Chapter 21: Rehabilitation of Groin, Hip and Thigh Injuries

1. Chapter 21: Rehabilitation of Groin, Hip and Thigh Injuries

2. Functional Anatomy and Biomechanics • Hip • Pelvic girdle • Femoral head • Acetabulum • Labral rim (fibrocartilage) • Ball and socket joint • Angle of inclination • Frontal projection of the angled formed by the shaft and neck • Angle of declination • Angle formed by femoral neck and condyles (angle of anteversion)

3. Pelvic Motion and Muscle Involvement • Anteroposterior tilting • Iliopsoas and hip flexors • Abdominal musculature and lumbar spine extensors • Gluteus maximus and hamstrings • Lateral tilting • Hip abductors • Rotation • Gluteal muscles • External rotators • Adductors • Pectineus • Iliopsoas

4. Ball and Socket Joint • Intrinsic stability with a great deal of mobility • Motion in all three planes • Fibrocartilage rim increases level of stability within the joint • Muscles and tendons seem to be most affected by injury • Multiple points of muscle attachment on the pelvis

5. Rehabilitation Techniques for Specific Injuries Hip Pointer • Pathomechanics • Subcutaneous contusion with possible muscle tearing at origins/insertions • No immediate concern – pain and swelling will ultimately impact athlete’s mobility • Fracture may be associated with injury • Injury Mechanism • Result of direct blow to iliac crest or ASIS • Must differentiate between hip pointer and abdominal strain

6. Rehabilitation Concerns • Must rule out fx with X-rays • Treatment must be prompt in order to limit severe pain and loss of trunk motion • Graded injury • Grade I – normal gait, pain on palpation, full ROM of trunk • Grade II – moderate to severe pain on palpation, swelling, and abnormal gait (short swing phase), decreased hip ROM • Grade III- Pain on palpation, swelling and discoloration, restricted gait, decreased ROM and trunk motion • RICE, anti-inflammatory drugs and modalities for pain and swelling • ROM and strengthening (include trunk)

7. Rehabilitation Progression • Grade I – no loss of activity • Grade II – miss 5-14 days • Grade III – miss 2-3 weeks • Should progress through strengthening exercises if pain-free after initial 2 days of RICE and active ROM • Criteria for Return • Full trunk ROM • Performance of sports-specific activity • Padding for protection during rehabilitation and return to play

8. Injury to ASIS and AIIS • Pathomechanics • Contusion of apophysitis • Severe pain with disability should be assessed with X-ray (rule out avulsion) • Injury Mechanism • Sartorius and rectus femoris attachment • Violent, forceful passive stretch of hip into extension • Violent, forceful active contraction into hip flexion • Rehabilitation Concerns and Progression • Should follow same guidelines as hip pointer after avulsion is ruled out

9. PSIS Contusion • Pathomechanics • Must differentiate from vertebral fracture and possible internal organ injury • Avulsion fractures are usually rare • While injury is often painful it usually does not cause disability • Injury Mechanism and Rehabilitation Concerns • Caused by a direct blow or fall • Pain on palpation with swelling, possibly altered gait (choppy steps) • Possible postural disruption (forward flexion) • Severe cases may require 3 days rest prior to return to competition

10. Piriformis Syndrome • Pathomechanics • Sciatic nerve may be irritated in conjunction with low back pain • Possibly a traumatic injury – related to sciatic nerve passage beneath/through piriformis • Piriformis irritation – more common in women • Tight musculature is often associated with syndrome • Hamstring injury can result in nerve or ischial bursa irritation • Sciatic nerve disruption may occur in conjunction with posterior dislocation of femoral head

11. Injury Mechanism • Most common cause is direct blow to buttocks • Also associated with nerve irritation due to piriformis tightness/piercing • Rehabilitation Concerns • Must rule out disk disease • Stretches indicated for sciatica may be contraindicated for disk disease • Determine if athlete has low back pain with irritation into extremity or just nerve irritation – sciatica • With piriformis syndrome must assess gait (reduced heel strike, foot-flat landing, stride shortening, flexed knee to decrease nerve stretch • Altered hip ROM due to pain

12. Rehabilitation Progression • Severe sciatica may keep athlete from competition for 2-3 weeks (possibly longer) • With radiating pain RICE for the first 3-5 days is indicated • Following reduction in acute pain stretching for low back and hamstrings should begin • Assess ROM and gait cycle to correct for deficits

13. Criteria for Full Return • Capable of performing full, pain-free activity with no neurological symptoms • Running, cutting • If participation continues to result in radiating pain, could become a chronic condition • Prevention of injury is critical – institute good flexibility program for athletes

