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
Anatomy of the Thigh

Review
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
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
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
 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
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
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
Thigh Injuries: Quadriceps Muscle Strain

 Management
 RICE
 NSAID’s and analgesics
 Manage swelling
 Compression, crutches
 Stretching
 PRE strengthening exercises
 Neoprene sleeve for added support
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
 Thigh Injuries: Hamstring Muscle Strains
 Signs and Symptoms  Grade 2
 Partial tear
 Pain in muscle belly  <70% of fibers torn
or point of  Sharp snap or tear
attachment  Severe pain

 Capillary  Loss of function

 Grade 3
hemorrhage
 Ecchymosis
 Grade 1
 Pain with movement
 Point tenderness
 <20% of fibers torn
 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
 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: 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
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
Anatomy of the Hip,
Groin, and Pelvic Region

Review
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
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?
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
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
Leg Length Discrepancy Measures
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
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
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
Hip and Groin Injuries
Trochanteric Bursitis (continued
 Management
 RICE
 NSAID’s and analgesics
 ROM and PRE exercises for hip abductors
and external rotators
 Phonophoresis
 Evaluate biomechanics and Q-angle
 Runners should avoid inclined surfaces
Hip and Groin Injuries
Sprains of the Hip Joint
 Etiology
 Unusual movement exceeding normal ROM
 MOI = force from opponent/object, or, trunk
forced over planted foot in opposite direction
 Signs and Symptoms
 Pain, which increases with hip rotation
 Inability to circumduct hip
 Similar S&S to stress fracture
Hip and Groin Injuries

Sprains of the Hip Joint (continued)

 Management
 RICE
 NSAID’s and analgesics
 Depending on severity, crutches may be
required
 ROM and PRE are delayed until hip is pain-free
 X-rays or MRI should be performed to rule out
a possible fracture
Hip and Groin Injuries
Dislocated Hip
 Etiology
 Result of traumatic force directed along the long axis of
the femur
 Posterior dislocation more common
Hip flexed, adducted, and internally rotated
 Knee flexed
 Rarely occurs in sport
 Signs and Symptoms
 Flexed, adducted, and internally rotated hip
 Palpation reveals displaced femoral head
 Medical emergency
 Compications include soft tissue damage,
neurological damage, and possible fracture
Hip and Groin Injuries
Dislocated Hip (continued)
 Management
 Immediate medical care
 Blood and nerve supply may be compromised
 Contractures may further complicate reduction
 2 weeks immobilization
 Crutch use for at least one month
 Hip and Groin Injuries
Avascular Necrosis
 Etiology
 Temporary or permanent loss of blood supply to the
proximal femur
 MOI = traumatic conditions (ie: hip dislocation) or non-
traumatic conditions (ie: steroids, blood coagulation
disorders)
 Signs and Symptoms
 Possibly no S&S in early stages
 Develop over the course of months to a year

 Joint pain with weight bearing, progressing to pain at rest

 Limited ROM
 Osteoarthritis may develop
Hip and Groin Injuries
Avascular Necrosis (continued)
 Management
 Must be referred for X-ray, MRI, or CT scan
 Most cases will ultimately require surgery
 Conservative treatment
 Non-weight bearing;ROM exercises; e-stim for
bone growth; medication to treat pain
 Limit necrosis
 Reduce fatty substances, which react with
corticosteroids
 Limit blood clotting in the presence of clotting
disorders
Hip Problems in the Young Athlete
Legg Calve’-Perthes Disease (Coxa Plana)
 Etiology
 Avascular necrosis of the femoral head in child
ages 4-10
 MOI = trauma (accounts for 25% of cases)
 Signs and Symptoms
 Pain in groin
 Referred pain to the abdomen or knee
 Limping
 may exhibit limited ROM
Hip Problems in the Young Athlete
Legg Calve’-Perthes Disease (continued)
 Management
 Bed rest to alleviate synovitis
 Brace to avoid direct weight bearing
 With early treatment, the femoral head may
re-ossify and revascularize
 Complications
 If not treated early, will result in ill-shaping
 May develop into osteoarthritis in later life
Hip Problems in the Young Athlete
Slipped Capital Femoral Epiphysis
 Etiology
 Found mostly in tall boys between ages 10-17
 May be growth hormone related
 MOI = trauma (accounts for 25% of cases)
 25% of cases are seen in both hips
 Femoral head slippage on X-ray appears in
posterior and inferior direction
Hip Problems in the Young Athlete
Slipped Capital Femoral Epiphysis
(continued)
 Signs and Symptoms
 Pain in groin that progresses over weeks or months
 Hip and knee pain during passive and active motion
 Limitations of hip abduction, flexion, and medial rotation
 Limp
 Management
 Minor slippage
 Rest and non-weight bearing may prevent further slippage
 Major slippage results in displacement
 Requires surgery
 If condition goes undetected or if surgery fails, severe
problems will result
Hip Problems in the Young Athlete
The Snapping Hip Phenomenon
 Etiology
 Common in young female dancers, gymnasts,
and hurdlers
 MOI = repetitive movement that leads to
muscle imbalance
 Related to narrow pelvis, increased hip
abduction, and limited lateral rotation
 Hip stability is compromised
Hip Problems in the Young Athlete
The Snapping Hip Phenomenon (continued)
 Signs and Symptoms
 Pain while balancing on one leg
 Possible inflammation
 Management
 ROM exercises to increase flexibility
 Flexion and lateral rotation
 Cryotherapy and ultrasound may be utilized
 PRE exercises to strengthen weak muscles
 Pelvic Injuries
Contusion (hip pointer)
 Etiology
 Contusion of iliac crest or abdominal
musculature
 MOI = direct blow
 Signs and Symptoms
 Pain, spasm, and transitory paralysis
 Decreased ROM due to pain
 Rotation of trunk, thigh/hip flexion
Pelvic Injuries
Contusion (hip pointer) continued
 Management
 RICE for at least 48 hours
 NSAID’s,
 Bed rest 1 - 2 days
 Referral must be made for X-ray
 Modailities
 Ice massage, ultrasound, occasionally steroid
injection
 Recovery lasts 1 - 3 weeks
Pelvic Injuries
Stress Fractures
 Etiology
 Seen in distance runners – more common in women
than men
 MOI = repetitive cyclical forces from ground reaction
forces
 Common sites include inferior pubic ramus, femoral
neck, and subtrochanteric area of the femur
 Signs and Symptoms
 Groin pain
 Aching sensation in thigh that increases with activity
and decreases with rest
 Standing on one leg may be impossible
 Deep palpation results in point tenderness
Pelvic Injuries
Stress Fractures (continued)
 Management
 Rest for 2 - 5 months
 Crutch walking
 Especially for ischium and pubis stress fractures
 X-rays are usually normal for 6 -10 weeks,
therefore a bone scan will be required to
detect the stress fracture
 Swimming can be used to maintain CV fitness
 Breast stroke should be avoided
Pelvic Injuries
Avulsion Fractures and Apophysitis
 Etiology
 Common sites include ischial tuberosity, AIIS,
and ASIS
 MOI = sudden accelerations and decelerations
 Signs and Symptoms
 Sudden localized pain
 Limited ROM
 Pain, swelling, point tenderness
 Muscle testing increases pain
Pelvic Injuries

Avulsion Fractures and Apophysitis

(continued)
 Management
 X-ray required for diagnosis
 RICE, NSAID’s, crutch “toe-touch” walking
 ROM exercises
 PRE exercises
 When 80 degrees of ROM have been regained
 Return to play when full ROM and strength are
restored