Pelvis, Hip, and Thigh Conditions

1. Pelvis, Hip, and Thigh Conditions Chapter 17

2. Skeletal Features of Pelvis, Hip, and Thigh

3. Pelvis • Function • Protects organs • Transmits loads between trunk and lower extremity • Provides site for muscle attachments • 4 fused bones • Sacrum • Coccyx • Innominate bones • Ilium, ischium, and pubis

4. Pelvis (cont.) • SI joint • Critical link between the two pelvic bones • Strong ligamentous support • Sacrococcygeal joint • Fused line symphysis united by a fibrocartilaginous disc • Pubic symphysis • Interpubic disc located between the two joint surfaces

5. Bony Structure of Thigh • Femur • Weakest at femoral neck • Angle of inclination • Angle of depression formed by a line drawn through the shaft of femur and a line passing through the long axis of femoral neck • Approximately 125 in the frontal plane • 125 coxa valga • 125 coxa vara

7. Bony Structure of Thigh (cont.) • Femur • Angle of torsion • Relationship between femoral head and femoral shaft in transverse plane • Approximately 12 • 12 anteversion • 12 retroversion

9. Hip Joint • Head of femur and acetabulum of pelvis • Ball and socket joint • Very stable

10. Hip Joint Capsule • Completely surrounds joint, attaching to the labrum of the acetabular socket • Passes over a fat pad internally to join to the distal aspect of femoral neck • Zona orbicularis

11. Ligaments of Hip Joint • Iliofemoral ligament • Limits hyperextension • Pubofemoral ligament • Limits abduction and hyperextension • Ischiofemoral ligament • Limits extension

12. Femoral Triangle • Borders • Inguinal ligament—superior • Sartorius—lateral • Adductor longus—medial • Contents • Femoral nerves • Femoral artery • Femoral vein

13. Bursae • Iliopsoas • Reduces friction between iliopsoas and articular capsule • Deep trochanteric bursa • Provides cushion between greater trochanter and gluteus maximus at its attachment to iliotibial tract • Gluteofemoral bursa • Separates gluteus maximus from origin of vastus lateralis • Ischial bursa • Weight-bearing structure during sitting • Cushions ischial tuberosity where it passes over gluteus maximus

14. Q-Angle • Angle between line of resultant force produced by quadriceps and line of patellar tendon • Males 13°; females 18°

15. Muscles

16. Muscles (cont.)

17. Muscles (cont.)

18. Nerves • Lumbar plexus • Femoral nerve • Obturator nerve • Sacral plexus • Sciatic nerve

19. Blood Vessels • External iliac • Femoral • Deep femoral • Femoral circumflex • F16.10

20. Kinematics (cont.) • Hip flexors • Iliopsoas, pectineus, rectus femoris, sartorius, and tensor fascia latae • Two-joint muscles • Rectus femoris—active during hip flexion and knee extension • Sartorius—active during hip flexion and knee extension • Hip extensors • Gluteus maximus and hamstrings (biceps femoris, semitendinosus, and semimembranosus) • Hamstrings—two-joint; hip extension and knee flexion

21. Kinematics (cont.) • Hip abductors • Gluteus medius, gluteus minimus • Active in stabilizing pelvis during single-leg support and during support phase of walking and running • Hip adductors • Adductor longus, adductor brevis, and adductor magnus

22. Kinematics (cont.) • Lateral rotators • Piriformis, gemellus superior, gemellus inferior, obturator internus, obturator externus, and quadratus femoris • Lateral rotation of femur of swinging leg accommodates lateral rotation of pelvis during stride • Medial rotators • Gluteus minimus • Tensor fascia latae, semitendinosus, semimembranosus, gluteus medius, and adductors

23. Kinetics • Body weight places compression on hip, as does tension in hip muscles • Forces are less during standing than with running and walking • Forces translated through the lower extremity; result ↑ compression on hip

24. Prevention • Protective equipment • Hip joint well protected but iliac and pelvis need protection • Thigh • Physical conditioning • Shoes • Cushion forces

25. Contusions • Hip pointer • Mechanism:direct blow to iliac crest • Common—anterior or lateral portion of crest • Often from improperly fitting (or absent) hip pads

26. Contusions (cont.) • S&S • Point tenderness; swelling; ecchymosis • Individual prefers slightly forward flexed position to relieve tension of abdominals and iliopsoas • Antalgic gait with shortened swing phase • ↑ pain with active trunk flexion and active hip flexion • Pain with coughing, laughing, breathing • Abdominal muscle spasm • Management: standard acute; rest; protect with hard-shell pad for return to activity

27. Contusions (cont.) • Quadriceps contusion • Mechanism: direct blow • Common – anterolateral thigh • S&S • Transitory loss of function • With continued play, progressively stiffer and unresponsive • ↑ pain with active knee extension and hip flexion • Limited AROM due to pain; knee flexion limited actively and passively

28. Contusions (cont.) • Management: • Standard acute; with knee in maximum flexion • Hard-shell pad for return to activity • Physician referral if myositis ossificans orcompartment syndrome is suspected

30. Contusions (cont.) • Myositis ossificans • Develops secondary to single significant blow or repetitive blows to same area • Evident on radiograph 3–4 weeks after injury

