Hip/Thigh/Pelvis Conditions

Pelvis, Hip, and Thigh Conditions

Chapter 17

Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Skeletal Features of Pelvis, Hip, and Thigh


Pelvis

• Function

– Protects organs

– Transmits loads between trunk and lower extremity

– Provides site for muscle attachments

• 4 fused bones

– Sacrum

– Coccyx

– Innominate bones

• Ilium, ischium, and pubis


Pelvis (cont.)

• SI joint

– Critical link between the two pelvic bones

– Strong ligamentous support

• Sacrococcygeal joint

– Fused line symphysis united by a fibrocartilaginous disc

• Pubic symphysis

– Interpubic disc located between the two joint surfaces


Bony Structure of Thigh

• Femur

– Weakest at femoral neck

– Angle of inclination

• Angle of depression formed by a line drawn through the shaft of femur and a line passing through the long axis of femoral neck

• Approximately 125  in the frontal plane

•  125  coxa valga

•  125  coxa vara



Bony Structure of Thigh (cont.)

• Femur

– Angle of torsion

• Relationship between femoral head and femoral shaft in transverse plane

• Approximately 12 

•  12  anteversion

•  12  retroversion



Hip Joint

• Head of femur and acetabulum of pelvis

• Ball and socket joint

• Very stable


Hip Joint Capsule

• Completely surrounds joint, attaching to the labrum of the acetabular socket

• Passes over a fat pad internally to join to the distal aspect of femoral neck

• Zona orbicularis


Ligaments of Hip Joint

• Iliofemoral ligament

– Limits hyperextension

• Pubofemoral ligament

– Limits abduction and hyperextension

• Ischiofemoral ligament

– Limits extension


Femoral Triangle

• Borders

– Inguinal ligament— superior

– Sartorius—lateral

– Adductor longus—medial

• Contents

– Femoral nerves

– Femoral artery

– Femoral vein


Bursae

• Iliopsoas

– Reduces friction between iliopsoas and articular capsule

• Deep trochanteric bursa

– Provides cushion between greater trochanter and gluteus maximus at its attachment to iliotibial tract

• Gluteofemoral bursa

– Separates gluteus maximus from origin of vastus lateralis

• Ischial bursa

– Weight-bearing structure during sitting

– Cushions ischial tuberosity where it passes over gluteus maximus


Q-Angle

• Angle between line of resultant force produced by quadriceps and line of patellar tendon

• Males 13°; females

18°


Muscles


Muscles (cont.)


Muscles (cont.)


Nerves

• Lumbar plexus

– Femoral nerve

– Obturator nerve

• Sacral plexus

– Sciatic nerve


Blood Vessels

• External iliac

– Femoral

• Deep femoral

• Femoral circumflex

• F16.10


Kinematics (cont.)

• Hip flexors

– Iliopsoas, pectineus, rectus femoris, sartorius, and tensor fascia latae

– Two-joint muscles

• Rectus femoris—active during hip flexion and knee extension

• Sartorius—active during hip flexion and knee extension

• Hip extensors

– Gluteus maximus and hamstrings (biceps femoris, semitendinosus, and semimembranosus)

• Hamstrings—two-joint; hip extension and knee flexion



• Hip abductors

– Gluteus medius, gluteus minimus

– Active in stabilizing pelvis during single-leg support and during support phase of walking and running

• Hip adductors

– Adductor longus, adductor brevis, and adductor magnus



• Lateral rotators

– Piriformis, gemellus superior, gemellus inferior, obturator internus, obturator externus, and quadratus femoris

– Lateral rotation of femur of swinging leg accommodates lateral rotation of pelvis during stride

• Medial rotators

– Gluteus minimus

– Tensor fascia latae, semitendinosus, semimembranosus, gluteus medius, and adductors


Kinetics

• Body weight places compression on hip, as does tension in hip muscles

• Forces are less during standing than with running and walking

– Forces translated through the lower extremity; result

↑ compression on hip


Prevention

• Protective equipment

– Hip joint well protected but iliac and pelvis need protection

– Thigh

• Physical conditioning

• Shoes

– Cushion forces


Contusions

• Hip pointer

– Mechanism: direct blow to iliac crest

• Common—anterior or lateral portion of crest

• Often from improperly fitting (or absent) hip pads


Contusions (cont.)

