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

1. Chapter 21: The Thigh, Hip, Groin, and Pelvis

2. Anatomy of the Thigh

5. Nerve and Blood Supply • Tibial and common peroneal are given rise from the sacral plexus which form the largest nerve in the body the sciatic nerve complex • The main arteries of the thigh are the deep circumflex femoral, deep femoral, and femoral artery • The two main veins are the superficial great saphenous and the femoral vein

6. Fascia • The fascia lata femoris is part of the deep fascia that invests the thigh musculature • Thick anteriorly, laterally and posteriorly but thin on the medial side • Iliotibial track (IT-band) is located laterally serving as the attachment for the tensor fascia lata and greater aspect of the gluteus maximum

7. Functional Anatomy of the Thigh • Quadriceps insert in a common tendon to the proximal patella • Rectus femoris is the only quad muscle that crosses the hip • Extends knee and flexes the hip • Important to distinguish between hip flexors relative to injury for both treatment and rehab programs

8. Hamstrings cross the knee joint posteriorly and all except the short of head of the biceps crosses the hip • Bi-articulate muscles produce forces dependent upon position of both knee and hip joints • Position of the knee and hip during movement and MOI play important roles and provide information to utilize w/ rehab and prevention of hamstring injuries

9. Assessment of the Thigh • History • Onset (sudden or slow?) • Previous history? • Mechanism of injury? • Pain description, intensity, quality, duration, type and location? • Observation • Symmetry? • Size, deformity, swelling, discoloration? • Skin color and texture? • Is athlete in obvious pain? • Is the athlete willing to move the thigh?

10. Medial and lateral femoral condyles Greater trochanter Lesser trochanter Anterior superior iliac spine (ASIS) Sartorius Rectus femoris Vastus lateralis Vastus medialis Vastus intermedius Semimembranosis Semitendinosis Biceps femoris Adductor brevis, longus and magnus Gracilis Sartorius Palpation: Bony and Soft Tissue

11. Pectineus Iliotibial Band (IT-band) Gluteus medius Tensor fasciae latae Palpation: Soft Tissue (continued)

12. Special Tests • If a fracture is suspected the following tests are not performed • Beginning in extension, the knee is passively flexed • A normal muscle will elicit full range of motion pain free (one w/ swelling or spasm will have restricted motion) • Active movement from flexion to extension • Strong and painful may indicate muscle strain • Weak and pain free may indicate 3rd degree or partial rupture • Muscle weakness against an isometric resistance may indicate nerve injury

13. Prevention of Thigh Injuries • Thigh must have maximum strength, endurance, and extensibility to withstand strain • In collision sports thigh guards are mandatory to prevent injuries

14. Recognition and Management of Thigh Injuries • Quadriceps Contusions • Etiology • Constantly exposed to traumatic blunt blow • Contusions usually develop as a result of severe impact • Extent of force and degree of thigh relaxation determine depth and functional disruption that occurs • Signs and Symptoms • Pain, transitory loss of function, immediate effusion with palpable swollen area • Graded 1-4 = superficial to deep with increasing loss of function (decreased ROM, strength)

15. Quad Contusion

16. Management • RICE, NSAID’s and analgesics • Crutches for more severe cases • Aspiration of hematoma is possible • Following exercise or re-injury, continued use of ice • Follow-up care consists of ROM, and PRE w/in pain free range • Heat, massage and ultrasound to prevent myositis ossificans

17. General rehab should be conservative • Ice w/ gentle stretching w/ a gradual transition to heat following acute stages • Elastic wrap should be used for support • Exercises should be graduated from stretching to swimming and then jogging and running • Restrict exercise if pain occurs • May require surgery of herniated muscle or aspiration • Once an athlete has sustained a severe contusion, great care must be taken to avoid another

18. Myositis Ossificans Traumatica • Etiology • Formation of ectopic bone following repeated blunt trauma (disruption of muscle fibers, capillaries, fibrous connective tissue, and periosteum) • Gradual deposit of calcium and bone formation • May be the result of improper thigh contusion treatment (too aggressive) • Signs and Symptoms • X-ray shows calcium deposit 2-6 weeks following injury • Pain, weakness, swelling, decreased ROM • Tissue tension and point tenderness w/ • Management • 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)

19. Quadriceps Muscle Strain • Etiology • Sudden stretch when athlete falls on bent knee or experiences sudden contraction • Associated with weakened or over constricted muscle • Signs and Symptoms • Peripheral tear causes fewer symptoms than deeper tear • Pain, point tenderness, spasm, loss of function and little discoloration • Complete tear may live athlete w/ little disability and discomfort but with some deformity • Management • RICE, NSAID’s and analgesics • Manage swelling, compression, crutches • Move into isometrics and stretching as healing progresses • Neoprene sleeve may provide some added support

20. Hamstring Muscle Strains (second most common thigh injury) • Etiology • 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 and Symptoms • Muscle belly or point of attachment pain • Capillary hemorrhage, pain, loss of function and possible discoloration • Grade 1 - soreness during movement and point tenderness (<20% of fibers torn( • Grade 2 - partial tear, identified by sharp snap or tear, severe pain, and loss of function (<70% of fiber torn)

21. Signs and Symptoms (continued) • Grade 3 - Rupturing of tendinous or muscular tissue, involving major hemorrhage and disability, edema, loss of function, ecchymosis, palpable mass or gap • >70% muscle fiber tearing • Management • RICE, NSAID’s and analgesics • Grade I - don’t resume full activity until complete function restored • Grade 2 and 3 should be treated conservatively w/ gradual return to stretching and strengthening in later stages of healing (modalities and isometrics) • When soreness is eliminated, isotonic leg curls can be introduced (focus on eccentrics) • Recovery may require months to a full year • Greater scaring = greater recurrence of injury