31. Contusions (cont.) • S&S • Warm, firm, swollen thigh; 2–4 cm larger • Palpable, painful mass may limit passive knee flexion to 20–30° • Active quadriceps contractions and straight leg raises—difficult • Management: standard acute; physician referral • Self-limiting injury • Maturation—6–12 months

32. Contusions (cont.) • Compartment syndrome • Neurovascular compression • Due to uncontrolled internal bleeding and swelling • S&S • Progressive, severe pain with passive motion and isometric contraction of quadriceps •  pressure →↓ femoral sensation and motor weakness; distal pulse and capillary refill may be normal • Management: ice (no compression); immediate physician referral

33. Bursitis • Mechanism • Excessive friction or shear forces due to overuse • Posttraumatic bursitis from direct blows that cause bleeding in the bursa • Greater trochanteric bursitis • Influence of Q-angle

34. Bursitis (cont.) • S&S • Burning or aching over or posterior to greater trochanter • Aggravated with: • Hip abduction against resistance • Hip flexion and extension on weight bearing • Referred pain—lateral aspect of the thigh

35. Bursitis (cont.) • Iliopsoas bursitis • Pain medial and anterior to joint; cannot be easily palpated •  pain with passive hip rotation; resisted hip flexion, abduction, and external rotation • Ischial bursitis • Pain aggravated by prolonged sitting and uphill running, • Point tenderness directly over ischial tuberosity •  pain with passive and resisted hip extension

36. Bursitis (cont.) • Bursitis management • Standard acute; deep friction massage; NSAIDs; stretching program for involved muscle • On-going prevention: biomechanical analysis; technique analysis

37. Bursitis (cont.) • Snapping hip syndrome • Causes: intra- and extra-articular (refer to Box 15.2) • Types • External—IT band or gluteus maximus snapping over greater trochanter during hip flexion → trochanteric bursitis • Internal—iliopsoas snaps over structures deep to musculotendinous unit (e.g., iliopsoas bursa) • Intra-articular—lesions of the joint (e.g., labral tear)

38. Bursitis (cont.) • S&S • Snapping sensation heard or felt during hip motion, especially with lateral rotation and flexion while balancing on one leg • Iliopsoas bursa affected—snapping in medial groin • Management: NSAIDs; rehabilitation program to address specific deficits

39. Hip Sprains and Dislocations • Mechanism • Violent twisting actions • With hip and knee flexed to 90°, force through shaft of femur

40. Hip Sprains and Dislocations (cont.) • S&S • Mild/moderate: pain with internal rotation • Severe: intense pain; inability to move hip • Position of flexion and internal rotation • Management • Mild/moderate—standard acute • Severe—activate EMS; immobilize in position found; assess distal vascular integrity; monitor and treat for shock; NPO

41. Hip Dislocation

42. Strains • Mechanism • Explosive movements • Tensile stress from overstretching • Muscles • Quadriceps • Typically rectus femoris

43. Strains (cont.) • Hamstrings • Initial swing—flex knee; late swing—eccentrically contract to decelerate knee extension and re-extend hip in prep for stance phase • Overemphasis on stretching without strengthening • Strength imbalance • Adductors • Common with quick change of direction and explosive propulsion and acceleration • Strength imbalance

44. Strains (cont.) • S&S • Point tender with palpable spasm • Possible palpable defect/divot • Ecchymosis may or may not be present • Pain with AROM; pain with PROM (muscles placed on stretch)

45. Strains (cont.) • Piriformis strain • In some individuals, sciatic nerve passes through or above piriformis, subjecting nerve to compression from trauma, hemorrhage, or spasm

46. Strains (cont.) • S&S • History of prolonged sitting, overuse, recent ↑ in activity, or buttock trauma • Dull ache in midbuttock—worse at night • Numbness or weakness may extend down posterior leg • ↑ pain or weakness during: • Passive hip flexion, adduction, and internal rotation • Active hip external rotation • Resisted hip external rotation

47. Strains (cont.) • Predisposing factors • Beginning of season – too much too soon • Fatigue • History of strains; reinjury common • Restricted flexibility of involved muscle group • Management: standard acute; restrict weight bearing if unable to assume normal gait

48. Vascular and Neural Disorders • Legg-Calvé-Perthes disease • Avascular necrosis of proximal femoral epiphysis • Seen esp in males ages 3–8 • Osteochondrosis - femoral head • S&S • Gradual onset of limp and mild hip or knee pain of several months in duration • Pain -activity related •  ROM in hip abduction, extension, and external rotation due to spasm in hip flexors and adductors

49. Vascular and Neural Disorders (cont.) • Venous disorders • Direct blow may damage a vein causing • Thrombophlebitis • Superficial thrombophlebitis (ST) • Deep venous thrombosis (DVT) • Phlebothrombosis

50. Vascular and Neural Disorders (cont.) • S&S • ST—acute, red, hot, palpable, tender cord in course of a superficial vein • Extension of ST to deep veins—via proximal long and short saphenous veins to common femoral and popliteal veins, respectively • Management: anticoagulant therapy; external support (e.g., compression stockings); therapeutic exercise