14. Trochanteric Bursitis • Pathomechanics • Bursa located between gluteus maximus and greater trochanter • Often mistaken for other injuries due to location • Aside from lubricating adjacent surfaces – may be involved with joint capsule, tendons, ligaments and skin • Bleeding associated with bursitis (hemorrhagic bursitis) with pain and swelling may limit motion • Possible infection must be considered

15. Injury Mechanism • Generally caused by direct trauma or overuse stress • Irritation by iliotibial band (IT-band) at insertion of gluteus maximus • Running with one leg slightly adducted (causes irritation on adducted side) • Often seen in female runners due to increased Q-angle with or without leg-length discrepancy • Tight adductors causing feet to cross midline resulting in excessive tilting of the pelvis in the frontal plane • Lateral heel wear can increase hip adduction

16. Rehabilitation Concerns • Traumatic bursitis is more easily diagnosed • Gait may be slightly abducted on affected side to relieve pressure on the bursa • Possible decreased weight-bearing phase during gait • Complete history is necessary to determine cause • Posture, flexibility, footwear, and gait should be assessed • Rehabilitation Progression • NSAID’s and RICE for pain and inflammation • Modality use and stretching • Orthotic fabrication • Progressive stretching and strengthening of hip abductors when athlete is pain free

17. Hip Stretching

18. Criteria for Full Return • Athlete may miss 3-5 days of competition • Dependent on severity of condition • Protective padding should be used for contact sports upon return to play • Athlete should be able to perform sports-specific functional tests

19. Ischial Bursitis • Pathomechanics and Injury Mechanism • Often seen in people who sit for long periods of time • Also the result of direct trauma (falling or direct hit when hip is flexed) • Rehabilitation Concerns • Pain on palpation and with ambulation • Hip flexed position • Stair climbing and uphill walking/running may reproduce pain

20. Rehabilitation Progression • Must flex hip to treat affected area • Following initial treatment of pain and inflammation gradual stretching can be initiated • Criteria for Full Return • Is some instances no time will be lost • Avoid direct trauma to area for 3-5 days during initial stages of healing • Protective padding should be worn with involvement in contact sports • Should be able to perform full range of functional and sports-related activities prior to returning to play

21. Iliopectineal Bursitis • Pathomechanics and Injury Mechanism • Often mistaken for iliopsoas strain • Rarely seen in athletes • May be the result of a tight iliopsoas or related to osteoarthritis of the hip • Rehabilitation Concerns • Pain with seated or supine hip flexion • Passive hip extension may result in discomfort • Palpable tenderness • Possible femoral artery inflammation due to proximity of condition

22. Rehabilitation Progression • NSAID’s will be useful • Deep heating or ice massage can be utilized to decrease inflammation and pain • Initiate some light stretching of the iliopsoas tendon • Hip flexion strengthening should be performed pain-free

23. Groin Injuries • Full understanding of biomechanics, anatomy and mechanism of injury are necessary to assess groin injuries • Could be a number of possible causes with respect to pain • Must consider abdominal, hip joint, lumbosacral and pelvic conditions when assessing groin injuries

24. Groin and Hip Flexor Strain • Pathomechanics • Injury to muscles (generally adductor muscles) in and around the groin region • Pain that develops (moderate to severe) that can become disabling • Chronic strain can cause bleeding and result in development of myositis ossificans • Injury Mechanism and Rehabilitation Concerns • Result of over-extending or externally rotating hip • Forceful contraction into flexion and internal rotation

25. Must differentiate between hip flexor and adductor strain • Monitor gait and pelvic motion during ambulation • Pain and swelling must be controlled as they will greatly limit the recovery process • Rehabilitation and Return to Play Criteria • With a Grade I injury gentle stretching can begin immediately • Progress to some progressive strengthening exercises • Emphasize adduction and hip flexion • PNF exercises should also be incorporated • Time out from competition may be limited • Functionally oriented training should be incorporated (slide board, plyometrics and sports specific drills)

26. Grade II injuries should begin with immediate, gentle and pain free action ROM exercises • Ice and stretch position with iliopsoas involvement – decrease pain and spasm • Isometrics and gait re-training should be incorporated as pain allows

27. Strengthening Exercises

28. As strength gains are made plyometrics and slide board activities can be added • Athlete will likely miss 3-14 days • Adductor strain will generally require additional time as compared to hip flexor strains • Treatment and rehabilitation will be modified as necessary • Grade III should undergo RICE, immobilization and be non-weight-bearing initially • Modality use for pain is encouraged • Rest for 1-3 days with compression is suggested • If surgery is not required isometrics can be implemented at days 3-5 • Appropriate gait mechanics should be emphasized with and without crutch use