– S&S

• Point tenderness; swelling; ecchymosis

• Individual prefers slightly forward flexed position to relieve tension of abdominals and iliopsoas

• Antalgic gait with shortened swing phase

• ↑ pain with active trunk flexion and active hip flexion

• Pain with coughing, laughing, breathing

• Abdominal muscle spasm

– Management: standard acute; rest; protect with hard-shell pad for return to activity



• Quadriceps contusion

– Mechanism: direct blow

– Common – anterolateral thigh

– S&S

• Transitory loss of function

• With continued play, progressively stiffer and unresponsive

• ↑ pain with active knee extension and hip flexion

• Limited AROM due to pain; knee flexion limited actively and passively



– Management:

• Standard acute; with knee in maximum flexion

• Hard-shell pad for return to activity

• Physician referral if myositis ossificans or compartment syndrome is suspected




• Myositis ossificans

– Develops secondary to single significant blow or repetitive blows to same area

– Evident on radiograph 3–4 weeks after injury



– S&S

• Warm, firm, swollen thigh; 2–4 cm larger

• Palpable, painful mass may limit passive knee flexion to

20–30°

• Active quadriceps contractions and straight leg raises— difficult

– Management: standard acute; physician referral

– Self-limiting injury

– Maturation—6–12 months



• Compartment syndrome

– Neurovascular compression

– Due to uncontrolled internal bleeding and swelling

– S&S

• Progressive, severe pain with passive motion and isometric contraction of quadriceps

•  pressure → ↓ femoral sensation and motor weakness; distal pulse and capillary refill may be normal

– Management: ice (no compression); immediate physician referral


Bursitis

• Mechanism

– Excessive friction or shear forces due to overuse

– Posttraumatic bursitis from direct blows that cause bleeding in the bursa

• Greater trochanteric bursitis

– Influence of Q-angle


Bursitis (cont.)

– S&S

• Burning or aching over or posterior to greater trochanter

• Aggravated with:

• Hip abduction against resistance

• Hip flexion and extension on weight bearing

• Referred pain—lateral aspect of the thigh



• Iliopsoas bursitis

– Pain medial and anterior to joint; cannot be easily palpated

–  pain with passive hip rotation; resisted hip flexion, abduction, and external rotation

• Ischial bursitis

– Pain aggravated by prolonged sitting and uphill running,

– Point tenderness directly over ischial tuberosity

–  pain with passive and resisted hip extension



• Bursitis management

– Standard acute; deep friction massage; NSAIDs; stretching program for involved muscle

– On-going prevention: biomechanical analysis; technique analysis



• Snapping hip syndrome

– Causes: intra- and extra-articular (refer to Box 15.2)

– Types

• External—IT band or gluteus maximus snapping over greater trochanter during hip flexion → trochanteric bursitis

• Internal—iliopsoas snaps over structures deep to musculotendinous unit (e.g., iliopsoas bursa)

• Intra-articular—lesions of the joint (e.g., labral tear)



– S&S

• Snapping sensation heard or felt during hip motion, especially with lateral rotation and flexion while balancing on one leg

• Iliopsoas bursa affected—snapping in medial groin

– Management: NSAIDs; rehabilitation program to address specific deficits


Hip Sprains and Dislocations

• Mechanism

– Violent twisting actions

– With hip and knee flexed to 90°, force through shaft of femur


Hip Sprains and Dislocations (cont.)

• S&S

– Mild/moderate: pain with internal rotation

– Severe: intense pain; inability to move hip

– Position of flexion and internal rotation

• Management

– Mild/moderate—standard acute

– Severe—activate EMS; immobilize in position found; assess distal vascular integrity; monitor and treat for shock; NPO


Hip Dislocation


Strains

• Mechanism

– Explosive movements

– Tensile stress from overstretching

• Muscles

– Quadriceps

• Typically rectus femoris


Strains (cont.)

