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Chapter 8

Chapter 8. The Pelvis and Thigh. Introduction. Pelvic girdle forms structural base of support between lower extremity and trunk Hip articulation – strongest and most stable joint in the body This benefit gained at the expense of ROM. Clinical Anatomy. Bones and Bony Landmarks

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Chapter 8

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  1. Chapter 8 The Pelvis and Thigh

  2. Introduction • Pelvic girdle forms structural base of support between lower extremity and trunk • Hip articulation – strongest and most stable joint in the body • This benefit gained at the expense of ROM

  3. Clinical Anatomy • Bones and Bony Landmarks • Figures 8-1 and 8-2 • Ilium, • Ischium • Pubis • Sacrum • Acetabulum • Labrum

  4. Clinical Anatomy • Bones and Bony Landmarks cont. • Femoral head and neck • Angle of inclination • Head is angled at 125 degrees in frontal plane • Angle of torsion • Relationship between head and shaft, 15 degrees • Figures 8-3, 8-4, 8-5 • Greater trochanter • Lesser trochanter

  5. Clinical Anatomy • Articulations and Ligamentous Support • Pubic symphysis • Fibrocartilaginous interpubic disc • Small degree of spreading, compression and rotation between halves of girdle • Sacroiliac joint (SI joint) • Very study, limited ROM

  6. Coxofemoral joint (hip joint) • Ball-and-socket • 3 degrees of freedom • Flexion and extension • Abduction and adduction • Internal and external rotation • Rom supported by depth of acetabulum, strength of ligaments, strong muscular support • Joint capsule • Dense synovial capsule from acetabular rim to distal femoral neck

  7. Iliofemoral ligament (Y ligament of Bigelow) • Figure 8-6 • AIIS to distal and proximal intertrochanteric line • Reinforces anterior jt capsule and limits hyperextension • Allows us to stand upright with minimal muscular activity • Pubofemoral ligament • Also reinforces anterior capsule • Pubis ramus to intertrochanteric fossa

  8. Ligamentum teres (ligament of the head of the femur) • Conduit for medial and lateral circumflex arteries • Little function in stabilizing hip • Figure 8-7 • Inguinal ligament • ASIS to pubic symphysis • Serves to contain soft tissues as they course anteriorly from trunk to lower extremity • Superior border of femoral triangle

  9. Muscular Anatomy • Table 8-1, pages 276-277 • Anterior Musculature • Quadriceps • Iliopsoas group • Psoas major, psoas minor, iliacus • Primary hip flexors when knee extended • Figure 8-8 • Medial Musculature • Adductor group • Gracilis • Figure 8-9

  10. Lateral Musculature • Gluteus medius • Tensor fascia latae • Figure 8-10 • Trendelenburg’s gait pattern • Intrinsic muscles form cuff around femoral head and externally rotate hip • Piriformis, quadratus femoris, obturator internus, obturator externus, gemellus superior, gemellus inferior • Figure 8-11

  11. Posterior Musculature • Gluteus maximus • hamstrings

  12. Femoral Triangle • Figure 8-12 • Formed by: • Inguinal ligament (superiorly) • Sartorius (laterally) • Adductor longus (medially) • Landmark for: • Femoral nerve, artery and vein • Femoral pulse • Lymph nodes

  13. Bursae • 3 bursa to decrease friction between gluteus maximus and adjacent bony structures • Trochanteric bursa • Gluteus max – greater trochanter • Gluteofemoral bursa • Gluteus max – vastus lateralis • Ischial bursa • Gluteus max – ischial tuberosity

  14. Clinical Evaluation of Pelvis and Thigh • May necessitate evaluation of lower extremity, spinal column, and posture • Patient preparedness • Clinician preparedness • Gender issues • Evaluation Map • Page 280

  15. History • Location of symptoms • Table 8-2, page 281 • Onset • Training techniques • Mechanism of injury • Prior medical conditions • Legg-Calve-Perthes Disease • Slipped capital femoral epiphysis

