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

1. Chapter 21: The Thigh, Hip, Groin, and Pelvis Jennifer Doherty-Restrepo, MS, LAT, ATC Academic Program Director, Entry-Level ATEP Florida International University Acute Care and Injury Prevention

2. Anatomy of the Thigh Review

5. Nerve and Blood Supply • Tibial and common peroneal nerves • Arise from the sacral plexus to form the largest nerve in the body, the sciatic nerve • The main arteries of the thigh include: • Deep circumflex, deep femoral, and femoral • The two main veins of the thigh include: • Great saphenous and femoral

6. Muscles • Fascia lata femoris • Deep fascia that surrounds thigh musculature • Thick anteriorly, laterally, and posteriorly • Thin on the medial side • IT-band • Attachment site for the tensor fascia lata and gluteus maximum

7. Quadriceps • Insertion at proximal patella via common tendon • Pre-patellar tendon • Rectus femoris = bi-articulate muscle • Only quad muscle that also crosses the hip • Extends knee and flexes the hip • Important: distinguish between knee extensors and hip flexors • Injury evaluation • Treatment and rehabilitation programs

8. Hamstrings • Cross the knee joint posteriorly • All hamstrings, except the short of head of the biceps femoris, are bi-articulate • Crosses the hip joint as well • Forces dependent upon position of both knee and hip • Important: distinguish between knee flexors and hip extensors • Injury evaluation • Treatment and rehabilitation programs

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 the athlete in obvious pain? • Is the athlete willing to move the thigh?

10. Palpation: Bony Tissue • Medial and lateral femoral condyles • Greater trochanter • Lesser trochanter • Anterior superior iliac spine (ASIS)

11. Sartorius Rectus femoris Vastus lateralis Vastus medialis Vastus intermedius Semimembranosus Semitendinosus Biceps femoris Adductor brevis, longus, and magnus Gracilis Sartorius Pectineus Iliotibial Band (IT-band) Gluteus medius Tensor fasciae latae Palpation: Soft Tissue

12. Special Tests • Not performed if a fracture is suspected!!! • Passive knee flexion • Normal = full, pain-free ROM • Injury = swelling or spasm restricting ROM • Active knee extension • Muscle strain = strong and painful ROM • 3rd degree strain or partial rupture = weak and pain free ROM • Resistive knee extension • Nerve injury = muscle weakness against an isometric resistance

13. Prevention of Thigh Injuries • Maximum strength • Endurance • Flexibility • In collision sports, thigh guards are mandatory to prevent injuries

14. Thigh Injuries: Quadriceps Contusions • Etiology • MOI = severe impact, direct blow • Extent (depth) of injury depends upon… • Force • Degree of thigh relaxation • Signs and Symptoms • Pain, transitory loss of function, immediate effusion (palpable) • Graded 1 - 4 = superficial to deep • Increased loss of function 1 - 4 • Decreased ROM 1 - 4 • Decreased strength 1 - 4

15. Thigh Injuries: Quadriceps Contusions • Management • RICE • NSAID’s and analgesics • Crutches, if indicated • Aspiration of hematoma • Ice post exercise or re-injury • Follow-up care • ROM exercises • PRE in pain-free ROM • Modalities • Heat • Massage • Ultrasound to prevent myositis ossificans

16. Thigh Injuries: Myositis Ossificans Traumatica • Etiology • Formation of ectopic bone • MOI = repeated blunt trauma • May be the result of improper thigh contusion treatment (too aggressive) • Signs and Symptoms • X-ray shows Ca++ deposit 2 - 6 weeks post injury • Pain, weakness, swelling, tissue tension, point tenderness, and decreased ROM • Management • Treatment must be conservative • May require surgical removal

17. Thigh Injuries: Quadriceps Muscle Strain • Etiology • MOI = over-stretching or too forceful contraction • Signs and Symptoms • Pain, point tenderness, spasm, loss of function, and ecchymosis • Superficial strain results in fewer S&S than deeper strain • Complete tear results in deformity • Athlete displays little disability and discomfort

18. Thigh Injuries: Quadriceps Muscle Strain • Management • RICE • NSAID’s and analgesics • Manage swelling • Compression, crutches • Stretching • PRE strengthening exercises • Neoprene sleeve for added support

19. Thigh Injuries: Hamstring Muscle Strains • Etiology: multiple theories of injury • Hamstrings and quadriceps contract together • Change from hip extender to knee flexor • Fatigue • Posture • Leg length discrepancy • Lack of flexibility • Strength imbalances

20. Signs and Symptoms Pain in muscle belly or point of attachment Capillary hemorrhage Ecchymosis Grade 1 Pain with movement Point tenderness <20% of fibers torn Grade 2 Partial tear <70% of fibers torn Sharp snap or tear Severe pain Loss of function Grade 3 Rupture of tendinous or muscular tissue >70% muscle fiber tearing Severe hemorrhage Disability Edema Loss of function Ecchymosis Palpable mass or gap Thigh Injuries: Hamstring Muscle Strains

