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

Anatomy of the Thigh

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

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

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

• 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

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?

•Palpation: Bony and Soft Tissue • 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: Soft Tissue (continued) • Pectineus • Iliotibial Band (IT band) • Gluteus medius • Tensor fasciae latae

• 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

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

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)

Quad Contusion

• 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

– 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

• 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)

• 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

• 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)

– 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

• 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

• 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

Anatomy of the Hip, Groin and Pelvic Region

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

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?

• 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

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

Special Tests

• Functional Evaluation – ROM, strength tests – Hip adduction, abduction, flexion, extension, internal and external rotation • Tests for Hip Flexor Tightness –

Kendall test

– for rectus femoris (hip flexor) tightness • Supine, injured leg flexed to chest, uninjured leg flexed off table • (+) tightness = uninjured leg moves off table with inj hip flexion

Kendall’s Test

•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

•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

•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

•

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

•

Ober’s Test

– Used to determine presence of contracted TFL or IT-band – Knee flexed to 90 and leg abducted as far as possible.

– (+) = When released, thigh will remain in abducted position, not falling into adduction

•

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)

•

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 – 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

– 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

Leg Length Discrepancy Measures

Recognition and Management of Specific Hip, Groin, and Pelvic Injuries

• Groin Strain – Etiology • One of the more difficult problems to diagnose • generally adductor muscle group • 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

• Groin Strain (continued) – Management • RICE, NSAID’s and analgesics for 48-72 hours • Rest is critical; daily whirlpool and cryotherapy, moving into ultrasound • Delay exercise until pain free • Restore normal ROM and strength -- provide support w/ wrap

• Trochanteric Bursitis – Etiology • Inflammation at the site where the gluteus medius ties into the IT-band – Signs and Symptoms • Complaint of lateral hip pain that may radiate down the leg • Palpation reveals tenderness over lateral aspect of greater trochanter • IT-band and TFL tests should be performed – Management • RICE, NSAID’s and analgesics • ROM and PRE directed toward hip abductors and external rotators • Phonophoresis if pain doesn’t respond in 3-4 days • Look at biomechanics and Q-angle • Avoid inclined surfaces;

• Sprains of the Hip Joint – Etiology • Due to substantial support, any unusual movement exceeding normal ROM may result in damage • Force from opponent/object or trunk forced over planted foot in opposite direction – Signs and Symptoms • Signs of acute injury and inability to circumduct hip • Similar S & S to stress fracture • Pain in hip region, w/ hip rotation increasing pain – Management • 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

• Dislocated Hip – Etiology • Rarely occurs in sport • Result of traumatic force directed along the long axis of the femur (posterior dislocation w/ hip flexed and adducted and knee flexed) – Signs and Symptoms • Flexed, adducted and internally rotated hip • Palpation reveals displaced femoral head, posteriorly • Serious pathology – Soft tissue, neurological damage and possible fx – Management • 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

• Avascular Necrosis – Etiology • Result of temporary or permanent loss of blood supply to proximal femur • Can be caused by traumatic conditions (hip dislocation), or non traumatic circumstances (steroids, blood coagulation disorders, excessive alcohol use compromising blood vessels) – Signs and Symptoms • Early stages - possibly no S&S • Joint pain w/ weight bearing progressing to at times of rest • Pain gradually increases (mild to severe) particularly as bone collapse occurs • May limit ROM • Osteoarthritis may develop • Progression of S&S can develop over the course of months to a year

• Avascular Necrosis (continued) – Management • Must be referred for X-ray, MRI or CT scan • Must work to improve use of joint, stop further damage and ensure survival of bone and joint • Most cases will ultimately require surgery to repair joint permanently • Conservative treatment involves ROM exercises to maintain ROM; electric stim for bone growth; non weight bearing if caught early • Medication to treat pain, reduce fatty substances reacting w/ corticosteroids or limit blood clotting in the presence of clotting disorders may limit necrosis

Hip Problems in the Young Athlete

• Legg Calve’-Perthes Disease (Coxa Plana) – Etiology • Avascular necrosis of the femoral head in child ages 4-10 • Trauma accounts for 25% of cases • Articular cartilage becomes necrotic and flattens – Signs and Symptoms • Pain in groin that can be referred to the abdomen or knee • Limping is also typical • Varying onsets and may exhibit limited ROM

•Legg-Calve’-Perthes Disease (continued) • Management – Bed rest to alleviate synovitis – 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

• Slipped Capital Femoral Epiphysis – Etiology • Found mostly in boys ages 10-17 who are characteristically tall and thin or obese • May be growth hormone related • 25% of cases are seen in both hips, trauma accounts for 25% • Head slippage on X-ray appears posterior and inferior – Signs and Symptoms • 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 – 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

• The Snapping Hip Phenomenon – Etiology • Common in young female dancers, gymnasts, hurdlers • Habitual movement predispose muscles around hip to become imbalanced (lateral rotation and flexion) • Related to structurally narrow pelvis, increased hip abduction and limited lateral rotation • Hip stability is compromised – Signs and Symptoms • Pain w/ balancing on one leg, possible inflammation – Management • Focus on cryotherapy and ultrasound to stretch musculature and strengthen weak musculature in hip region

