The Thigh, Hip, Groin, & Pelvis

1. The Thigh, Hip, Groin, & Pelvis Anatomy, prevention, common injuries, assessment, treatment, & rehabilitation

2. Anatomy - Femur Femoral Head Femoral Neck Lesser Trochanter Greater Trochanter Greater Trochanter Lateral Condyle Lateral Condyle Medial Condyle

3. Anatomy – Pelvis

4. Anatomy – Anterior Muscles

5. Anatomy – Posterior Muscles

6. Functional Anatomy = Thigh Muscles • Quads = all assist in knee extension • Rectus Femoris – hip flexion as well • Hamstrings = all assist in knee flexion and hip extension • Adductor magnus, longus, and brevis, & Pectineus= all adduct the thigh • Gracilis = adduct the thigh and flex the hip • Sartorius = hip and knee flexion

7. Functional Anatomy = Hip Muscles Psoas Major & Iliacus = hip and trunk flexion Tensor Fasciae Latae = hip flexion, abduction, and medial rotation Gluteus Maximus = hip extension and lateral rotation Gluteus Medius & Minimus = hip abduction and medial rotation Piriformis = hip extension, adbuction, and lateral rotation Superior & Inferior Gemellus, ObturatorInternus & Externus, and QuadratusFemoris = hip lateral rotation

8. Prevention Like all other muscles in sports, the thigh must have max strength, endurance, and extensibility to withstand strain. In collision sports such as football, thigh guards are mandatory.

9. Common Thigh Injuries • Quad Contusions • How it Happens: • Severe impact to the relaxed thigh • Extent of force and degree of relaxation determine depth of injury and amount of damage • Signs & Symptoms: • Grade 1: superficial bruise; little pain, no swelling, mild point tenderness, no ROM restriction • Grade 2: mild pain, swelling, and point tenderness; inability to flex knee more than 90° • Grade 3: pain swelling, knee flexion reduced 90°-45°, obvious limp • Grade 4: major disability; severe pain and swelling, knee flexion limited to 45° or less

10. Common Thigh Injuries • Myositis Ossificans • How it Happens: • Severe blow or repeated blows to the thigh • Internal hemorrhage produce calcified formations • Too vigorous treatment of a contusion – massage directly over, ultrasound, superficial heat • Signs & Symptoms: • Pain • Muscle weakness • Soreness • Swelling • Decreased ROM

11. Common Thigh Injuries • Quad Strain • How it Happens: • Sudden stretch of a muscle that is weakened or one that is overly constricted • Signs & Symptoms: • Pain • Point tenderness • Spasm • Loss of function

12. Common Thigh Injuries • Hamstring Strain • How it Happens: • Hamstrings function as decelerators of leg swing • Sudden change in direction or starting too slow • Signs & Symptoms: • Grade 1: muscle soreness, point tenderness, fewer than 20% of fibers torn • Grade 2: partial tear, fewer than 70% of fibers torn, sudden snap or tear, severe pain, loss of function • Grade 3: full tear, more than 70% of fibers torn, severe bruising, tenderness, loss of function, and palpable gap

13. Common Thigh Injuries • Femoral Stress Fractures • How it Happens: • Occur most often in endurance athletes • Overuse injury • More common in women • Signs & Symptoms: • May occur several weeks after increasing intensity of a training program • Pain in groin or anterior thigh that increases during activity • Pain may refer to the knee • Athlete walks with an abduction lurch-type movement

14. Thigh Assessment - History Sudden or slow? What happened? Is pain constant? When does pain increase? Can you specifically point to where it hurts? What type of pain? Dull vs. sharp vs. bone pain vs. deep, etc.

15. Thigh Assessment - Observation • Are the thighs: • Symmetrical? • Same size? Swelling? • Skin color and texture normal? • Athlete willing to move the thigh?