– Hamstrings

• Initial swing—flex knee; late swing—eccentrically contract to decelerate knee extension and re-extend hip in prep for stance phase

• Overemphasis on stretching without strengthening

• Strength imbalance

– Adductors

• Common with quick change of direction and explosive propulsion and acceleration

• Strength imbalance


Strains (cont.)

• S&S

– Point tender with palpable spasm

– Possible palpable defect/divot

– Ecchymosis may or may not be present

– Pain with AROM; pain with PROM (muscles placed on stretch)


Strains (cont.)

• Piriformis strain

– In some individuals, sciatic nerve passes through or above piriformis, subjecting nerve to compression from trauma, hemorrhage, or spasm


Strains (cont.)

– S&S

• History of prolonged sitting, overuse, recent ↑ in activity, or buttock trauma

• Dull ache in midbuttock—worse at night

• Numbness or weakness may extend down posterior leg

• ↑ pain or weakness during:

• Passive hip flexion, adduction, and internal rotation

• Active hip external rotation

• Resisted hip external rotation


Strains (cont.)

• Predisposing factors

– Beginning of season – too much too soon

– Fatigue

– History of strains; reinjury common

– Restricted flexibility of involved muscle group

• Management: standard acute; restrict weight bearing if unable to assume normal gait


Vascular and Neural Disorders

• Legg-Calvé-Perthes disease

– Avascular necrosis of proximal femoral epiphysis

– Seen esp in males ages 3–8

– Osteochondrosis - femoral head

– S&S

• Gradual onset of limp and mild hip or knee pain of several months in duration

• Pain -activity related

•  ROM in hip abduction, extension, and external rotation due to spasm in hip flexors and adductors


Vascular and Neural Disorders (cont.)

• Venous disorders

– Direct blow may damage a vein causing

• Thrombophlebitis

 Superficial thrombophlebitis (ST)

 Deep venous thrombosis (DVT)

• Phlebothrombosis



– S&S

• ST—acute, red, hot, palpable, tender cord in course of a superficial vein

• Extension of ST to deep veins—via proximal long and short saphenous veins to common femoral and popliteal veins, respectively

– Management: anticoagulant therapy; external support (e.g., compression stockings); therapeutic exercise



• Toxic synovitis of hip

– Transient inflammatory condition

– Painful hip joint with an antalgic gait

– Management: physician referral

• Obturator nerve entrapment

– Possible causes: pelvic tumors, obturator hernias, or pelvic and proximal femoral fractures

– S&S: exercise-induced medial thigh pain; described as vague groin or medial knee pain



Hip Fractures

• Avulsion fractures

– Apophyseal sites

• ASIS with displacement of sartorius

• AIIS with rectus femoris displacement

• Ischial tuberosity with hamstrings displacement

• Lesser trochanter with iliopsoas displacement

– Due to rapid, sudden acceleration and deceleration


Hip Fractures (cont.)

– S&S

• Sudden, acute, localized pain—may radiate down muscle

• Swelling and discoloration

• Palpable gap between tendon attachment and bone

•  pain with AROM, PROM, RROM of involved muscle

– Management: immobilize with elastic bandage; fit with crutches; immediate physician referral



• Slipped capital femoral epiphysis

– Boys ages 12–15

– Femoral head slips at epiphyseal plate— displaces inferiorly and posteriorly relative to femoral neck



– S&S

• Early stages—diffuse knee pain

• Later stages

• More comfortable holding leg in slight flexion

• Unable to touch abdomen with thigh because hip externally rotates with flexion

• Unable to rotate femur internally or stand on one leg

– Management: fit with crutches; physician referral



• Stress fractures

– Pubis, femoral neck, and proximal one-third of femur

– Risk factors



– S&S

• Diffuse or localized aching pain in anterior groin or thigh during weight-bearing activity, relieved with rest

