Transcript Injuries to the Hip and Pelvis

Injuries to the Hip and Pelvis








We will discuss a basic overview of the anatomy in the
region of the hip and pelvis
We will have a brief description of movements by the joints
and actions of the musculature in the area
We will target more common hip and pelvis injuries incurred
in sports and outlines emergency procedures
We will also talk about injuries that aren’t common in sports
The chapter reviews injuries to the male genitalia, including
both testicular contusion and torsion
It also covers hernia and nerve problems and discusses
proper referral
http://www.youtube.com/watch?v=7VpS0T_kt2w
http://www.nbcolympics.com/video/gracie-gold-confidentafter-outstanding-performance-team-event?ctx=olympicjourney
Anatomy Review…


The hip and pelvis
form a square in the
way they are
constructed
This area comprises
the two large,
irregularly shaped
pelvic bones on the
lateral sides, the
sacrum and coccyx
posteriorly, and the
articulation of the
pubic bones anteriorly
Anatomy Review…

The pelvic bones are
also known as the
innominate bones
and are made up
three distinct parts:
◦ The ilium
◦ The ischium
◦ And pubis
Anatomy Review…

In the adult, the
three parts are fused
and come together
at a lateral point
called the
acetabulum, which is
where the head of
the femur articulates
with the hip to form
the hip joint
Anatomy Review…

The bony pelvis has several functions in
the body:
◦ The lower extremities attach here
◦ Muscle attachments are prevalent
◦ It provides substantial protection for the
entire pelvic region
Anatomy Review…
The major articulations of the bony pelvis
include the hip joint, the sacroiliac joints,
and the symphysis pubis
 The hip joint is the articulation of the
head of the femur and the acetabulum in
the hip bone; it is a true ball-and-socket
joint that is well supported by strong
ligaments

Anatomy Review
The sacroiliac joints are formed by the
sacral bones and the iliac portion of the
hip bones
 The symphysis pubis is formed by the two
pubic bones meeting in anterior portion
of the bony pelvis
 All of these joints have strong
ligamentous support that assist in joint
stability

Anatomy Review…
Several nerves and
blood vessels course
through the bony
pelvis
 Some of the more
important nerves
that course down
the lower extremity
are subdivisions of
the make up of the
cauda equina

Anatomy Review…


The spinal cord ends
at L2 level, and the
cauda equina exits the
spinal cord beginning
at L2 and proceeding
inferiorly (Gray, 1974)
Nerves exiting the
spinal cord below the
L1 level typically pass
through the bony
pelvis
Anatomy Review…
These nerves include the formation of the
lumbar plexus, the sacral plexus, the
coccygeal plexus and other individual
nerves
 Probably the most well known of these is
the sciatic nerve, which is the largest in
the body and is made up of nerve roots
L4 – S3

Anatomy Review…



The sciatic nerve passes
through the posterior
portion of the bony
pelvis and down the
posterior aspect of the
leg
The blood vessels of the
area include both
arteries and veins that
supply the pelvis and
lower extremities
The more well known of
these vessels include the
iliac artery and vein
Anatomy Review
Many of the muscles that
attach to the bony pelvis
are ones that move the
lower extremities
 The smaller muscles
consist of the medial and
lateral rotators of the
femur
 Some of the medial
rotators include the tensor
fasciae latae and gluetus
minimus
 These muscles are quite
active in many movements
of the lower extremity

Anatomy Review…


The lateral rotators of
the hip are small
muscles located deep
within the hip area
that are also quite
active in many
movements of the
lower extremity
Some of those muscles
more commonly
injured include the
piriformis
◦ Which attaches to the
anterior surface of the
sacrum and to the
greater trochanter of
the femur
Anatomy Review…

The piriformis is a
lateral rotator of the
thigh; the sciatic
nerve runs directly
beneath the
piriformis and can be
irritated by the
overuse of this
muscle
Anatomy Review…

Other external
rotators of the thigh
include the gemelli
(superior and
inferior), which
attach on the ischium
and run to the
greater trochanter of
the femur
Anatomy Review…



