AT 359
Chapter 21 - The Thigh, Hip, Groin & Pelvis

Anatomy:
-Ball and socket joint
-Very stable joint
        -reasons: deeper socket, surrounded by strong muscles, limited ROM, strong ligaments
-Bones consist of: femur, patella, and pelvis

Nerves:
-The tibial and common peroneal nerves originate from sacral plexus (or sciatic nerve) to innervate muscles of the thigh and lower leg
-The femoral nerve also innervates muscles of the anterior thigh\

Blood Supply:
-Branches of the femoral and iliac arteries supply the region

Ligaments:
-very strong ligaments at hip joint
-the iliofemoral (Y ligament of Bigelow) is the strongest ligament in the body

Bursae:
-the deep trochanteric bursa is the most commonly affected
        -ex: snapping hip syndrome

Muscles:

Thigh Injuries
-Quadriceps Contusion
        -blunt force trauma to thigh muscles
        -a severe blow or repeated blows can develop into myositis ossificans
        -area should be protected by padding when returned to normal activity
        -s/s include: stiffness, loss of ROM, severe pain, limping, ecchymosis, moderated swelling
        -treatment: crutches if needed, ice with knee flexed for several days, NSAIDs
        -if it is a bad bruise, you may have to continue ice for up to 5 days to a week
        -after a few days, light massage with elevation should be done to decrease swelling

-Myositis Ossificans Traumatica
        -ectopic bone formation in the muscle tissue
        -results from severe trauma or repeated trauma to the same area
        -may be removed after one year to avoid risk of it regenerating
        -s/s are similar to a quadriceps contusion

-Quadriceps/Hamstring/Groin Muscle Strains
        -grades 1, 2 & 3
        -grades 2 and 3 tend to be more focal and point tender, whereas grade 1 strains are more generalized
        -grades 2 & 3 will have more functional loss
        -treatment consists of RICE, and as soon as possible, heat with stretching and exercises
        -hamstring strains occur more frequently because they are a lot weaker than the quad muscles
                -they are also more neglected when it comes to lifting weights - most exercises involve the quads
        -a high quad to hamstring strength ratio increases the risk of hamstring strain
        -neoprene sleeves or pad w/wrap are very effective when coming back from a strain

-Femoral Fractures
        -can be acute or from a stress fracture that is chronic
        -usually is fractured at the middle 1/3 of the bone
        -very painful and has a lot of deformity
        -can be an open fracture
        -s/s include: intense pain, muscle spasms, deformity - leg is shortened and rotated, palpable mass in thigh
        -shock can result from the internal blood loss - monitor vitals
        -stress fx's usually develop around the femoral neck area and typically produces consistent pain most of the time
        -bone scan is helpful to diagnose stress fx; also can use the fulcrum test

Hip, Groin & Pelvis Injuries
-Special Tests and what they test for

-Groin Strains
        -see thigh strains

-Trochanteric Bursitis
        -affects bursa over greater trochanter
        -snapping hip syndrome
        -tensor fascia latae and gluteus medius tendons can rub over greater trochanter and become inflamed
        -usually seen in distance runners, especially in females
        -treatment consists of: ultrasound, strengthening gluteus medius muscle and stretching lateral musculature

-Hip Sprains
        -the hip is the strongest and best-protected joint in the body
        -injury usually results from a violent twist or traumatic force
        -s/s include: hip pain especially when trying to circumduct leg
       
-Hip Dislocations
        -rarely seen in sports setting
        -requires significant trauma or force
        -foot is usually planted and trunk/torso gets rotated in another direction
        -s/s include: severe pain, spasms, affected leg will be shortened and adducted w/ internal rotation

-Avascular Necrosis
        -usually occurs at femoral neck/head
        -can be from trauma or non-trauma
        -affects blood flow to bone which will start to necrose
        -may require surgery and joint replacement

Adolescent Injuries:
-Legg-Calve-Perthes Disease (Coxa Plana)
        -considered an osteochondrosis condition
        -avascular necrosis of femoral head
        -occurs in boys more often than girls
        -most are non-traumatic related
        -usually develops a limp and pain
        -if not treated immediately, can cause improper healing and osteoarthritis later in life

-Slipped Capital Femoral Epiphysis
        -similar to Legg-Calve-Perthes disease
        -femoral head slips or shifts over
        -if treated properly, healing can occur
        -usually seen in boys
        -usually is atraumatic related

-Snapping Hip Phenomenon
        -usually affects girls
        -results from a weakness of muscles and/or an imbalance between muscles or muscle groups
        -treatment should consist of strengthening, ice and stretching
   
Pelvic Injuries:
-Hip Pointer
        -blow to the iliac crest
        -s/s include: swelling, ecchymosis, spasms, limited ROM
        -can be very debilitating
        -should be protected with padding
        -treatment consists of stretching, NSAIDs, and ice

-Osteitis Pubis
        -a chronic inflammatory condition
        -pain in groin area, especially upon running, doint sit-ups or doing squats
        -x-rays can aid in diagnosis
        -rest, ice and NSAIDs are the choice of treatment

-Athletic Pubalgia
        -catch-all term for chronic pubic or inguinal pain
        -MOI is repetitive stress to pubic symphysis from kicking or twisting or cutting at high speeds
        -s/s include: pain upon activity, usually around lower abdominals and into testicles; pain is increased with
            contraction of the abdominals, hip flexion and/or internal rotation; also pain on hip adduction with no adductor
            tenderness is a common sign
        -treatment consists of deep massage for about a week followed by stretching of torso/hip musculature for another
            week and then starting abdominal, hip adductor and flexor strengthening; at 3 to 4 weeks, running can begin
        -if conservative treatment is not successful, steroid shots or surgery is indicated

-Stress Fractures
        -pelvic stress fx's are most commonly seen in distance runners
        -s/s include: aching pain in groin/thigh, will not be able to stand on one leg, and deep palpation will elicit a lot of
            tenderness
        -usually occurs in competition or hard interval training
        -treatment consists of rest for several months, obtaining a bone scan for diagnosis, swimming can be done as
            rehab activity but not breast-stroke

-Avulsion Fx's and Apophysitis
        -common in sports with sudden acceleration and deceleration such as football, soccer and basketball
        -s/s include: sudden localized pain with limited movement, swelling, muscle pain upon testing strength
        -treatment includes: xrays, RICE, crutches for 1 to 2 months, stretching program after 2-3 weeks and then
            progress to PRE's

Rehabilitation of Thigh, Hip, Groin & Pelvis Injuries
-Utilize as much closed chain activities as possible including: minisquats, leg press, stepping machines & balance
        boards
-When doing balance boards for upper leg/hip area, make sure athlete has knees straight - this works the muscles of
        the thigh and hip more.  When you slightly bend at the knees while balancing, you work mostly the lower leg/ankle
        musculature.

Web Sites for further study/learning:
www.ccsd.k12.wy.us/cchs_web/cramerfirstaider/fstaider.htm - Cramer First Aider

www.worldortho.com - World Ortho

www.medmedia.com/med.htm - Wheeless Textbook of Orthopedics

www.sportsmed.org - American Orthopaedic Society for Sports Medicine

www.orthonet.com - OrthoNet

www.orthoinfo.aaos.org/fact/ - AAOS fact sheet on pelvic fractures

www.uihealthcare.com/topics/sportsmedicine/spor3340.html - biomechanics of hip/knee/thigh injuries