• Night pain

• Antalgic gait may be present

• Pain with deep palpation in inguinal

• ↑ pain on extremes of hip rotation

• + Trendelenburg sign




• Osteitis pubis

– Continued stress on pubic symphysis

• From repeated overload of the adductor muscles

• From repetitive running activities

– S&S

• Gradual onset of pain in the adductor musculature, aggravated by kicking, running, and pivoting on one leg

•  pain with sit-ups and abdominal strengthening exercises

• Pain may radiate distally into groin or medial thigh

– Management: standard acute—treat symptoms


Sacral and Coccygeal Fractures

• Rare in sports

• Direct blow to area due to fall on buttock

• S&S: extremely painful; unable to sit

• Management: immediate referral to a physician


Femoral Fractures

• Mechanism

– Tremendous impact forces

– Direct compressive forces

• Potential for neurovascular damage


Femoral Fractures (cont.)

• S&S

– Previous history of femoral stress fracture ↑ risk of complete fracture

– Extreme pain and inability/unwillingness to move involved side

– Shock

– Neck

• Individual supine, lower extremity in external rotation and abduction; appears shortened compared with other side

– Shaft

• Limb appears shortened; thigh appears externally rotated


Femoral Fractures (cont.)

• Management

– Activate EMS

– Assess distal vascular integrity

– Monitor and treat for shock

– Defer immobilization until emergency medical personnel arrive (traction splint will typically be applied)

– NPO—possible surgical intervention


Assessment

• History

• Observation/inspection

– Contranutation and nutation

• Palpation

• Physical examination tests


Observation

• Contranutation at the SI joint

– Indicates anterior torsion of joint, or posterior rotation of sacrum on ilium on one side

• Nutation

– Backward rotation of ilium on sacrum


Range of Motion (ROM)

• Active range of motion (AROM)

– Hip

• Flexion

• Extension

• Abduction

• Adduction

• Lateral rotation

• Medial rotation


ROM (cont.)

– Knee

• Flexion

• Extension


ROM (cont.)

• Normal ranges

– Hip flexion (110–120°) with knee flexed

– Hip extension (10–15°)

– Abduction (30–50°)

– Adduction (30°)

– Lateral rotation (40–60°)

– Medial rotation (30–40°)

– Knee flexion (0–135°)

– Knee extension (0–15°)


ROM (cont.)


ROM (cont.)

• Passive range of motion (PROM)

– Normal end feel

• Hip flexion and adduction—tissue approximation

• Hip extension, abduction, and medial and lateral rotation—tissue stretch

– Passive movements at pelvic joint also stress the ligamentous structures

• Sacroiliac compression and distraction test


ROM (cont.)

• RROM


ROM (cont.)


ROM (cont.)


Stress Tests

• Sacroiliac compression and distraction test

• “Squish” test

• Sacroiliac rocking test


Stress Tests

• Approximation test

• Patrick’s (FABER) test


Special Tests

• Leg length measurement

– Anatomic

– Apparent


Special Tests (cont.)

• Thomas Test for flexion contractures



• Gaenslen’s test



• Kendall test for rectus femoris contracture

• Hamstring contracture test

• 90° – 90° straight leg raising test



• Straight leg raising

(Lasegue's) test

• Trendelenburg test



• Piriformis test

• Long sitting test

• Ober’s test



• Sign of the buttock test


Neurologic Tests

• Myotomes

– Hip flexion—L1, L2

– Knee extension—L3

– Ankle dorsiflexion—L4

– Toe extension—L5

– Ankle plantarflexion, foot eversion, or hip extension—S1

– Knee flexion—S2

• Reflexes

– No specific reflexes to test the pelvic or hip area

– Lower extremity reflexes

• Patella—L3, L4

• Achilles tendon—S1


Neurologic Tests (cont.)

• Dermatomes • F16.35


Neurologic Tests (cont.)

• Cutaneous patterns


Rehabilitation

• Restoration of motion

– Refer to Field Strategies 16.1 and 17.1

• Restoration of proprioception and balance

– Closed-chain exercises

• Muscular strength, endurance, and power

– Open-chain exercises

– PNF-resisted exercises

• Cardiovascular fitness
