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
Nerve and Blood Supply
 Tibial and common peroneal nerves

Arise from the sacral plexus to form the largest
nerve in the body, the sciatic nerve
 The main arteries of the thigh include:

Deep circumflex, deep femoral, and femoral
 The two main veins of the thigh include:

Great saphenous and femoral
Muscles
 Fascia lata femoris



Deep fascia that surrounds thigh musculature
Thick anteriorly, laterally, and posteriorly
Thin on the medial side
 IT-band

Attachment site for the tensor fascia lata and
gluteus maximum
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
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 the athlete in obvious pain?
 Is the athlete willing to move the thigh?
Palpation: Bony Tissue
 Medial and lateral femoral condyles
 Greater trochanter
 Lesser trochanter
 Anterior superior iliac spine (ASIS)
Palpation: Soft Tissue
 Sartorius
 Adductor brevis, longus,
 Rectus femoris
 Vastus lateralis

 Vastus medialis

 Vastus intermedius

 Semimembranosus

 Semitendinosus

 Biceps femoris

and magnus
Gracilis
Sartorius
Pectineus
Iliotibial Band (IT-band)
Gluteus medius
Tensor fasciae latae
Special Tests
 Not performed if a fracture is suspected!!!
 Passive knee flexion
 Normal = full, pain-free ROM
 Injury = swelling or spasm restricting ROM
 Active knee extension
 Muscle strain = strong and painful ROM
 3rd degree strain or partial rupture = weak and
pain free ROM
 Resistive knee extension
 Nerve injury = muscle weakness against an
isometric resistance
Prevention of Thigh Injuries
 Maximum strength
 Endurance
 Flexibility
 In collision sports, thigh guards are
mandatory to prevent injuries
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



Pain in muscle belly
or point of
attachment
Capillary
hemorrhage
Ecchymosis
 Grade 2

Partial tear

Sharp snap or tear
 Severe pain
 Loss of function
 Grade 3
 Rupture of tendinous or
muscular tissue


 Grade 1



Pain with movement
Point tenderness
<20% of fibers torn
<70% of fibers torn






>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)


Lower limb alignment


ASIS, PSIS, iliac crest
Standing on one leg


Knees, patella, feet
Pelvic landmarks


Lordosis or flat back
Pubic symphysis pain or drop to one side
Ambulation
Palpation: Bony Tissue
 Iliac crest
 Pubic symphysis
 Anterior superior iliac
 Ischial tuberosity
spine (ASIS)
 Anterior inferior iliac
spin (AIIS)
 Posterior superior iliac
spine (PSIS)
 Greater trochanter
 Femoral neck
 Poster inferior iliac
spine (PIIS)
Palpation: Soft Tissue
 Rectus femoris
 Gluteus maximus,
 Sartorius
 Iliopsoas

 Inguinal ligament

 Gracilis

 Adductor magnus,

medius & minimus
Piriformis
Hamstrings
Tensor fasciae latae
Iliotibial Band
longus & brevis
 Pectineus
Major regions of concern are the groin, femoral triangle,
sciatic nerve, and lymph nodes
Special Tests
 Functional Evaluation




PROM, AROM, RROM
Hip adduction and abduction
Hip flexion and extension
Hip internal and external rotation
Special Tests: Hip Flexor Tightness
 Kendall test

Test for rectus femoris tightness
Special Tests: Hip Flexor Tightness
 Thomas test

Test for hip contractures
Special Tests: 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
Special Tests: Hip and Sacroiliac Joint
 Gaenslen’s Test
 Test forces SI joint into
extension
 Hyperextension on the
affected side
increases pain
Special Tests: Tensor Fasciae Latae
and Iliotibial Band
 Renne’s test


Athlete stands with knee
bent at 30 - 40 degrees
Pain at lateral femoral
condyle indicates tensor
fasciae latae tightness
Special Tests: Tensor Fasciae Latae
and Iliotibial Band
 Nobel’s Test



Lying supine, knee is
flexed to 90 degrees
Pressure is applied to
lateral femoral condyle
while knee is extended
Pain at 30 degrees of
knee flexion in the area of
the lateral femoral condyle
indicates IT band irritation
Special Tests: Tensor Fasciae Latae
and Iliotibial Band
 Ober’s Test


Used to determine presence of contracted
TFL or IT-band
Thigh will remain in abducted position
Special Tests: Tensor Fasciae Latae
and Iliotibial Band
 Trendelenburg’s Test


Stand on one leg and compare level of PSIS
and iliac crests bilaterally
Test is positive when
affected side is higher

Indicates weak
hip abductors
(gluteus medius)
Special Tests: Piriformis
 Piriformis Test


Hip is internally rotated
Tightness or pain is
indicative of piriformis
tightness
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 nontraumatic 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



Major slippage results in displacement


Rest and non-weight bearing may prevent further slippage
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
Osteitis Pubis
 Etiology


Often seen in distance runners
MOI = repetitive stress
 Signs and Symptoms



Chronic pain and inflammation of groin
Point tenderness on pubic tubercle
Pain with running, sit-ups, and squats
 Management

Rest, NSAID’s, and gradual return to activity
Pelvic Injuries
Athletic Pubalgia
 Etiology


Chronic pubic region pain
MOI = repetitive stress to pubic symphysis
from kicking, twisting, or cutting
 Signs and Symptoms
 No presence of hernia
 Chronic pain during exertion
 Sharp and burning pain that radiates into
adductors and testicles
Pelvic Injuries
Athletic Pubalgia (continued)
 Signs and Symptoms (continued)


Point tenderness on pubic tubercle
Increased pain with resisted hip flexion,
internal rotation, abdominal contraction, and
hip adduction
 Management
 Conservative treatment (rarely effective): rest,
ROM exercises, and PRE exercises
 Aggressive treatment: cortisone injection or
surgical tightening of pelvic wall
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
Rehabilitation Techniques
 General Body Conditioning


Must maintain cardiovascular fitness, muscle
endurance, and strength of total body
Avoid weight bearing activities if painful
 Flexibility


Regaining pain free ROM is a primary concern
Progress from passive to PNF stretching
Rehabilitation Techniques
 Strength





Progression from isometric exercises to isotonic
strengthening PREs
Isokinetic exercises may be utilized
PNF strengthening could be incorporated to enhance
functional activity
Active exercise should occur in pain free ranges
 Avoid re-aggravating the injury
Exercises for the core must also be included
 Develop functional strength and dynamic stabilization
Rehabilitation Techniques
 Neuromuscular Control
 Established through postural alignment and stability
strength
 As neuromuscular control is enhanced, the ability of
the kinetic chain to maintain appropriate forces and
dynamic stabilization increases
 Focus on balance and closed kinetic chain activities
Functional Progression and Return
to Activity
 Begin in pool, non-weight bearing
 Progression of walking, to jogging, to running,
and to more difficult agility tasks
 Before returning to play, athlete should
demonstrate pain free function, full ROM,
strength, balance, and agility