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

Chapter 21: The Thigh, Hip,
Groin, and Pelvis
Anatomy of the Thigh
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 joints
• 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
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Onset (sudden or slow?)
Previous history?
Mechanism of injury?
Pain description, intensity, quality, duration,
type and location?
• Observation
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Symmetry?
Size, deformity, swelling, discoloration?
Skin color and texture?
Is athlete in obvious pain?
Is the athlete 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
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Vastus medialis
Vastus intermedius
Semimembranosis
Semitendinosis
Biceps femoris
Adductor brevis,
longus and magnus
• Gracilis
• Sartorius
•Palpation: Soft Tissue (continued)
• Pectineus
• Iliotibial Band (ITband)
• 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 Injuries
• Thigh must have maximum strength,
endurance, and extensibility to withstand
strain
• In collision sports thigh guards are
mandatory to prevent injuries
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
Contusion
• 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
– 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 athlete 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 if too painful and
restricts motion (after one year - remove too early
and it may come back)
• Quadriceps Muscle Strain
– Etiology
• Sudden stretch when athlete falls on bent knee or
experiences sudden contraction
• Associated with weakened or over constricted muscle
– Signs and Symptoms
• Peripheral tear causes fewer symptoms than deeper tear
• Pain, point tenderness, spasm, loss of function and little
discoloration
• Complete tear may live athlete w/ little disability and
discomfort but with some deformity
– Management
• RICE, NSAID’s and analgesics
• Manage swelling, compression, crutches
• Move into isometrics and stretching as healing
progresses
• Neoprene sleeve may provide some added support
• Hamstring Muscle Strains
(second 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 (modalities and isometrics)
• 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 great force
• Occurs in middle third due to structure and point of
contact
– Signs and Symptoms
• Pain, swelling, deformity
– 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
• Compression or distraction fracture generally occur
– Signs and Symptoms
• Persistent pain in thigh
• X-ray or bone scan will reveal fracture
• 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
• Complete stress fracture may require pins
Anatomy of the Hip, Groin and
Pelvic Region
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 injuries attach in this region and
therefore injury to one can be very disabling and
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
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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)
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Pubic symphysis
Ischial tuberosity
Greater trochanter
Femoral neck
•Palpation: Soft Tissue
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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
Thomas Test
•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
•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
• Gaenslen’s Test
– Test works to
push SI joint into
extension
– Test is positive if
hyperextension
on affected side
increases pain
•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
• 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
• Ober’s Test
– Used to determine
presence of
contracted TFL or
IT-band
– Thigh will remain
in abducted
position, not falling
into adduction
•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)
• Piriformis Test
– Hip is internally
rotated
– Tightness or pain is
indicative of piriformis
tightness
• Ely’s Test
– Used to assess tightness of rectus femoris
– Athlete 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
Recognition and Management of
Specific Hip, Groin, and Pelvic
Injuries
• 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
ties into the IT-band
– 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
• Look at biomechanics and Q-angle
• 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
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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),
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 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; nonweight 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
– Early treatment and
head may reossify and
revascularize
• Complication
– If not treated early, will
result in ill-shaping and
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 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 (lateral rotation and flexion)
• Related to structurally narrow pelvis, increased hip
abduction and limited lateral rotation
• Hip stability is compromised
– Signs and Symptoms
• Pain w/ balancing on one leg, possible inflammation
– Management
• Focus on cryotherapy and ultrasound to stretch
musculature and strengthen weak musculature in hip
region
Pelvic Conditions
• Athletes 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 lordosis 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
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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
• Repetitive stress on pubic symphysis and adjacent
muscles
– Signs and Symptoms
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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
later 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
• Intense interval or competitive racing may cause
• Stress Fractures (continued)
– Management
• Rest for 2-5 months
• Crutch walking for ischium and pubis fractures
• X-ray normal 6-10 weeks and bone scan will be
required
• Swimming can be used -- breast stroke 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,
athlete can return to competition
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
into isokinetics
• PNF strengthening should then be
incorporated to enhance functional activity
• 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
Balance Shoe for Neuromuscular
Control
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