29. Pain free stretching should begin between 7-10 days post-injury • A strengthening program should also be initiated as ROM improves • More advanced training should begin 10 days after initiating strength training – strength levels must be adequate to begin • As strength improves plyometrics and functional activities should be incorporated • Timetable varies depending on severity but may lose from 3 weeks to 3 months of competition

30. Osteitis Pubis • Pathomechanics • Pain in region of pubic symphysis • Difficult to determine injury unless complaint of direct trauma or contact is rendered • Pubic pain can also be caused by inferior ramus fx or groin strain • Often seen in athletes that make repetitive changes in direction (overuse) • Soccer and football • Injury Mechanism • Repetitive stress on pubic symphysis caused by muscle attachment • Direct trauma or contact • Signs and symptoms will develop gradually

31. Rehabilitation Concerns • Must rule out hernia and other medical conditions (physician referral) • X-rays may take 4-6 weeks to show anything significant • Athlete will have pain with running, sit-ups and squats • Lower abdominal pain, radiating to inner thigh • Pain on palpation • Altered gait due to pain • Prevent shearing motions and focus on core stabilization • Progression of CKC to OCK may occur due stabilization

32. Rehabilitation Progression and Return to Play Criteria • Rest and NSAID’s early on for pain and to limit shear forces acting on pelvis • Initiate pain-free adductor stretching and core stabilization training as pain allows • OKC hip exercises can be utilized early on as long as tolerated by athlete • Stabilization should be focused on to limit shear forces • CKC exercise may be more comfortable due to the pelvic stabilization involved • Return may take anywhere from 3-5 days or 3 weeks to 3-6 months depending on severity • Return to plyometrics and functional drills will be dependent on pain

33. Fractures of Inferior Ramus • Pathomechanics • Rule out stress and avulsion fractures • May detect a palpable mass under skin • May appear to be osteitis pubis • Injury Mechanism • Caused by a violent, forceful contraction of hip adductor or forceful passive hip abduction • Stress fractures will be the result of some overuse situation

34. Rehabilitation Concerns, Progression and Return to Play • Rest is critical • Stretching and strengthening can begin as pain-free ROM is achieved • Avulsion may require 3 months for healing and return to competition • Stress fractures will require 3-6 weeks with rest being key to treatment • Stabilization exercises should be emphasized in addition to CKC activities • Return to activity should be gradual and deliberate, pain free

35. Hip Dislocation • Pathomechanics • Rarely occurs in athletics • Requires considerable force due to deep socket of hip joint • Fractures and avascular necrosis are often involved in dislocations • Vascular and nerve supply may be disrupted • Injury Mechanism • Generally posterior – femur driven posteriorly when hip is flexed • Severely painful, trochanter may appear larger with extremity internally rotated, flexed and adducted

36. Rehabilitation Concerns, Progression and Return Criteria • 2-3 weeks of immobilization initially • Full lower extremity rehabilitation may be necessary • Electric stimulation may be required for muscle re-education • Isometrics should be performed for the hip when pain-free • At 3-6 weeks pain free active ROM should be performed • Crutch walking should continue until normal gait returns without pain

37. At 6 weeks gentle progressive resistance exercises with cuff weights can begin • All motions of the hip should be emphasized • Stretching should not be initiated for at least 8-12 weeks • At 12 weeks CKC exercises can begin • Plyometrics, slide board exercise, and functional drills can be initiated between 16 and 20 weeks • Pain must be utilized as a gauge • Return to competition in 6-12 months if there have been no delays and the athlete is pain free with all activity

38. Sports Hernia/Groin Disruption • Pathomechanics • Syndrome of groin – groin pain without resolution • May last 4-6 months and possibly up to a year • Weakening of posterior inguinal wall with possible undetectable hernia • Injury Mechanism • Result of torques in all planes • Continuous and gradually increasing pain in deep groin and pelvis • Trunk hyperextension injury • Adductor and abdominal musculature pain at main sites of attachment on pubis • Other groin/abdominal conditions may contribute to groin syndrome

39. Rehabilitation Concerns • Contributing factors of other conditions • Significant inflammation • Possible surgical intervention • Pelvic floor repair • Rehabilitation Progression • First 4 weeks should involve significant rest with no activity/exercise • At 5 weeks, pelvic tilting exercises can be initiated

