Ch. 21 Thigh, Hip, Groin, and Pelvis

Anterior muscles of the thigh
Sartorius and quadriceps femoris
What four muscles make up the quadriceps femoris?
rectus femoris, vastus lateralis, vastus medialis, and vastus intermedius
Posterior muscles of the thigh
Biceps femoris, semitendinosus, semimembranosus, and popliteus
Medial muscles of the thigh
adductor magnus, adductor longus, adductor brevis, pectineus, and gracilis
What anterior thigh muscle crosses both the hip and knee joint?
rectus femoris
What three muscles are called the "hamstrings"?
biceps femoris, semimembranosus, and semitendinosus
What is the longest and strongest bone of the body?
What three muscles all together form the pes anserinus tendon?
sartorius, gracilis, and semitendinosus
The medial thigh compartment muscles all act as what two movements?
adductors and lateral rotators of the thigh at the hip joint
The medial thigh muscles are commonly know as what?
What is the largest nerve in the body, which happens to supply the muscles of the thigh and lower leg?
greater sciatic nerve
What are the three main arteries that supply the thigh?
medial circumflex femoral, deep femoral, and femoral arteries
What is the strongest ligament in the body?
iliofemoral ligament (Y ligament of Bigelow)
What ligament supplies the femoral head with nutrients and vascularization?
ligamentum teres
What are the circular fibers that surround the femoral neck that serve as a tight collar to hold the femoral head in the joint?
zona orbicularis
Which portion of the fascia lata is thin?
on the medial side where it covers the adductors
What is the only muscle of the hamstring group that does not cross the hip joint?
short head of the biceps femoris
What are the two main veins of the thigh?
great saphenous and femoral vein
When would you not do a special test?
when a fracture is suspected
What special test may indicate nerve injury?
muscle weakness against an isometric resistance
What three properties should the thigh have to withstand strain?
maximum strength, endurance, and extensibility
What is the usual mode of injury for quadricep contusions?
traumatic blunt blow (extent of force and degree of thigh relaxation will determine the severity of injury)
What are the signs and symptoms of the quadricep contusion?
pain, transitory loss of function, immediate effusion with palpable swollen area
How many different grads of a quad contusion are there?
4; Grade 1 -4 (superficial to deep with increasing loss of function)
True/False. If thigh is contracted, a direct blow will probably be less affected than if the thigh were relaxed.
How should a quad contusion be treated?
Immediately place knee in 90 degree flexion and apply ice (stretch the muscle and prevent shortening)
What should be avoided at first with a quad contusion?
Heat, massage, and ultrasound to prevent myositis ossificans
What is it called when calcified formations that resemble cartilage or bone are found in the thigh muscle?
myositis ossificans
A quadricep strain usually occurs from a sudden, violent motion with the hip and knee in what position?
Hip and knee in flexion with the hip initially extended. Another mode is if the hip is in extension and the knee is flexed
What quadricep muscle is the most disabling when strained?
Rectus femoris (due to its involvement in two joints)
What are the common signs and symptoms of a grade 1 quad strain?
Patient complains of tightness of front of thigh; near normal ambulation; limited swelling; mild discomfort during palpation
What are the common signs and symptoms of a grade 2 quad strain?
abnormal gait cycle; noticeable swelling with pain during palpation, possible defect in muscle; resistive knee extension will produce pain
What are the common signs and symptoms of a grade 3 quad strain?
pain with palpation; may be unable to perform knee extension and unable to amubulate; isometric contractions may produce defect or bulging in muscle belly
What is the treatment for a grade 1 quad strain?
Neoprene sleeve may provide added support
What is the treatment for a grade 2 quad strain?
Ice and compression for 3-5 days with gradual increase in isometric exercises and pain free knee ROM exercises
What do you want to avoid doing at first with quad strains?
Stretching because it will further tear muscle fibers
What is the treatment of a grade 3 quad strain?
Crutch usage for 7-14 days; compression for support; may require 12 weeks until returning to full activity
What is the 2nd most common thigh injury?
Hamstring muscle strain
What is the most common reason for a hamstring strain?
lack of flexibility
What grade of a hamstring strain shows soreness during movement and point tenderness?
Grade 1
What grade of a hamstring strain is identified by a sharp snap or teark, severe pain, and loss of function?
Grade 2
What grade of a hamstring strain is it when more than 70% of the muscle fibers tore producing edema, loss of function, ecchymosis, palpable mass or gap in muscle?
Grade 3
How should grade 2 and 3 hamstring strains be treated?
RICE, NSAIDS, and analgesics and gradual return to stretching and strengthening in later stages of healing
What is ecchymosis?
discoloration (black and blue)
What type of exercise should a trainer focus on when rehabilitating a hamstring strain when soreness is eliminated?
isotonic leg curls focusing on eccentric
True/False. A fracture lateral to femoral neck tend to be more complicated because of decreased blood supply.
