and internal hemorrhaging


• Groin Strain (continued)– Management

• RICE, NSAID’s and analgesics for 48-72 hours• Determine exact muscle or muscles involved• Rest is critical; daily whirlpool and

cryotherapy, moving into ultrasound• Delay exercise until pain free• Restore normal ROM and strength -- provide

support w/ wrap


• Trochanteric Bursitis– Etiology

• Inflammation at the site where the gluteus medius inserts or the IT-band passes over the trochanter

– Signs and Symptoms• Complaint of lateral hip pain that may radiate

down the leg• Palpation reveals tenderness over lateral aspect

of greater trochanter• IT-band and TFL tests should be performed


– Management• RICE, NSAID’s and analgesics• ROM and PRE directed toward hip

abductors and external rotators• Phonophoresis if pain doesn’t respond in

3-4 days• Must look at biomechanics and Q-angle• Runners should avoid inclined surfaces


• Sprains of the Hip Joint– Etiology

• Due to substantial support, any unusual movement exceeding normal ROM may result in damage

• Force from opponent/object or trunk forced over planted foot in opposite direction

– Signs and Symptoms• Signs of acute injury and inability to circumduct hip• Similar S & S to stress fracture• Pain in hip region, w/ hip rotation increasing pain


– Management• 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– Etiology

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

(posterior dislocation w/ hip flexed and adducted and knee flexed)

– Signs and Symptoms• Flexed, adducted and internally rotated hip• Palpation reveals displaced femoral head posteriorly• Serious pathology

– Soft tissue, neurological damage and possible fx

– Management• 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


• Avascular Necrosis– Etiology

• Result of temporary or permanent loss of blood supply to proximal femur

• Can be caused by traumatic conditions (hip dislocation – disruption of circumflex artery), or non-traumatic circumstances (steroids, blood coagulation disorders, excessive alcohol use compromising blood vessels)

– Signs and Symptoms• Early stages - possibly no S&S• Joint pain w/ weight bearing progressing to pain at

times of rest• Pain gradually increases (mild to severe) particularly

as bone collapse occurs• May limit ROM• Osteoarthritis may develop• Progression of S&S can develop over the course of

months to a year


• Avascular Necrosis (continued)– Management

• Must be referred for X-ray, MRI or CT scan• Must work to improve use of joint, stop further damage

and ensure survival of bone and joint• Most cases will ultimately require surgery to repair joint

permanently• Conservative treatment involves ROM exercises to

maintain ROM; electric stim for bone growth; non-weight bearing if caught early

• Medication to treat pain, reduce fatty substances reacting w/ corticosteroids or limit blood clotting in the presence of clotting disorders may limit necrosis


Hip Problems in the Young Athlete

• Legg Calve’-Perthes Disease (Coxa Plana)– Etiology

• Avascular necrosis of the femoral head in child ages 4-10• Trauma accounts for 25% of cases• Articular cartilage becomes necrotic and flattens

– Signs and Symptoms• Pain in groin that can be referred to the abdomen or knee• Limping is also typical• Varying onsets and may exhibit limited ROM


•Legg-Calve’-Perthes Disease (continued)

• Management– Bed rest to alleviate synovitis– Brace to avoid direct weight bearing– With early treatment and the head may

re-ossify and revascularize

• Complication– If not treated early, will result in ill-

shaping and develop into osteoarthritis in later life


• Slipped Capital Femoral Epiphysis

– Etiology• Found mostly in boys ages 10-17 who are

characteristically tall and thin or obese• May be growth hormone related• 25% of cases are seen in both hips, trauma

accounts for 25%• Head slippage on X-ray appears posterior

and inferior


– Signs and Symptoms• Pain in groin that comes on over weeks or months• Hip and knee pain during passive and active

motion• Limitations of abduction, flexion, medial rotation

and presents with a limp

– Management• W/ minor slippage, rest and non-weight bearing

may prevent further slippage• Major displacement requires surgery• If undetected or surgery fails severe problems will

result


• The Snapping Hip Phenomenon– Etiology

• Common in young female dancers, gymnasts, hurdlers• Habitual movement predispose muscles around hip to become imbalanced• Manifested as:

– IT-band moving over greater trochanter resulting in trochanteric bursitis

– Iliopsoas tendon moving over iliopectineal eminence– Iliofemoral ligament moving over femoral head– Long head of biceps femoris moving over ischial tuberosity

• Extraarticular cause Hip ER and flexion• Related to structurally narrow pelvis, increased hip abduction and limited

lateral rotation• Intraarticular causes loose bodies, labral tears, joint subluxations


– Signs and Symptoms• Due to extraarticular causes hip joint capsule,

ligaments, muscles become loosened and hip becomes unstable

• Patient complains of snapping with severe pain and disability upon each snap

– Management• Decrease pain and inflammation

– Ice, NSAID’s, ultrasound

• Move on to stretch and strengthen weak musculature in hip region


Pelvic Conditions

• Patients can suffer serious, acute and chronic injuries to the pelvic region

• Pelvis rotates along longitudinal axis when running, proportionate to the amount of arm swing

