Thigh, Hip and Pelvis

1. Thigh, Hip and Pelvis • Joints are rarely injured in sport • Soft tissue is commonly injured • Bony Structure • Femur • Pelvis • Sacrum and Coccyx

2. Pelvis • Iliac Crest • ASIS and PSIS • Ischial tuberosity • Innominate Bone- Consist of: • Ilium • Ischium • Pubis

3. Hip Joint • Ball and Socket Joint • Head of the femur- Convex • Acetabulum of the pelvis- Concave • Highly Stable from a bony perspective; several very strong ligaments that aid in keeping the head of femur in the acetabulum • Bursae • Iliopsoas bursa • Deep trochanteric bursa

4. Nerves and Blood Supply • Nerve supply • Lumbar plexus (L1 – L4) - forms the femoral nerve • Sacral Plexus (L4 – S4) – forms the sciatic nerve • Blood supply • Femoral artery

5. Muscles and Movements • Hip flexion • Normal ROM • 80 degrees knee straight • 120 degrees knee bent bent • Iliacus and psoas major (major flexors)- both form the illiopsoas- knee bent • Rectus femoris (function when knee is extended and with kicking the ball) • Sartorius • Hip Extension • Normal ROM 10 – 20 degrees • Hamstrings, gluteus maximus

6. Muscles and Movements (2) • Abduction • Normal ROM • 45 degrees • Gluteus medius • Adduction • Normal ROM • 30 degrees • Adductor magnus, longus, brevis, and gracilis

7. Muscles and Movements (3) • Internal Rotation or Medial Rotation • Normal ROM • 45 degrees • Glueteus Minimus and Tensor Fascia Latae • External Rotation or Lateral Rotation • Normal ROM • 45 degrees • 6 deep external rotators- piriformis

8. Quadriceps Contusions • MOI: direct blow • HOPS • Pain, swelling and ecchymosis • Walk with a limp • Palpable hematoma, with heat • Tx • Ice in stretched position, crutches if needed, wrap, See field strategy 10.2 (pg. 352), refer for x-ray

9. Myositis Ossificans • Accumulation of mineral deposits (bone) in muscle tissue • MOI: Single severe blow, repeated blows to muscle, mismanagement of contusion • HOPS • Firm swollen area in muscle • Palpable mass • Limited knee flexion • Active contraction of muscle difficult • Tx • Refer to physician (surgery may be needed)

10. Hip Pointer • Contusion caused by direct compression to the iliac crest • MOI: Direct blow • Hops • Pn with rotation, trunk flexion • Ecchymosis, pain, swelling, • Point tender over illiac crest • TX • RICE, refer for x-ray, donut pad and hard outer shell, to protect

11. Bursitis • Most common = trochanteric bursitis • MOI: overuse • HOPS: • Deep achy pain in lateral thigh • Pn with resisted abduction • TX • Heat, stretch abductors, Ultrasound • If condition does not resolve: refer to physician

12. Hip Sprains/ Dislocations • MOI: violent twisting/ severe trauma; rare in sports • HOPS: S/S  with degree and type • Intense pain, • Inability to walk or move hip • Hip flexed and internally rotated – Fig 10-12 • TX • Symptomatic with mild to moderate sprains • Medical emergency, summon EMS, check distal neurovascular status; treat for shock

13. Muscle Strains • Hamstring strains more probable than Quadriceps strains; Adductor strains are more common than Abductor • Hamstring Strains are most common • Precursors • muscle imbalances, tight muscles, improper warm-up, overuse, fatigue, dynamic overload

14. Muscle Strains (2) • HOPS-In isolated region in question • “twinge” or “pull” • Weakness on RROM testing • Limping; Ecchymosis • Pop is heard when severe; Palpable defect • Pain with passive stretch, and resistive motion • Treatment- Hip Flexor or Hip Adductor Wrap; RICE, E-Stim, Strengthening/Stretching, NSAID’s; crutches if necessary

15. Muscle Strength Testing • 5 (normal) full strength against resistance • 4 (good) partial strength against resistance • 3 (fair) ability to move the body part no resistance • 2 (poor) able to contract muscle • 1 (trace) no evidence of contractility

16. Legg-Calve-Perthes Disease • Avascular necrosis (decreased blood supply to the head of femur) of the proximal femoral epiphysis-Fig 10-13 • Precursors: young males 3-8 years old • HOPS: • Gradual onset of pain in hip/groin or knee with no explanation • Gradual onset of a limp; • Decreased range of motion in the hip- AB, EX, ER • TX: refer to physician if unexplained hip, thigh or knee pain last for more than a week.

17. Avulsion Fractures (1) • Precursors: • Individuals who perform rapid acceleration/ deceleration • Locations: • ASIS: Sartorius • AIIS: Rectus Femoris • Ischial tuberosity: hamstrings

18. Avulsion Fractures (2) • HOPS • Sudden acute localized pain • Pain, swelling, discoloration over area • Pain with resisted stretching of the involved muscle • TX • Hip Spica Wrap if able • Fit for crutches • Refer to physician

19. Slipped Femoral Epiphysis • Epiphyseal/ Growth Plate fracture- Fig 10-15 • Precursor: Adolescent boys ages 8 – 15, obese or slender rapidly growing boys • HOPS: • Painful limp • Pain in the groin, anterior thigh or knee • Unable to internally rotate femur • Unable to stand on injured leg • TX: Refer to physician, surgery

20. Stress Fractures • Precursor: Box 10-3 • Common locations • Pubis • Femoral neck • Proximal 1/3 of femur • HOPS • Aching pain in groin or thigh during WB • Pn relieved by rest • Night pain • TX: Refer to physician

21. RROM testing • Hip Flexion • Hip Extension • Hip Abduction • Hip Adduction • Hip Internal Rotation • Hip External Rotation • Knee Extension • Knee flexion

22. Measuring for Leg Length • ASIS • Medial Malleolus • Patient Position: • Lying on table, pelvis square and balanced • Legs parallel • Heels approximately 6-8 inches apart

23. Special Tests • Thomas Test = Hip flexion contractures • Kendall Test = Hip flexion contractures (Rectus Femoris) • Straight Leg Raise=Disc Lesions or tight hamstrings • Pelvic Rock Test=Pelvic Fracture/SI Joint Sprain • Trendelenburg’s Test

24. Specialized Rehab • SLR’s- all 4 planes • Quad Sets/Glute Sets/Ham Sets • Stretching • Strengthening • Electrical Stimulation, US, Massage