What population can femoral stress fractures be dominantly found in?
Athletes in the female triad and/or endurance athletes
What are the signs and symptoms of an acute femoral fracture?
pain, swelling, deformity, leg with fracture may be shorter due to a displacement fracture, muscle guarding (hip is adducted and externally rotated)
What is one noticeable sign of a femoral stress fracture?
patient walks with an abduction lurch
True/False. Most acute femoral fractures occur in the bottom 1/3 of the bone.
False; occur in the middle 1/3 due to structure and point of contact
What are the three main parts of the pelvis?
ilium, ischium, and pubis
What type of joint is the hip joint?
ball and socket joint
True/False. Anterior tilting changes degree of lumbar lordosis and lateral tilting changes degree of hip abduction.
Where is the body's center of gravity located?>
just anterior to the sacrum
What three pelvic landmarks should be identified during observation?
ASIS (anterior superior iliac spine), PSIS (posterior superior iliac spine), and iliac crest
What are the four major regions of concern in the pelvic region?
groin, femoral triangle, sciatic nerve, and lymph nodes
What movements should the trainer test during functional evaluation of the hip joint?
adduction, abduction, flexion, extension, internal rotation and external rotation
What tests check for hip flexor tightness?
Kendall test (active) and Thomas test (passive)
What is the positive sign for hip flexor tightness in these tests?
During flexion of the one leg the other leg will not be able to lay flat on the table and will rise off the table
True/False. Retroversion is the internal rotation of the hip and anteversion is the external rotation of the hip.
False; it's the reverse - retroversion is external rotation and anteversion is internal rotation
What does the Patrick test or FABER test check?
conditions of the hip and sacroiliac joint
What position is the patient in during the FABER test?
lying supine on table and trainer pushes on the ASIS with one hand and the other moves the affected leg into external rotation, abduction, and flexion with the patient's foot on superior to the opposite leg knee.
What angle degree denotes anteversion and retroversion?
More than 35 degrees of internal rotation is anteversion and more than 45 degrees of external rotation is retroversion. (15 degrees is the normal angle)
A rodeo cowboy gets kicked in the anterior thigh after being thrown off a bull. What is the most important thing that an athletic trainer can do to allow this cowbody to continue to compete?
Treat the quad contusion appropriately with leg in flexion with applied ice and compression, also have cowboy wear a protective thigh pad as to prevent repeat injuries. These are important because without these measures myositis ossificans can develop.
A sprinter competing in a 100-yard dash experiences a sudden snap, severe pain, and weakness in the left hamstring muscle. Examination reveals a grade 2 strain. In terms of exercise, how should this injury be managed?
Initially, activit should be significantly reduced. Isometric exercise should be carried out after the early inflammatory phase. In later stages of healing, pain-free exercise such as gentle stretching, jogging, stationary cycling, and high speed isokinetics may be employed.
What joint articulated the sacrum and the ilium and produces a small backward-forward movement?
sacroiliac joint
True/False. The femoral head is a sphere that fits into the acetabulum in a medial, downward, and slightly backward direction.
False; Fits in a medial, upward, and slightly forward direction
What fibrocartilage surround the rim of the acetabulum?
Glenoid labrum
What ligament prevents hyperextension, controls external rotation and adduction of the thigh, and limits pelvis during any backward rolling of the femoral head during weight bearing?
iliofemoral ligament (Y ligament of Bigelow)
What are the anterior hip muscles?
iliacus and psoas
What are the posterior hip muscles?
tensor fasciae latae, gluteus maximus, gluteus medius, gluteus minimus, 6 outward rotators (superior gemellus, inferior gemellus, piriformis, obturator internus, obturator externus, quadratus femoris)
What muscle allows the body to rise from a sitting to a standing position?
gluteus maximus
True/False. Due to all the attachments in a small area, injury to the hip structures can be very disabling and difficult to distinguish.
True/False. The most injured structures of the hip, groin, and pelvis are the ligaments and tendons.
False; (muscles and tendons that perform movements)
True/False. During normal gait, the hip joint does not move in all three planes.
False; the hip joint does move in all three planes (sagittal, frontal, and transverse)
True/False. The PSIS, represented by the depression above the buttocks, and the ASIS should be horizontal to one another when checking symmetry.
True; uneven depressions could indicate that one side of the pelvis is rotated
A young gymnast has a history of moderate groin pain. She is susceptible to strains in that region. The patient also appears to have an exaggerated lumbar lordotic curve. What tests should be given to evaluate the tightness of the groin region?