22. Acute Femoral Fractures • Etiology • Generally involving shaft and requiring great force • Occurs in middle third due to structure and point of contact • Signs and Symptoms • Pain, swelling, deformity • Management • Treat for shock, verify neurovascular status, splint before moving, reduce following X-ray • Analgesics and ice • Extensive soft tissue damage will also occur as bones will displace due to muscle force

23. Femoral Stress Fractures • Etiology • Overuse (10-25% of all stress fractures) • Excessive downhill running or jumping activities • Compression or distraction fracture generally occur • Signs and Symptoms • Persistent pain in thigh • X-ray or bone scan will reveal fracture • Commonly seen in femoral neck • Management • Analgesics, NSAID’s RICE • ROM and PRE exercises are carried out w/ pain free ROM • Rest, limited weight bearing • Complete stress fracture may require pins

24. Anatomy of the Hip, Groin and Pelvic Region

31. Functional Anatomy • Pelvis moves in three planes through muscle function • Anterior tilting changes degree of lumbar lordosis, lateral tilting changes degree of hip abduction • Hip is a true ball and socket joint w/ intrinsic stability • Hip also moves in all three planes, particularly during gait (body’s relative center of gravity) • Tremendous forces occur at the hip during varying degrees of locomotion • Muscles are most commonly injured in this region • Numerous injuries attach in this region and therefore injury to one can be very disabling and difficult to distinguish

32. Assessment of the Hip and Pelvis • Body’s center of gravity is located just anterior to the sacrum • Injuries to the hip or pelvis cause major disability in the lower limbs, trunk or both • Low back may also become involved due to proximity • History • Onset (sudden or slow?) • Previous history? • Mechanism of injury? • Pain description, intensity, quality, duration, type and location?

33. Observation • Symmetry- hips, pelvis tilt (anterior/posterior) • Lordosis or flat back • Lower limb alignment • Knees, patella, feet • Pelvic landmarks (ASIS, PSIS, iliac crest) • Standing on one leg • Pubic symphysis pain or drop on one side • Ambulation • Walking, sitting - pain will result in movement distortion

34. Iliac crest Anterior superior iliac spine (ASIS) Anterior inferior iliac spin (AIIS) Posterior superior iliac spine (PSIS) Pubic symphysis Ischial tuberosity Greater trochanter Femoral neck Palpation: Bony

35. Rectus femoris Sartorius Iliopsoas Inguinal ligament Gracilis Adductor magnus, longus & brevis Pectineus Gluteus maximus, medius & minimus Piriformis Hamstrings Tensor fasciae latae Iliotibial Band Palpation: Soft Tissue - Major regions of concern are the groin, femoral triangle, sciatic nerve, lymph nodes

36. Special Tests • Functional Evaluation • ROM, strength tests • Hip adduction, abduction, flexion, extension, internal and external rotation • Tests for Hip Flexor Tightness • Kendall test • Test for rectus femoris tightness • Thomas test • Test for hip contractures

37. Kendall’s Test

38. Thomas Test

39. Femoral Anteversion (A) and Retroversion (B) • Relationship between neck and shaft of femur • Normal angle is 15 degrees anterior to the long axis of the femur and condyles • Internal rotation in excess of 35 degrees is indicative of anteversion, 45 degrees of external rotation is an indicator of retroversion

40. Test for Hip and Sacroiliac Joint • Patrick Test (FABER) • Detects pathological conditions of the hip and SI joint • Pain may be felt in the hip or SI joint

41. Gaenslen’s Test • Test works to push SI joint into extension • Test is positive if hyperextension on affected side increases pain

42. Testing the Tensor Fasciae Latae and Iliotibial Band • Renne’s test • Athlete stands w/ knee bent at 30-40 degrees • Positive response of TFL tightness occurs when pain is felt at lateral femoral condyle

43. Nobel’s Test • Lying supine the athlete’s knee is flexed to 90 degrees • Pressure is applied to lateral femoral condyle while knee is extended • Pain at 30 degrees at lateral femoral condyle indicates a positive test

44. Ober’s Test • Used to determine presence of contracted TFL or IT-band • Thigh will remain in abducted position, not falling into adduction

45. Trendelenburg’s Test- Iliac crest on unaffected side should be higher when standing on one leg- Test is positive when affected side is higher indicating weak abductors (glut medius)

46. Piriformis Test • Hip is internally rotated • Tightness or pain is indicative of piriformis tightness

47. Ely’s Test • Used to assess tightness of rectus femoris • Athlete is prone, w/ pelvis stabilized and knee on the affected side is flexed • If hip on that side extends as the knee is flexed, rectus femoris is tight • Measuring Leg Length Discrepancy • With inactive individual, difference of more that 1” may produce symptoms • Active individuals may experience problems w/ as little 3mm (1/8”) difference • Can cause cumulative stresses to lower limbs, hips, pelvis or low back

48. True or anatomical • Shortening may be equal throughout limb or localized w/in femur or lower leg • Measurement taken from medial malleolus to ASIS • Apparent or functional • Result of lateral pelvic tilt or from a flexion or adduction deformity • Measurement is taken from umbilicus to medial malleolus

49. Leg Length Discrepancy Measures

50. Recognition and Management of Specific Hip, Groin, and Pelvic Injuries • Groin Strain • Etiology • One of the more difficult problems to diagnose • Injury to one of the muscles in the regions (generally adductor longus) • Occurs from running , jumping, twisting w/ hip external rotation or severe stretch • Signs and Symptoms • Sudden twinge or tearing during active movement • Produce pain, weakness, and internal hemorrhaging