All of these muscles are small in comparison
with the surrounding muscles, but they play
an important part in the proper functioning
of the hip and leg
Many muscles attach on the pelvis and
provide musculature for the leg, back, and
abdomen
These muscles responsible for many of the
large movements at the hip joint include
flexors, extensors, adductors, and abductors
Anatomy Review…


The main hip flexors
include the rectus
femoris, the iliopsoas
group, the tensor
fasciae latae, and the
sartorius
The rectus femoris
attaches at the ASIS
and runs down the
front of the leg to the
common attachment
of the quadriceps
group at the patellar
tendon
Anatomy Review…

The iliopsoas group is a combination of the
iliacus and psoas muscles, which attach on the
anterior lumbar spine and iliac crest and come
together as they run down to the lesser
trochanter of the femur
Anatomy Review…



The tensor fasciae latae
and sartorius attach on
the anterior iliac spine
The tensor fasciae latae
runs to the lateraly
condyle of the tibia,
whereas the sartoris
runs across the anterior
thigh and attaches to the
anterior medial aspect of
the tibia
The sartorius becomes
one of the muscles of
the pes anserinus group
Anatomy Review…



The main muscles of
hip extension are the
gluteals and the
hamstrings
The gluteus maximus
is the main hip
extensor of the
gluteals
Attaches on the
posterior surface of
the ilium and runs
inferiorly to the femur
Anatomy Review…
The hamstrings attach mainly on the ischial tuberosity;
then, two of the muscles, the semitendinosus and
semimembranosus, run more medially on the posterior
leg and attach near the sartorius and on the
posterior/medial condyle of the tibia
 The biceps femoris runs more laterally on the posterior
leg and attaches to the lateral aspect of the tibia and head
of the fibula

Anatomy Review…


The muscles that
adduct the hip are
located on the medial
portion of the leg are
commonly called the
groin area
Main muscles included
in this group are the
three adductors
(brevis, longus,
magnus) as well as the
pectineus and gracilis
Anatomy Review…
The adductors attach on the pubis and
run to the femur
 The pectineus also attaches at the pubis
and runs to the femur
 The gracilis attaches on the inferior
portion of the pubis and runs medially
down the leg to the anterior medial
portion of the tibia

Anatomy Review


The sartoris, gracilis and
the semitendinosus
compose the pes
anserinus group
Say grace before tea
◦ How to remember them in
order

http://www.youtube.com
/watch?v=PHttidEwqz8
◦ (MMG, 2008)
Common Sports Injuries…





The hip and pelvic regions are well designed
anatomically
Sports-related injuries to the skeletal structures
of the hip and pelvis are not common
Injuries to the soft tissues in the region are more
common and can be quite debilitating to the
athlete
Injuries commonly involve collision sports or
forceful movements pursuant to an activity that
requires power and speed of the lower
extremities
Overuse injuries may also be associated wit hthe
hip and pelvis
Skeletal Injuries…FX of the Pelvis
One of the most devastating injuries to the
pelvic region is the fracture of one of the
pelvic bones
 Typically, a great deal of force is necessary to
cause a fracture of this type
 This is not a common injury related to
sports participation
 Still, it can occur in sports such as hockey,
pole-vaulting, or football in which there is
the possibility of direct compression from
another athlete, a fall from a height, or being
twisted and hit by another player

Skeletal Injuries…FX of the Pelvis


Skeletal injuries to the
pelvis in the
adolescent population
can be extremely
serious, especially if
the injury involves an
open epiphysis
Any suspected skeletal
injury to this area
should be referred to a
physician as quickly as
possible
Skeletal Injuries…FX of the Pelvis

S&S:
◦ Abdominal pain in the
pelvic region after the
injury
◦ There might be swelling
at the site, with the rare
occurrence of a visual or
palpable deformity at the
injury
◦ Pain is elicited when the
iliac crests are pressed
together
◦ Associated injuries to
internal organs such as
the bladder are possible
and should be ruled out