40. Gentle pain free stretching can also begin at 5 weeks • A slow progression of aquatic therapy can also be initiated • At 8 weeks strengthening exercises can be added with some more advanced aquatic therapy activities • Cardiovascular work on UBE or stair master should also be added • Additional core strengthening should also be added • For dry land activities athletes may progressively begin jogging regimen while hockey players can begin light, pain free skating • At 12 weeks, heavy lifting can begin (squats, lunges, plyometrics) • Sports specific training can also be added • From 3 months forward athlete may be cleared to activity

41. Snapping or Clicking Hip Syndrome • Pathomechanics and Injury Mechanism • Result of excessive repetitive motion • Muscle imbalances • Snapping of IT-band over greater trochanter or iliopsoas over iliopectineal eminence • Other contributing causes • Iliofemoral ligament snapping over femoral head • Long head of biceps tendon snapping over ischial tuberosity • Narrow pelvis width • Excessive abduction ROM • Decreased IR or excessive ER • Loose bodies • Synovial chondromatosis • Joint subluxation

42. Rehabilitation Concerns, Progression and Return to Play Criteria • Extra-articular causes may contribute to hip instability • Snapping associated with pain • Key to management is decreasing pain and inflammation • Ice and NSAID’s • Additional modalities • Determine source of imbalance • Work on flexibility and strength to achieve balance • After 3-5 days a jogging progression can be initiated along with functional drills – must be pain free

43. Acetabulum Labrum Tears • Pathomechanics • Difficult to diagnose • Antalgic gait (hip flexor strain) • Changes in hip motion and strength will occur with continued pain • Clicking and catching usually associated with pain • Injury Mechanism • Minor hip twist caused by direct blow • Forceful cutting, quick change of direction resulting in tear of labrum

44. Rehabilitation Concerns and Progression • Varied of mixed results • Conservative treatment, modalities and NSAID’s initially • Signs and symptoms generally return • Possible injection for pain reduction – pain often returns • Treatment of choice = labral arthroscopic surgery • Following surgery (1-2 days) pain free motion should be initiated • After day 5 light strengthening should begin • At 3 weeks pain free stretching can be added • Sports-specific functional training and return to activity will occur at 4-6 weeks

45. Hamstring Stain and Avulsion Fracture of the Ischial Tuberosity • Pathomechanics • Ischial tuberosity is a common injury site due to hamstring attachment • Injury Mechanism • Result of violent, forceful hip flexion with knee in extension • Rehabilitation Concerns, Progression and Return to Play Criteria (Strain) • Pain with sitting, walking (particularly stairs and hills) • Generally normal gait, no antalgic gait • May experience pain with running • Pain with RROM

46. Initial treatment involves RICE and gentle pain free stretching • Isolate the hamstring as the stretching is being performed • Addition of pain free hamstring strengthening as soon as possible • CKC and PNF exercises should be added as tolerated • Time loss may be minimal • Rehabilitation Concerns (Avulsion Fracture) • More severe pain with abnormal gait • Attempts to avoid hip flexion • Pain with hamstring related motion • After 3 weeks and initial healing, pain free ROM and stretching should be initiated

47. As ROM returns, progressive resistance training exercises should be added to the routine (weeks 6-12) • Isotonics, CKC, PNF, isokinetics, plyometrics, fxn training • Because surgery is generally required immobilization may serve as a limiting factor early during the process. \ • Restoration of motion is critical • Progressive strengthening will allow for a full return to play

48. Hamstring Strains • Pathomechanics • Common injury • Complexity of hamstring and quadriceps functioning together while crossing 2 joints • Musculotendinous region is generally involved • Often resulting some degree of swelling, comparable to severity of injury • Injury Mechanism • Quick explosive contraction is often the cause • Other factors • Muscle imbalances, fatigue, running posture, gait, leg length discrepancy, decreased ROM, muscle innervation

49. Rehabilitation Concerns • Identification of muscles and positions involved with injury • Must assess swelling, ROM, gait and strength • Will vary based on severity of injury • Possible immobilization associated with severe strain • Must prepare athlete to engage in high intensity and high volume, explosive activity (concentric and eccentric) • Rehabilitation Progression • Re-establishment of normal gait is critical • RICE and maintenance of lordotic curve should be addressed on day 1

50. Modality use for pain is suggested early in the treatment process • Hamstring isometrics and light stretching should occur as tolerated within pain free range • Gradual transition to isotonic strength training • OKC & CKC • Increases in volume and intensity should be modified as tolerable • Criteria for Full Return • Grade I injury may result in no lost time • Grade II injury could result in 5-12 days loss of participation while grade III could require missing 3-12 weeks • Athlete should be able to participate pain free and have completed full plyometric, functional and sports specific training regimen