  16. Inspection • Most trauma to area cannot be visualized • Inspection of Hip Angulations • Angle of inclination • Relationship of femoral head and shaft • Coxa valga • Increase in angle, may lead to genu varum or lateral patella • Coxa vara • Decrease in angle, may lead to genu valgum or squinting patella • Mechanical advantage of glut medius is reduced

  17. Angle of torsion • Measured through radiograph • Box 8-1 • Anteverted hips • Increases greater than 15 degrees result in internal femoral rotation, squinting patellae and a toe-in gait • Retroverted hips • Angle less than 15 degrees, femur externally rotates, resulting in a toe-out position, laterally positioned patellae

  18. Inspection of Medial Structures • Adductor group • Inspection of Anterior Structures • Hip flexors • Inspection of Lateral Structures • Iliac crest (figure 8-13) • Nelaton’s line • ASIS to ischial tuberosity • Figure 8-14

  19. Inspection of Posterior Structures • PSIS • Gluteus maximus • Hamstring muscle group (figure 8-15) • Median sacral crests • Inspection of Leg Length Discrepancy

  20. Palpation • Refer to list of Clinical Proficiencies • Utilize pages 283 - 285

  21. Range of Motion Testing • Limited by bony and soft tissue restraints • Position of knee • Flexed vs. extended • Table 8-3, page 286 (Muscle actions) • Box 8-2, page 287 (Goniometry)

  22. Active Range of Motion • Flexion and Extension • Figure 8-17 • 130-150 degrees (range, knee flexed) • Majority occurs during flexion • Extending knee limits hip flexion • Adduction and Abduction • Figure 8-18 • Abduction – 45 degrees • Adduction – 20-30 degrees

  23. Active Range of Motion • Internal and External Rotation • Figure 8-19 • ER – 40-50 degrees • IR – 45 degrees • Hip flexed vs. extended

  24. Passive Range of Motion • Flexion and Extension • Flexion • Figure 8-20 • End-feel: soft w/knee flexed; firm w/knee extended • Thomas Test • Box 8-3, page 289 • Extension • Figure 8-21 • End-feel: firm w/knee extended and flexed but due to different structures

  25. Passive Range of Motion • Adduction and abduction • Figure 8-22 • End-feel: firm • Adduction – due to tension in lateral structures • Abduction – due to tension in medial structures • Internal and external rotation • Figure 8-23 • End-feel: firm • IR – due to tension in posterior capsule and external hip rotators • ER – due to tension in anterior capsule and ligament support • Anteverted vs. retroverted hips

  26. Resisted Range of Motion • Box 8-4, pages 291-292 • Trendelenburg’s Test for Gluteus Medius Weakness • Box 8-5, page 293

  27. Ligamentous Testing • No specific tests for hip ligaments • Dysfunction is determined through passive testing of movement • Hyperextension places iliofemoral, pubofemoral, and ischiofemoral ligaments on stretch

  28. Neurologic Testing • Complete lower quarter screening should be performed • Pathology involving femoral or sciatic nerve • Piriformis Syndrome • Impingement of sciatic nerve from spasm of piriformis muscle

  29. Pathologies and Related Special Tests • Acute • Contusions or strains • Chronic • Improper biomechanics from poor posture, leg length discrepancies, overuse syndromes • Injury to hip joint is rare • Potential medical emergency

  30. Muscle Strains • Table 8-4, page 294 • Occur secondary to dynamic overload during eccentric muscle contraction • Commonly injured • Iliopsoas, quadriceps, adductors, hamstrings • Signs and Symptoms

  31. Bursitis • Onset related to biomechanical factors, congenital influences, or environmental conditions, such as prolonged periods of sitting • Septic infection may be a cause

  32. Bursitis • Trochanteric Bursitis • Evaluative Findings - Table 8-5, page 295 • May result from a single blow or friction from IT band • History of training changes or increased Q angle may be predisposing factors • “Snapping Hip” syndrome

