Chapter 17: The Thigh, Hip, Groin, and Pelvis

1. Chapter 17: The Thigh, Hip, Groin, and Pelvis

2. Anatomy of the Pelvis, Thigh, and Hip

9. 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?

10. 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

11. Special Tests • Thomas test • Test for hip contractures • Straight Leg Raise • Test for hip extensor tightness • Can also be used to assess low back, SI joint dysfunction, sciatic nerve pain

12. 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 • Squats, lunges, leg press • Core strengthening

13. Recognition and Management of 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

14. 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

15. Myositis Ossificans • 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 • 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) • If condition is recurrent it may indicate problem with blood clotting

17. Quadriceps Muscle Strain • Cause of Injury • Sudden stretch when athlete falls on bent knee or experiences sudden contraction • Associated with weakened or over constricted muscle • Signs of Injury • Peripheral tear causes fewer symptoms than deeper tear • Pain, point tenderness, spasm, loss of function and little discoloration • Complete tear may leave athlete w/ little disability and discomfort but with some deformity • Care • Rest, ice and compression to control internal bleeding • Determine extent of injury early • Neoprene sleeve may provide some added support

18. 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, • 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 • Grade 2 - partial tear, identified by sharp snap or tear, severe pain, and loss of function

19. 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

20. Femoral Fractures • Cause of Injury • More common in auto accidents; less common in sports • Involves significant force • Occurs in middle third 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

21. Recognition and Management of Specific Hip, Groin, and Pelvic Injuries • Groin Strain • Cause of Injury • One of the more difficult problems to diagnose • Often seen in early part of season due to poor strength and flexibility • Occurs from 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

22. Groin Strain • 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

23. 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

24. 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

25. Dislocated Hip • 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

26. Hip Labral Tears • Cause of Condition • Result of repetitive overuse (i.e. running or pivoting) • May occur due to acute trauma (i.e. dislocation) • Signs of Injury • Often present as asymptomatic • Causes clicking, locking, or catching • Pain in the groin; stiffness; limited motion • Care • Exercises to maintain ROM, strength & stability • Avoid aggravating activities • NSAID’s, corticosteroids • Surgical repair

27. Piriformis Syndrome • Cause of Condition • Compression of sciatic nerve; irritation due to tightness or spasm of muscle • May mimic sciatica • Signs of Injury • Pain, numbness and tingling in butt – may extend below knee and into foot • Pain may increase following periods of sitting, climbing stairs, walking or running

28. Care • Stretching and massage • NSAID’s may be prescribed • Cessation of aggravating activities will be prescribed • Corticosteroid injection may also be suggested • Surgery is sometimes an option as well

29. Hip Problems in Adolescent Athletes • Legg Calve’-Perthes Disease (Coxa Plana) • Cause of Condition • Avascular necrosis of the femoral head in child ages 4-10 • Articular cartilage becomes necrotic and flattens • Signs of Condition • Pain in groin that can be referred to the abdomen or knee • Limping is also typical • Varying onsets and may exhibit limited ROM

31. Legg-Calve’-Perthes Disease (continued) • Care • Bed rest to reduce chance of chronic condition • Brace to avoid direct weight bearing • Early treatment and head may reossify and revascularize • Complication • If not treated early, will result in ill-shaping and osteoarthritis in later life

32. Slipped Capital Femoral Epiphysis • Cause of Condition • May be growth hormone related • 25% of cases are seen in both hips • Epiphysis slips from femoral head in backwards direction due to weakness in growth plate • May occur during periods of elevated growth • Signs of Condition • Pain in groin that comes on over weeks or months • Hip and knee pain during passive and active motion; limitations of abduction, flexion, medial rotation and a limp

33. Slipped Capital Femoral Epiphysis • Management • W/ minor slippage, rest and non-weight bearing may prevent further slippage • Major displacement requires surgery • If undetected or surgery fails severe problems will result

34. 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 • Padding should be used upon return to minimize chance of added injury

35. Osteitis Pubis • Cause of Injury • Seen in distance runners • Repetitive stress on pubic symphysis and adjacent muscles • Signs of Injury • Chronic pain and inflammation of groin • Point tenderness on pubic tubercle • Pain w/ running, sit-ups and squats • Management • Rest, NSAID’s and gradual return to activity

36. 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

37. 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

38. Avulsion Fractures • Cause of Injury • Avulsions seen in sports w/ sudden accelerations and decelerations • Pulling of tendon away and off of bony insertion • Common sites include ASIS (sartorius), AIIS (rectus femoris attachment), ischial tuberosity (hamstring • Signs of Injury • Sudden localized pain w/ limited movement • Pain, swelling, point tenderness • Care • Rest, limited activity and graduated exercise