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

1. Chapter 21: The Thigh, Hip, Groin, and Pelvis © 2011 McGraw-Hill Higher Education. All rights reserved.

2. Anatomy of the Thigh © 2011 McGraw-Hill Higher Education. All rights reserved.

3. Figure 21-1 © 2011 McGraw-Hill Higher Education. All rights reserved.

4. Figure 21-2 © 2011 McGraw-Hill Higher Education. All rights reserved.

5. Nerve and Blood Supply Tibial and common peroneal are given rise from the sacral plexus, which forms 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 © 2011 McGraw-Hill Higher Education. All rights reserved.

6. 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 © 2011 McGraw-Hill Higher Education. All rights reserved.

7. 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 © 2011 McGraw-Hill Higher Education. All rights reserved.

8. 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 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 © 2011 McGraw-Hill Higher Education. All rights reserved.

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 patient in obvious pain? Is the patient willing to move the thigh? © 2011 McGraw-Hill Higher Education. All rights reserved.

10. 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 Semimembranosus Semitendinosus Biceps femoris Adductor brevis, longus and magnus Gracilis Sartorius © 2011 McGraw-Hill Higher Education. All rights reserved.

11. Palpation: Soft Tissue (continued) Pectineus Iliotibial Band (IT-band) Gluteus medius Tensor fasciae latae © 2011 McGraw-Hill Higher Education. All rights reserved.

12. 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 © 2011 McGraw-Hill Higher Education. All rights reserved.

13. Prevention of Thigh, Hip, Groin & Pelvic Injuries Thigh must have maximum strength, endurance, and extensibility to withstand strain While muscle function is critical to perform dynamic activities, also critical in providing a base of support with pelvis for whole body motion Due to demands of both dynamic force production and core stability, this region is vulnerable to injury © 2011 McGraw-Hill Higher Education. All rights reserved.

14. Maintaining strength and flexibility in this region is critical • Concentrate on dynamic stretching of quadriceps, hamstrings, groin muscles • Well designed strengthening program is also critical • Would include squats, lunges, leg presses and core stability work © 2011 McGraw-Hill Higher Education. All rights reserved.

15. 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) © 2011 McGraw-Hill Higher Education. All rights reserved.

16. Quad Contusion Figure 21-3 © 2011 McGraw-Hill Higher Education. All rights reserved.

17. 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 Figure 21-4 © 2011 McGraw-Hill Higher Education. All rights reserved.

18. 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 patient has sustained a severe contusion, great care must be taken to avoid another © 2011 McGraw-Hill Higher Education. All rights reserved.

19. 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 due to pain and decreased ROM © 2011 McGraw-Hill Higher Education. All rights reserved.

20. Myositis Ossificans Traumatica • Management • Treatment must be conservative • May require surgical removal due to pain and decreased ROM Figure 21-5 © 2011 McGraw-Hill Higher Education. All rights reserved.

21. Quadriceps Muscle Strain Etiology Sudden stretch, violent forceful contraction of hip and knee into flexion Overstretching of quadriceps Signs and Symptoms Peripheral tear causes fewer symptoms than deeper tear Pain, point tenderness, spasm, loss of function (decreased knee flexion) and little discoloration Complete tear may leave patient w/ disability, discomfort and some deformity Figure 21-6 © 2011 McGraw-Hill Higher Education. All rights reserved.

22. Signs & Symptoms • Grade 1: Complain of tightness in front of thigh; near normal ambulation; swelling may be limited; mild discomfort during palpation • Grade 2: Abnormal gait cycle; may be splinted in extension; swelling may be noticeable with pain on palpation; possible defect in muscle; resistive knee extension will reproduce pain • Grade 3: Possibly unable to ambulate; pain with palpation; may be unable to perform knee extension; isometric contractions may produce defect or bulging in muscle belly © 2011 McGraw-Hill Higher Education. All rights reserved.

23. Management RICE, NSAID’s and analgesics Manage swelling, compression, crutches With increased healing, progress to isometrics and stretching Grade 1: Neoprene sleeve may provide some added support Grade 2: Ice and compression for 3-5 days with gradual increase in isometric exercises and pain free knee ROM exercises Limit passive stretching until later phases Grade 3: Crutch use for 7-14 days; restore normal gait; compression for support; may require 12 weeks until returning to full activity © 2011 McGraw-Hill Higher Education. All rights reserved.