  33. Bursitis • Ischial Bursitis • Evaluative Findings - Table 8-6, page 296 • Movement of buttocks while patient is weight-bearing in seated position can irritate this bursa • Also irritated by prolonged sitting • Need to rule out hamstring strain or avulsion of its attachment • Doughnut padding may help

  34. Bursitis • Iliopsoas Bursitis • Associated with rheumatoid arthritis or osteoarthritis of hip • Signs and symptoms • Pain in anterior hip • Palpable mass in groin or inguinal ligament • “snapping hip” syndrome • Treatment includes strengthening hip rotators

  35. Degenerative Hip Changes • Due to age, repetitive trauma, acute trauma, or improper arrangements of hip • Degeneration of articular surfaces of femur and acetabulum • Arthritis, osteochondritis dissecans, acetabular labrum tears, avascular necrosis • Signs and symptoms • Pain, referred to low back, anterior thigh, knee • Loss of motion in all planes, decrease strength • Hip Scouring, Box 8-6, page 297 • Radiographic evaluation

  36. Piriformis Syndrome • Sciatic nerve passes under or through the piriformis muscle as nerve travels across posterior pelvis • Spasm or hypertrophy of muscle places pressure on sciatic nerve • Six times more common in women • Relatively undefined and confusing • Mimics lumbar nerve root impingement and intervertebral disk disease

  37. Piriformis Syndrome • Evaluative Findings • Table 8-7, page 298 • Straight leg raise, passive hip internal rotation resisted external rotation with patient seated, and resisted hip abduction may produce symptoms • Figure 8-24 • Treatment includes stretching and strengthening or surgical release

  38. On-Field Evaluation of Pelvis and Thigh Injuries • Trauma to coxofemoral joint is rare • Protection from padding • More commonly, strains, contusions, sprains of SI joint • Note position of athlete • If leg is moving, rule out dislocation • Fixed, immobile awkward position may indicate dislocation

  39. On-Field Evaluation of Pelvis and Thigh Injuries • After ruling out dislocation or subluxation and femoral fracture – AROM • Weight-bearing status • Removal from field

  40. Initial Evaluation and Management of On-Field Injuries • Iliac Crest Contusion (hip pointer) • Evaluative Findings, Table 8-8, page 299 • Disproportionate amount of pain, swelling, and loss of function • Recognition and immediate management of pain reduces time lost due to injury • Treatment • Ice, padding, reduced activity, crutches, if necessary

  41. Initial Evaluation and Management of On-Field Injuries • Quadriceps Contusion • As severity of impact increases, so does the proportion of muscle fiber death • Can result in decreased force during knee extension • Associated pain and spasm may limit flexion • Gross discoloration, painful to touch, intramuscular hematoma gives hardened feel, increase in girth of muscle • Overtime, atrophy may occur

  42. Risk of myositis ossificans is increased when effusion of knee joint occurs • Figure 8-25 • First 24 hours following injury are critical • Pain during AROM, or weakness during MMT = removal from activity • Ice applied in flexion • Maintaining ROM decrease possibility of myositis ossificans formation • Figure 8-26

  43. Hip Dislocation • Rare • Medical emergency • Majority involve posterior displacement of femoral head • Fractures to femoral neck and acetabulum • Most occur when hip is in flexion and adduction and axial force is placed on femur, displacing it posteriorly and causing head to be driven through posterior capsule

  44. Signs and Symptoms • Immediate pain within joint and buttocks • Sensation of “giving out” • Femur and lower leg positioned in internal rotation and adduction • Figure 8-27 • AROM is impossible • No attempt to reduce • Sensory and vascular check

  45. Immediate immobilization and transportation to emergency facility • Reduction under anesthesia

  46. Femoral Fracture • Torsional or shear force to shaft • Relatively rare • “weak link” principle • Immediate loss of function, pain, deformity, easily recognizable • Stress fracture • Shaft and neck, difficult to diagnosis • Similar s/s to hip flexor strain or tendinitis • Treatment

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