TX:
◦ Treat for possible shock
and internal bleeding
◦ Monitor the athlete’s
vital signs regularly
◦ Transport the athlete to
the hospital on a long
spine board with the
foot of the board
elevated to eliminate
pooling of blood in the
lower extremities
Skeletal Injuries…FX of the pelvis
A fracture of the pelvis is a serious injury
and should be evaluated by a physician
ASAP
 Treatment depends on the severity of the
injury and should be complete before the
athlete returns to practice or competition
 Under NO circumstances should an
athlete with a suspected FX of the pelvis
return to competition before seeing a
physician

Femoral Neck Stress Fracture


This injury occurs
more commonly in the
thin amenorrhea
athlete involved in
running or an
endurance sport
The femoral neck
stress fracture is a
result of a loss in
shock-absorbing
capacity of the fatigued
muscles in the hip area
Femoral Neck Stress Fracture
This problem can also be a partial result
of poor footwear, hard running surface, or
hip deformities (Lacroix, 2000)
 Typically, athletes c/o severe anterior thigh
or groin pain when they have a possible
femoral neck stress fracture
 The athlete will be able to walk but will
experience pain during ambulation
 Seeing a physician is necessary to get
radiographs

Slipped Capital Femoral Epiphysis
This problem occurs most commonly in 10
to 15 year old boys
 Typically, it occurs in boys who are tall and
have recently experienced a rapid growth
period, or in boys who are overweight
 The boy exhibits a flexed hip, thigh or knee
 Any child younger than the age of 12 who
complains of knee pain should have a
thorough hip evaluation by the physician to
r/o any one of a number of hip pathologies
that may exist in this population

Hip Pointer
Probably the most common injury to the
region is a contusion to the
superior/anterior portion of the iliac
crest, which is commonly referred to as a
hip pointer
 Typically, with this injury the athlete
receives a direct blow to the area from an
opponent’s helmet or falls to the ground
with great force

Hip Pointer

This can be an
extremely painful and
debilitating injury for
the athlete, but it is
not one that requires
emergency attention
or causes major
complications if
further activity is
necessary
Hip Pointer

S&S:
◦ Swelling at the site of
injury
◦ Discoloration at the site
of injury
◦ Pain and discomfort at
the site of injury
◦ The athlete may walk
with a slight limp on the
affected side
 Coughing, sneezing, and
laughing may also produce
pain at the site of injury

TX:
◦ Immediately apply ice to
the injured area
◦ Have the athlete rest
and avoid activity that
involves the lower
extremities
◦ If the injury is severe,
walking with crutches
may be necessary for a
few days
Hip Pointer
Long-term care for this type of injury is
rather simple
 The contusion has in most cases caused
minimal damage to an area where several
muscles attach directly to bone tissue
 The muscular attachments in the abdominal
region are the cause of pain when the
athlete coughs, sneezes, or laughs
 The player will usually be able to participate
on a limited basis within 1 to 2 weeks,
depending on the severity

Hip Pointer

It is important to note that if an athlete
wishes to continue participation in sports
while recovering from a hip pointer, the
area should be padded well so that
further damage can not occur if a similar
incident happens before recovery is
complete
Other Hip Problems
Athletes who participate in excessive
running as a part of their sport can
experience what is known as “snapping hip
syndrome”
 Snapping hip syndrome is a sensation that
occurs when the athlete moves the hip in a
specific direction
 Usually, there is little if any pain associated
with snapping hip
 This problem is attributed to one of the
muscles in the lateral hip riding over the top
of the greater trochanter of the femur

Other Hip Problems…




The structures that could be involved
include the iliotibial band, tensor fascia lata,
and the gluteus medius
There could be subluxation of the hip or
labral tears that induce extra movement of
the femur during locomotion
Typically, treatment consist of stretching
tightened muscles that may contribute to
the snapping sensation and correcting any
biomechanical deviations of the area
Anti-inflammatory medications may help
Other Hip Problems…



Trochanteric bursitis is another rare
problem experienced by some athletes
It is a problem seen most often in middleaged people, but athletes, especially runners,
are becoming more prone to trochanteric
bursitis
This bursitis is usually a result of either
acute trauma to the specific area or
repeated microtrauma to the tendon
attachments with secondary inflammation of
the bursae in the area
Other Hip Problems..
The iliotibial band can be a source of the
problem if it is tight and the athlete
continues to run when he/she is
experiencing S&S of trochanteric bursitis
 When an athlete is experiencing the
onset of trochanteric bursitis, he/she will
initially c/o pain over the greater
trochanter followed by pain radiating
down the anterior/lateral thigh to the
buttock region