• Also tilts as legs engage support and nonsupport

• Combination of motion causes shearing and changes in lordodic curve throughout activity


• Contusion (hip pointer)– Etiology

• Contusion of iliac crest or abdominal musculature• Result of direct blow (same MOI for iliac crest fx and

epiphyseal separation

– Signs and Symptoms• Pain, spasm, and transitory paralysis of soft structures• Decreased rotation of trunk or thigh/hip flexion due to pain

– Management• RICE for at least 48 hours, NSAID’s, • Bed rest 1-2 days• Referral must be made, X-ray• Ice massage, ultrasound, occasionally steroid injection

Recovery lasts 1-3 weeks


• Osteitis Pubis– Etiology

• Seen in distance runners and also in soccer, football, and wrestling

• Repetitive stress on pubic symphysis and adjacent muscles

– Signs and Symptoms• Chronic pain and inflammation of groin• Point tenderness on pubic tubercle• Pain w/ running, sit-ups and squats• Acute case may be the result of bicycle seat

– Management• Rest, NSAID’s and gradual return to activity


• Athletic Pubalgia– Etiology

• Chronic pubic region pain caused by repetitive stress to pubic symphysis from kicking, twisting, or cutting

– Forced adduction, from hyperextended position, creates shearing forces that are transmitted through pubic symphysis to insertion of rectus abdominus, hip adductors and conjoined tendon

– Result in microtears of tranversalis abdominis fascia, aponeurosis of obliques, or conjoined tightness

– Create weakening of anterior wall and inguinal canal

– Signs and Symptoms• No presence of hernia• Chronic pain during exertion, sharp and burning that laterally

radiates into adductors and testicles


– Signs and Symptoms (continued)• Point tenderness on pubic tubercle• Pain increased w/ resisted hip flexion, internal rotation,

abdominal contraction, resisted hip adduction (adductors not painful = adductor strain)

– Management• Conservative treatment (even though rarely effective) • Massage, stretching after 1 week of surrounding

musculature• 2 weeks, strengthening of abs and hip flexors and adductors• 3-4 weeks begin running progression• Aggressive treatment involves cortisone injection or

tightening of pelvic wall surgically


• Stress Fractures– Etiology

• Seen in distance runners - repetitive cyclical forces from ground reaction force

• More common in women than men• Common site include inferior pubic ramus, femoral neck

and subtrochanteric area of femur

– Signs and Symptoms• Groin pain, w/ aching sensation in thigh that increases

w/ activity and decreases w/ rest• Standing on one leg may be impossible• Deep palpation results in point tenderness• May be caused by intense interval or competitive racing


• Stress Fractures (continued)– Management

• Rest for 2-5 months• Crutch walking for ischium and pubis

fractures• X-ray are usually normal for 6-10 weeks

and bone scan will be required• Swimming can be used for training --

breast stroke should be avoided


• Avulsion Fractures and Apophysitis– Etiology

• Traction epiphysis (bone outgrowth)• Common sites include ischial tuberosity, AIIS,

and ASIS• Avulsions seen in sports w/ sudden

accelerations and decelerations

– Signs and Symptoms• Sudden localized pain w/ limited movement• Pain, swelling, point tenderness • Muscle testing increases pain


• Avulsion Fractures and Apophysitis– Management

• X-ray• If uncomplicated, RICE, NSAID’s, crutch toe-

touch walking• After control pain and inflammation, 2-3

weeks of gradual stretching• When 80 degrees of ROM have been

regained a PRE program should be instituted.• With full return of ROM and strength athlete

can return to play


Thigh and Hip Rehabilitation Techniques

• General Body Conditioning– Must maintain cardiovascular fitness,

muscle endurance and strength of total body

– Avoid weight bearing activities if painful

• Flexibility– Regaining pain free ROM is a primary

concern– Progress from passive to PNF stretching



Mobilization

• Will be necessary if injury and subsequent limitation is caused by tightness of ligaments and capsule surrounding the joint

• Use to re-establish appropriate arthrokinematics

• Series of glides (anterior and posterior) and rotations can be used to restore motion



Strength

• Progression should move from isometric exercises until muscle can be fully contracted to isotonic strengthening PRE’s and on into isokinetics

• PNF strengthening should then be incorporated to enhance functional activity


Strength (Continued)

• Active exercise should occur in pain free ranges -- in an effort not to aggravate condition

• Exercises for the core must also be included– Develop optimal levels of functional

strength and dynamic stabilization




Neuromuscular Control

• Establish through combination of appropriate postural alignment and stability strength

• As neuromuscular control is enhanced, the ability of the kinetic chain to maintain appropriate forces and dynamic stabilization increases

• Focus on balance and closed kinetic chain activities


Functional Progression and Return to Activity

• Begin in pool, non-weight bearing• Depending on activity, progression of

walking, to jogging, to running and more difficult agility tasks can occur

• Before returning to play, athlete should demonstrate pain free function, full ROM, strength, balance and agility


Figure 21-39 A-C Figure 21-40