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

Chapter 17: The Thigh, Hip,
Groin, and Pelvis
McGraw-Hill/Irwin
© 2013 McGraw-Hill Companies. All Rights Reserved.
Anatomy of the Pelvis, Thigh,
and Hip
17-2
17-3
17-4
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17-6
17-7
17-8
Assessment of the Thigh
• History
– Onset (sudden or slow?)
– Previous history?
– Mechanism of injury?
– Pain description, intensity, quality,
duration, type and location?
• Observation
– Postural symmetry?
– Size, deformity, swelling, discoloration?
– Skin color and texture?
– Is athlete in obvious pain?
– Is the athlete willing to move the thigh?
17-9
• 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
17-10
• Special Tests
– Thomas test
• Test for hip
contractures
– Straight Leg
Raise
• Test for hip
extensor tightness
• Can also be used
to assess low
back, SI joint
dysfunction,
sciatic nerve pain
17-11
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
– Squats, lunges, leg press
– Core strengthening
17-12
Recognition and Management
of 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
17-13
• 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
17-14
• Myositis Ossificans
– 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
– 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)
• If condition is recurrent it may indicate problem
with blood clotting
17-15
17-16
• Quadriceps Muscle Strain
– Cause of Injury
• Sudden stretch when athlete falls on bent knee or
experiences sudden contraction
• Associated with weakened or over constricted muscle
– Signs of Injury
• Peripheral tear causes fewer symptoms than deeper
tear
• Pain, point tenderness, spasm, loss of function and little
discoloration
• Complete tear may leave athlete w/ little disability and
discomfort but with some deformity
– Care
• Rest, ice and compression to control internal bleeding
• Determine extent of injury early
• Neoprene sleeve may provide some added support
17-17
• 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,
– 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 - partial tear, identified by sharp snap
or tear, severe pain, and loss of function
17-18
– Signs of Injury (continued)
• 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
17-19
• Femoral Fractures
– Cause of Injury
• More common in auto accidents; less common in
sports
• Involves significant force
• Occurs in middle third 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
17-20
Recognition and Management
of Specific Hip, Groin, and
Pelvic Injuries
• Groin Strain
– Cause of Injury
• One of the more difficult problems to diagnose
• Often seen in early part of season due to poor
strength and flexibility
• Occurs from 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
17-21
• Groin Strain
– 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
17-22
• 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
17-23
• 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
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• Dislocated Hip
– 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
17-25
• Hip Labral Tears
– Cause of Condition
• Result of repetitive overuse
(i.e. running or pivoting)
• May occur due to acute
trauma (i.e. dislocation)
– Signs of Injury
• Often present as
asymptomatic
• Causes clicking, locking, or
catching
• Pain in the groin; stiffness;
limited motion
– Care
• Exercises to maintain ROM,
strength & stability
• Avoid aggravating activities
• NSAID’s, corticosteroids
• Surgical repair
17-26
• Piriformis Syndrome
– Cause of Condition
• Compression of sciatic nerve; irritation due
to tightness or spasm of muscle
• May mimic sciatica
– Signs of Injury
• Pain, numbness and tingling in butt – may
extend below knee and into foot
• Pain may increase following periods of
sitting, climbing stairs, walking or running
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– Care
• Stretching and
massage
• NSAID’s may be
prescribed
• Cessation of
aggravating
activities will be
prescribed
• Corticosteroid
injection may also
be suggested
• Surgery is
sometimes an
option as well
17-28
Hip Problems in Adolescent
Athletes
• Legg Calve’-Perthes Disease (Coxa Plana)
– Cause of Condition
• Avascular necrosis of the femoral head in child ages
4-10
• Articular cartilage becomes necrotic and flattens
– Signs of Condition
• Pain in groin that can be referred to the abdomen or
knee
• Limping is also typical
• Varying onsets and may exhibit limited ROM
17-29
17-30
•Legg-Calve’-Perthes Disease (continued)
• Care
– Bed rest to reduce chance of chronic
condition
– 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
17-31
• Slipped Capital Femoral Epiphysis
– Cause of Condition
• May be growth hormone related
• 25% of cases are seen in both hips
• Epiphysis slips from femoral head in backwards
direction due to weakness in growth plate
• May occur during periods of elevated growth
– Signs of Condition
• 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
17-32
• Slipped Capital
Femoral Epiphysis
– 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
17-33
• 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
Padding should be used upon return to
minimize chance of added injury
17-34
• Osteitis Pubis
– Cause of Injury
• Seen in distance runners
• Repetitive stress on pubic symphysis and
adjacent muscles
– Signs of Injury
• Chronic pain and inflammation of groin
• Point tenderness on pubic tubercle
• Pain w/ running, sit-ups and squats
– Management
• Rest, NSAID’s and gradual return to activity
17-35
• 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
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• 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
17-37
• Avulsion Fractures
– Cause of Injury
• Avulsions seen in sports w/ sudden
accelerations and decelerations
• Pulling of tendon away and off of bony insertion
• Common sites include ASIS (sartorius), AIIS
(rectus femoris attachment), ischial tuberosity
(hamstring
– Signs of Injury
• Sudden localized pain w/ limited movement
• Pain, swelling, point tenderness
– Care
• Rest, limited activity and graduated exercise
17-38