Other Hip Problems..
Most athletes benefit from stretching the iliotibial
band and the low back area in the proximity of
the sacroiliac joints, and taking an NSAID
 For some athletes, it may be necessary to pad the
area if there is a chance of external trauma such
as falling or being hit by another athlete in the hip
 On rare occurrences, athletes do not respond to
conservative treatment and benefit from surgical
management
 http://www.youtube.com/watch?v=ZDBLdEpsvvk

Osteitis Pubis



Another type of skeletal injury to the pelvic
area is osteitis pubis, a condition resulting
from continued stress and possibly some
degeneration in the symphsis pubis joint
This injury is commonly a result of overuse
and chronic strain on the joint
Long-distance runners, basketball and soccer
players, and other athletes who experience
repetitive pelvic movements in sports may
c/o this condition
Osteitis Pubis
Athletes who produce repetitive shearing
forces of the pelvis and have increased
stresses on the lower abdominal
structures during their sport participation
are more susceptible to this problem
 Osteitis pubis is a difficult injury to
diagnose because the many muscles and
structures in the pelvic area, resulting in a
delayed diagnosis or a non-diagnosed
problem

Osteitis Pubis

S&S
◦ c/o an insidious onset
of pain that worsens
progressively
◦ May indicate that the
pain is in the groin
area

TX:
◦ Should be referred to
the appropriate
doctor for complete
evaluation
◦ Because this is a
chronic problem, first
aid is typically not
necessary
◦ Athlete may benefit
from RICES
Osteitis Pubis
The athlete typically responds well to
therapy, with very few if any long-term
side effects
 An athlete may take anywhere from 3
months to a year to return to preinjury
functioning levels

Injury of the Sacroiliac Joint…


The sacroiliac (SI)
joint, which is the
articulation between
the sacrum and pelvis,
is a common site of
pain in the posterior
aspect of the pelvis
Movement of this joint
is limited because of
the configuration of
the bones and
numerous ligaments
Injury of the Sacroiliac Joint…



This joint can present problems for the
athlete if it becomes completely immobile or
if it becomes inflamed from an injury or
other problem
Injuries resulting in an immobile SI joint
require specific movement techniques by a
trained professional to restore the normal
motion in the joint
Problems with inflammation in the SI joint
can be treated by a certified athletic trainer
or physical therapist under the direction of a
physician
Hip Dislocation…
Infinitely more serious is a hip dislocation
This injury is actually quite rare in athletic events;
however, it may occur to an athlete participating
in contact sports
 If a violent collision occurs between two players
or between a player and another object (for
example, the boards surrounding a hockey rink),
this type of injury can happen
 Typically, when the injury occurs the hip joint is in
flexion, and the force is applied through the femur
 Most often the hip dislocates posteriorly, and the
athlete experiences extreme pain and loss of
movement in the affected extremity


Hip Dislocation

S&S:
◦ Abnormal pain at the
site of injury
◦ Swelling at the site of
injury, with a palpable
defect
◦ Knee of the involved
extremity is angled
toward the opposite leg
◦ This injury is typically
quite visible to the
observer

TX:
◦ Treat for possible shock
◦ Immobilize the athlete
and transport to the
nearest medical center
◦ Care should be given to
monitor blood flow to
the leg at all times
Soft-tissue Injuries…



Because of the size and functions of the
musculature in the hip and pelvic region,
soft-tissue injures are not very common in
sport
The ligamentous support of the hip, sacrum,
and other structures in the area is very
strong; as a result, sprains rarely occur here
however, several muscles attach in the area
of the pelvis, including the musculature on
both the anterior and posterior aspects of
the thigh, and these are subject to avulsion
Avulsion Fractures…
The possibility of muscle avulsions during
forceful activity always exists
 Skeletally immature athletes are more
prone to avulsion fractures around the
hip because their tendons are stronger
than their cartilaginous growth centers
 The MOI is a sudden near maximal
muscle contraction
 This results in the tendon pulling off a
piece of bone at the attachment site

