Chapter 17: 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 hip • Ischial bursa • Greater 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? • Observation – Postural 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 Thomas Test tightness • Can also be used to assess low back or SI joint dysfunction • 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 –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 • 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 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 • Groin Strain (continued) –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 dislocation skate 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 Fractures – Cause 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 .