16. Thigh Assessment – Palpation • Bony • Medial and lateral femoral condyles • Greater trochanter • ASIS

17. Thigh Assessment – Palpation • Soft-Tissue • Anterior - sartorius, rectus femoris, vastuslateralis, vastusmedialis • Posterior – semimembranosus, semitendinosus, biceps femoris • Medial – adductor longus, brevis, magnus, gracilis • Lateral – IT band/tensor fasciae latae, gluteus medius

18. Thigh Assessment – Special Tests Strength & Break Tests

19. Common Hip Injuries • Hip Flexor (Groin) Strain • How it Happens: • Muscles include iliopsoas, rectus femoris, gracilis, pectineus, adductors (longus, brevis, magnus) • Running, jumping, or twisting with ER • Signs & Symptoms: • Pain • Weakness • Internal bleeding (bruising)

20. Common Hip Injuries • Legg-Calvé-Perthes Disease • How it Happens: • Avascular necrosis of the femoral head (temporary or permanent loss of blood supply) • Children ages 4-10 and in boys more often than girls • Trauma accounts for 25% of cases seen • Signs & Symptoms • Pain in the groin, sometimes referred to abdomen or knee • Limping typical • Limited hip movement

21. Common Hip Injuries • Hip Pointer • How it Happens: • Iliac crest contusion • Direct blow causing severe pinching of the soft tissue • One of the most handicapping injuries in sports, difficult to manage • Signs & Symptoms: • Immediate pain, spasms, and transitory paralysis of soft tissue • Unable to rotate trunk or flex hip w/o pain

22. Common Hip Injuries • Osteitis Pubis/Athletic Pubalgia • How it Happens: • Cross country, soccer, football, and wrestling • Repetitive stress on and inflammation of the pubic symphysis caused by pull of muscles in the area • Signs & Symptoms: • Pain in groin and pubic symphysis region • Point tenderness on pubic tubercle • Pain while running, doing sit-ups, doing squats

23. Common Hip Injuries • Stress Fractures • How it Happens: • Distance runners • More common in women than men • Femoral neck • Signs & Symptoms: • Groin pain • Aching sensation in the thigh that w/activity and w/rest • Standing on affected leg may be impossible

24. Common Hip Injuries • Avulsion Fractures • How it Happens: • Three most common sites: ischial tuberosity (hamstring attachment), ASIS (rectus femoris attachment), and ASIS (sartorius attachment) • Sports that have sudden acceleration or deceleration (football, soccer, basketball) • Signs & Symptoms: • Sudden localized pain with limited movement • Swelling and point tenderness • Muscle testing increases pain

25. Hip Assessment - History What are the athlete’s symptoms (weakness, disability, pain)? When did the athlete first notice the problem? Describe types of pain (groin pain, referred pain). When does pain occur (during activity, while turning in bed)? Note the age and gender.

26. Hip Assessment - Observation • Postural Asymmetry • Pelvic tilt (anterior or posterior) • Knee alignment (bow-legged, knock-knees, hyperextension) • Standing on One Leg • Ambulation • Observe during walking and sitting

27. Hip Assessment – Palpation • Bony • Iliac crest • ASIS • PSIS • Greater Trochanter • Pubic Symphysis • Ischial Tuberosity

28. Hip Assessment – Palpation • Soft-Tissue • Anterior – rectus femoris, sartorius, iliopsoas • Medial – gracilis, adductors • Posterior – gluteus maximus, hamstrings • Lateral – gluteus medius/minimus, IT band/tensor fasciae latae

29. Hip Assessment – Special Tests Hip flexor tightness – Thomas test SI Joint pain – Patrick (FABER) test, Gaenslen’s test IT Band – Ober’s test Piriformis test

30. Treatment/Rehab • Flexibility • Hamstrings • Gluteals • Quads • Hip Flexor • Groin • IT-Band • Piriformis

31. Treatment/Rehab • Strength • Knee Flexion, Extension with ankle weights • Hip flexion, extension with theraband • Hip adduction, abduction with ankle weights • Core exercises • Side-lying lift-and-hold • Planks • Quadroped • Stability ball push up • Stability ball hamstring curl

32. Treatment/Rehab • Functional Progressions • Walking • Jogging • Slow running • Zig-zag running (cutting) • Figure-8 running (w/ backpedaling) • Sprinting

33. Treatment/Rehab • Return-to-Play • Athlete must demonstrate full pain-free function of the thigh and hip region • Athlete must have full ROM, strength, balance, and agility