Avulsion Fracture


In a skeletally mature
adult, this action
usually results in a torn
muscle or tendon
because the bone is
stronger than the
tendon
In the adolescent, the
tendon is stronger
than the bone, so the
result is an avulsion
fracture
Avulsion Fracture


Avulsion fractures
occur more commonly
in adolescents who
participate in sports
requiring short bursts
of maximal muscle
contraction, such as
soccer, tennis, sprinting,
or jumping
The injured athlete will
c/o severe localized
pain and ecchymosis at
the site of injury
Avulsion Fracture

Common sites of injury in adolescents
are ASIS where the rectus femoris
attaches, and the ischial tuberosity where
the hamstrings attach
Avulsion Fracture

S&S:
◦ Pain and swelling at the site
of injury
◦ Inability to produce specific
movement that is usually
accomplished easily
◦ Point tenderness over the
affected area
◦ Movement of the muscle
closer to its opposite
attachment when
contracted
◦ May have felt or heard a
snap or pop at the time of
injury

TX:
◦ Immediately apply ice and
require the athlete to rest
◦ Limit motion as much as
possible
◦ Have the athlete evaluated
by a physician ASAP to
determine the extent of
the injury
Avulsion Fracture..
Are debilitating and should be treated
conservatively to reduce the amount of
scar tissue
 Without proper treatment and
rehabilitation, this type of injury can be a
problem in an athlete’s future career

Hernias…
A hernia is the protrusion of abdominal
viscera through the abdominal wall; this
typically occurs in the groin area
 In males, inguinal hernias are more
common
 Femoral hernias are more prevalent
among female athletes (Crowley, 2010)
 Most hernias are detected during a
preparticipation physical evaluation

Hernias
However, an athlete who is suffering from
a hernia most likely has an abnormal
protrusion in the groin area and
experiences pain in the groin and/or
testicles
 The area should seek proper medical
advice promptly to discern how soon the
hernia will have to be repaired

Hernia…
Athletes can experience “sports hernias”
in which the posterior inguinal wall is
weakened w/o any protrusion of
abdominal contents through the
abdominal wall
 In this situation, no palpable hernia is
discovered during a routine physical
examination, yet the athlete c/o
continuing pain in the groin and lower
abdominal regions

Hernia…



The sports hernia is difficult to diagnose for
the physician and usually exhibits diffuse,
deep groin that does not have a specific
onset and gradually gets worse as the days
pass
The athlete may c/o pain along the inguinal
ligament and into the rectus muscles
It has been suggested that sports hernias
may be a common cause of chronic groin
pain in athletes
Hernias…
In any case, groin pain must be addressed with
proper treatment and the course of action taken
needs to follow a predetermined timeline
 Conservative treatment of rest, ice, stretching,
and a change in kicking biomechanics may be all
that is needed to relieve groin pain in a soccer
player
 If the symptoms do not resolve over a 2-week
period, it is time to see the team physician
 Athletes need to understand that many different
techniques for surgical repair exist and new ideas
are being reported

Nerve Problems…




A common complaint among many athletes
is a burning or tingling sensation radiating
from the hip and buttocks area and going
down the back of the leg
These symptoms are often the result if
irritation of the sciatic nerve
Typically, if an athlete continues to pursue
the activity that has caused the irritation, the
pain will radiate farther down the leg to the
foot and become more debilitating over time
Strengthening and stretching exercises will
help depending on the situation
Prevention…



Many of these injuries can be prevented by
the use of proper conditioning and
strengthening of the associated musculature
Rest is important for the body to repair
micro damages incurred by stresses of
training
The use of proper shoes for each activity
can be helpful in preventing slipping or
sliding by the athlete that might result in
overstretch or tearing of muscles
Prevention
Soccer players or similar types of athletes
slipping on a wet field can sustain severe
groin injury
 Even though injuries to the hip and pelvis
are relatively uncommon as a result of
sports participation, it is important to
realize that injuries to this area do occur
and that they can be debilitating to the
athlete