24. Hamstring Muscle Strains (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) © 2011 McGraw-Hill Higher Education. All rights reserved.

25. 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 © 2011 McGraw-Hill Higher Education. All rights reserved.

26. Management (continued) Modalities and isometrics need to gradually be introduced during healing process 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 Figure 21-8 © 2011 McGraw-Hill Higher Education. All rights reserved.

27. Acute Femoral Fractures Etiology Generally involving shaft and requiring a great deal of force Occurs in middle third due to structure and point of contact Signs and Symptoms Pain, swelling, deformity Muscle guarding, hip is adducted and ER Leg with fx may also be shorter 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 © 2011 McGraw-Hill Higher Education. All rights reserved.

28. Femoral Stress Fractures Etiology Overuse (10-25% of all stress fractures) Excessive downhill running or jumping activities Often seen in endurance athletes Signs and Symptoms Persistent pain in thigh/groin X-ray or bone scan will reveal fracture Walk with antalgic gait (abduction lurch) Positive Trendelenburg’s sign Management Prognosis will vary depending on location Fx lateral to femoral neck tend to be more complicated Shaft and medially located fractures tend to heal well with conservative management © 2011 McGraw-Hill Higher Education. All rights reserved.

29. Anatomy of the Hip, Groin and Pelvic Region © 2011 McGraw-Hill Higher Education. All rights reserved.

30. Figure 21-10 © 2011 McGraw-Hill Higher Education. All rights reserved.

31. Figure 21-11 © 2011 McGraw-Hill Higher Education. All rights reserved.

32. Figure 21-12 A & B © 2011 McGraw-Hill Higher Education. All rights reserved.

33. Figure 21-13 © 2011 McGraw-Hill Higher Education. All rights reserved.

34. Figure 21-14 A © 2011 McGraw-Hill Higher Education. All rights reserved.

35. Figure 21-14 B & C © 2011 McGraw-Hill Higher Education. All rights reserved.

36. 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) © 2011 McGraw-Hill Higher Education. All rights reserved.

37. Tremendous forces occur at the hip during varying degrees of locomotion Muscles are most commonly injured in this region Numerous muscles attach in this region and therefore injury to one can be very disabling and difficult to distinguish © 2011 McGraw-Hill Higher Education. All rights reserved.

38. Assessment of the Hip and Pelvis © 2011 McGraw-Hill Higher Education. All rights reserved.

39. 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? © 2011 McGraw-Hill Higher Education. All rights reserved.

40. 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 © 2011 McGraw-Hill Higher Education. All rights reserved.

41. 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 Poster inferior iliac spine © 2011 McGraw-Hill Higher Education. All rights reserved.

42. 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 © 2011 McGraw-Hill Higher Education. All rights reserved.

43. Special Tests Functional Evaluation ROM, strength tests Hip adduction, abduction, flexion, extension, internal and external rotation Tests for Hip Flexor Tightness Kendall test Test for rectus femoris tightness Thomas test Test for hip contractures © 2011 McGraw-Hill Higher Education. All rights reserved.

44. Kendall’s Test Figure 21-15 © 2011 McGraw-Hill Higher Education. All rights reserved.

45. Thomas Test Figure 21-16 & 17 © 2011 McGraw-Hill Higher Education. All rights reserved.

46. Femoral Anteversion and Retroversion 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 Figure 21-18 B & E © 2011 McGraw-Hill Higher Education. All rights reserved.

47. Figure 21-18 A, C, D Retroversion Normal Anteversion © 2011 McGraw-Hill Higher Education. All rights reserved.

48. 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 Figure 21-19 © 2011 McGraw-Hill Higher Education. All rights reserved.

49. Gaenslen’s Test Test works to push SI joint into extension Test is positive if hyperextension on affected side increases pain Figure 21-20 © 2011 McGraw-Hill Higher Education. All rights reserved.

50. 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 Figure 21-21 © 2011 McGraw-Hill Higher Education. All rights reserved.