Pelvic Conditions

• Athletes can suffer serious acute and chronic injuries to the pelvic region • Pelvis rotates along longitudinal axis when running, proportionate to the amount of arm swing • Also tilts as legs engage support and nonsupport • Combination of motion causes shearing and changes in lordosis throughout activity

• Contusion (hip pointer) – Etiology • Contusion of iliac crest or abdominal musculature • Result of direct blow (same MOI for iliac crest fx and epiphyseal separation – Signs and Symptoms • Pain, spasm, and transitory paralysis of soft structures • Decreased rotation of trunk or thigh/hip flexion due to pain – Management • RICE for at least 48 hours, NSAID’s, • Bed rest 1-2 days • Referral must be made, X-ray • Ice massage, ultrasound, occasionally steroid injection Recovery lasts 1-3 weeks

• Osteitis Pubis – Etiology • Seen in distance runners • Repetitive stress on pubic symphysis and adjacent muscles – Signs and Symptoms • Chronic pain and inflammation of groin • Point tenderness on pubic tubercle • Pain w/ running, sit-ups and squats • Acute case may be the result of bicycle seat – Management • Rest, NSAID’s and gradual return to activity

• Athletic Pubalgia – Etiology • Chronic pubic region pain caused by repetitive stress to pubic symphysis from kicking, twisting, or cutting – Forced adduction, from hyperextended position, creates shearing forces that are transmitted through pubic symphysis to insertion of rectus abdominus, hip adductors and conjoined tendon – Result in microtears of tranversalis abdominis fascia, aponeurosis of obliques, or conjoined tightness – Create weakening of anterior wall and inguinal canal – Signs and Symptoms • No presence of hernia • Chronic pain during exertion, sharp and burning that later radiates into adductors and testicles

– Signs and Symptoms (continued) • Point tenderness on pubic tubercle • Pain increased w/ resisted hip flexion, internal rotation, abdominal contraction, resisted hip adduction (adductors not painful = adductor strain) – Management • Conservative treatment (even though rarely effective) • Massage, stretching after 1 week of surrounding musculature • 2 weeks, strengthening of abs and hip flexors and adductors • 3-4 weeks begin running progression • Aggressive treatment involves cortisone injection or tightening of pelvic wall surgically

• Stress Fractures – Etiology • Seen in distance runners - repetitive cyclical forces from ground reaction force • More common in women than men • Common site include inferior pubic ramus, femoral neck and subtrochanteric area of femur – Signs and Symptoms • Groin pain, w/ aching sensation in thigh that increases w/ activity and decreases w/ rest • Standing on one leg may be impossible • Deep palpation results in point tenderness • Intense interval or competitive racing may cause

• Stress Fractures (continued) – Management • Rest for 2-5 months • Crutch walking for ischium and pubis fractures • X-ray normal 6-10 weeks and bone scan will be required • Swimming can be used -- breast stroke avoided

• Avulsion Fractures and Apophysitis – Etiology • Traction epiphysis (bone outgrowth) • Common sites include ischial tuberosity, AIIS, and ASIS • Avulsions seen in sports w/ sudden accelerations and decelerations – Signs and Symptoms • Sudden localized pain w/ limited movement • Pain, swelling, point tenderness • Muscle testing increases pain

• Avulsion Fractures and Apophysitis – Management • X-ray • If uncomplicated, RICE, NSAID’s, crutch toe-touch walking • After control pain and inflammation, 2-3 weeks of gradual stretching • When 80 degrees of ROM have been regained, athlete can return to competition

Thigh and Hip Rehabilitation Techniques

• General Body Conditioning – Must maintain cardiovascular fitness, muscle endurance and strength of total body – Avoid weight bearing activities if painful • Flexibility – Regaining pain free ROM is a primary concern – Progress from passive to PNF stretching

Mobilization

• Will be necessary if injury and subsequent limitation is caused by tightness of ligaments and capsule surrounding the joint • Use to re-establish appropriate arthrokinematics • Series of glides (anterior and posterior) and rotations can be used to restore motion

Strength

• Progression should move from isometric exercises until muscle can be fully contracted to isotonic strengthening PRE’s into isokinetics • PNF strengthening should then be incorporated to enhance functional activity • Active exercise should occur in pain free ranges -- in an effort not to aggravate condition • Exercises for the core must also be included – Develop optimal levels of functional strength and dynamic stabilization

Neuromuscular Control

• Establish through combination of appropriate postural alignment and stability strength • As neuromuscular control is enhanced, the ability of the kinetic chain to maintain appropriate forces and dynamic stabilization increases • Focus on balance and closed kinetic chain activities

Balance Shoe for Neuromuscular Control

Functional Progression and Return to Activity

• Begin in pool, non-weight bearing • Depending on activity, progression of walking, to jogging, to running and more difficult agility tasks can occur • Before returning to play, athlete should demonstrate pain free function, full ROM, strength, balance and agility