21. Management RICE, NSAID’s and analgesics Modalities PRE exercises When soreness is eliminated, focus on eccentrics strengthening Recovery may require months to a full year Scaring increases risk of injury recurrence of Grade I Do not resume full activity until complete function restored Grade 2 and 3 Should treat conservatively Gradual return to stretching and strengthening in later stages of healing Thigh Injuries: Hamstring Muscle Strains

22. Thigh Injuries: Acute Femoral Fractures • Etiology • Fracture in middle third of femoral shaft • MOI = great deal of force • Signs and Symptoms • Pain, swelling, deformity, muscle guarding • Leg with fx positioned in hip adduction and ER • Leg with fx may appear shorter • Management • Medical emergency! • Treat for shock, splint, refer • Analgesics and ice

23. Thigh Injuries: Femoral Stress Fractures • Etiology • Overuse (10-25% of all stress fractures) • MOI = excessive downhill running or jumping • Often seen in endurance athletes • Signs and Symptoms • Persistent pain in thigh/groin region • X-ray or bone scan will reveal fracture • Positive Trendelenburg’s sign • Management • Prognosis will vary depending on location • Fx in shaft and medial to femoral neck heal well with conservative management • Fx lateral to femoral neck are more complicated

24. Anatomy of the Hip, Groin, and Pelvic Region Review

31. Functional Anatomy • Hip Joint • True ball and socket joint • Intrinsic stability • Moves in all three planes, particularly during gait • Pelvis • Moves in all three planes • Anterior tilting • Changes degree of lumbar lordosis • Lateral tilting • Changes degree of hip abduction

32. Assessment of the Hip and Pelvis • Injuries to the hip or pelvis cause major disability in the lower limbs, trunk, or both • Low back may also become involved • History • Onset (sudden or slow?) • Previous history? • Mechanism of injury? • Pain description, intensity, quality, duration, type, and location?

33. Assessment of the Hip and Pelvis • 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 to one side • Ambulation

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 Poster inferior iliac spine (PIIS) Palpation: Bony Tissue

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, and lymph nodes

36. Special Tests • Functional Evaluation • PROM, AROM, RROM • Hip adduction and abduction • Hip flexion and extension • Hip internal and external rotation

37. Special Tests: Hip Flexor Tightness • Kendall test • Test for rectus femoris tightness

38. Special Tests: Hip Flexor Tightness • Thomas test • Test for hip contractures

39. Special Tests: 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

40. Special Tests: Hip and Sacroiliac Joint • Gaenslen’s Test • Test forces SI joint into extension • Hyperextension on the affected side increases pain

41. Special Tests: Tensor Fasciae Latae and Iliotibial Band • Renne’s test • Athlete stands with knee bent at 30 - 40 degrees • Pain at lateral femoral condyle indicates tensor fasciae latae tightness

42. Special Tests: Tensor Fasciae Latae and Iliotibial Band • Nobel’s Test • Lying supine, knee is flexed to 90 degrees • Pressure is applied to lateral femoral condyle while knee is extended • Pain at 30 degrees of knee flexion in the area of the lateral femoral condyle indicates IT band irritation

43. Special Tests: Tensor Fasciae Latae and Iliotibial Band • Ober’s Test • Used to determine presence of contracted TFL or IT-band • Thigh will remain in abducted position

44. Special Tests: Tensor Fasciae Latae and Iliotibial Band • Trendelenburg’s Test • Stand on one leg and compare level of PSIS and iliac crests bilaterally • Test is positive when affected side is higher • Indicates weak hip abductors (gluteus medius)

45. Special Tests: Piriformis • Piriformis Test • Hip is internally rotated • Tightness or pain is indicative of piriformis tightness

46. Special Tests: Leg Length Discrepancy • True or anatomical • Shortening may be equal throughout limb or localized in femur or lower leg • Measure from ASIS to medial malleolus • Apparent or functional • May result due to lateral pelvic tilt, flexion, or adduction deformity • Measure from umbilicus to medial malleolus

47. Leg Length Discrepancy Measures

48. Hip and Groin Injuries Groin Strain • Etiology • Injury usually occurs to the adductor longus • MOI = running, jumping, or twisting with hip external rotation; over-stretching; or too forceful contraction • Signs and Symptoms • Sudden twinge or tearing during movement • Pain, weakness, and internal hemorrhaging

49. Hip and Groin Injuries Groin Strain (continued) • Management • RICE • NSAID’s and analgesics • Rest is critical • Modalities • Daily whirlpool and cryotherapy • Ultrasound • Delay exercise until pain free • Restore normal ROM and strength • Provide support with elastic wrap

50. Hip and Groin Injuries Trochanteric Bursitis • Etiology • Inflammation of bursa at greater trochanter • Insertion site for gluteus medius and where IT-band passes over the greater trochanter • Signs and Symptoms • Lateral hip pain that may radiate down the leg • Point tenderness over greater trochanter • IT-band and TFL tests should be performed