Kendall and Thomas test
What is the typical position for a hip dislocation?
slightly flexed, adducted, and internally rotated
True/False. An increased Q angle or a leg-length discrepancy can lead to trochanteric bursitis in women runners.
What tests can be used to identify a problem with the IT band or tensor fascia latae?
Renne's test (athlete stands w/knee bent at 30-40 degrees and positive response is when pain is felt at lateral femoral condyle), Nobel's test (lying supine the knee is flexed to 90 degrees and pressure is applied to lateral femoral condyle while knee is extended and pain present at 30 degrees is a positive sign), and Ober's test (sidelying patient's leg is extended and abducted and when trainer releases the thigh will remain in the abducted position)
The Trendelburg's test is used for to identify what problem?
weakness in the hip abductors mainly the gluteus medius (patient stands the foot on the unaffected side is lifted so that the hip flexes normally the iliac crest on the unaffected side is higher than on the affected side, but a positive sign is when the unaffected side is lower than the affected side)
Name the test that is performed as follows: The patient lies on the unaffected side with the affected leg in 60 degrees of hip flexion and the knee relaxed. The pelvis is stabilized and pressure is applied downward on the knee, rotating the hip internally. Tightness or pain is a positive sign.
Piriformis Test
What test is used to assess the tightness of the rectus femoris with the patient prone, pelvis stabilized, and knee on affected side is flexed.
Ely's Test - positive sign is if the hip on that side extends as the knee is flexed (butt rises when knee is bent)
True/False. With inactive individuals, difference of more that 1 inch may produce symptoms with leg length discrepancy, but with active individuals symptoms may occur with as little as 3mm (1/8 inch) difference.
What are the three types of leg-length discrepancy?
1. Anatomical (measurement taken from medial malleolus to ASIS)
2. Apparent (lateral pelvic tilt or from a flexion or adduction deformity)
3. Functional (due to deformity such as valgus knee that cannot be fixed and the measurement is taken from umbilicus to medial malleolus)
During a gait evalutation, an athletic trainer notices that the patient walks with a swinging hip - one side of the pelvis drops to the side during single-leg stance. What could be a cause of this movement?
weakness of the gluteus medius (positive sign of Trendelenburg's test)
What is the most common muscle injured in a groin strain?
adductor longus
How does an adductor/hip flexor (groin) strain occur?
running, jumping, twisting with hip external rotation or severe stretch
True/False. Do not stretch the groin if injury is possible.
True; could cause further injury.
What is the treatment of a groin strain?
RICE, NSAID's and analgesics for 48-72 hours; rest is critical; daily whirlpool and cryotherapy, moving into ultrasound; delay exercise until pain free; usage of neoprene compression shorts
What is the inflammation at the site where the gluteus medius inserts?
trochanteric bursitis (also the IT band passes over the trochanter; common overuse injury)
What are the signs and symptoms of trochanteric bursitis?
Complaints of lateral hip pain that may radiate down the leg, palpation reveals tenderness over lateral aspect of greater trochanter
What tests should be done to identify trochanteric bursitis?
IT band and TFL tests - Ober's test, Renne's test, Nobel's test
True/False. An increased Q angle or a leg-length discrepancy can lead to trochanteric bursitis in women runners.
Common management for what injury includes RICE, NSAID's and analgesics, ROM and PRE directed toward hip abductors and external rotators, phonophoresis if pain doesn't respond in 3-4 days, and runners should avoid inclined surfaces.
Trochanteric bursitis
True/False. The hip joint, the strongest and best protected joint in the human body, is seldom seriously injured during sports activities.
If a force is applied to a person in the hip region from an opponent/object or trunk forced over planted foot in opposite direction, what type of injury may occur?
Sprain of the hip joint
How does a dislocated hip occur?
traumatic force directed along the long axis of the femur (posterior dislocation with hip flexed and adducted and knee flexed)
If a person dislocated their hip, what should be done immediately?
Immediate medical care, check the pulse, sensations, and reflexes because blood and nerve supply could be compromised.
A construction worker jumps down off a ladder. Landing off balance, he violently twists his right hip. From the information provided, what type of injury could he have sustained?
Hip joint sprain
A sedentary office assistant has been determined to have a Q angle of 22 degrees. Her left leg is 3/4 inch shorter than her right leg. She complains of pain at the point just over the left greater trochanter when she walks. Based on the information provided, what might the condition be?
Could be inflammation of the gluteus medius muscle or IT band, or could be trochanteric bursitis caused by increased Q angle and short leg.
What is avascular necrosis?
Temporary or permanent loss of blood supply to the proximal femur in which the bone tissue dies and causes collapse of the joint surface. Can be caused by traumatic conditions such as hip dislocation or non-traumatic such as steroids, blood coagulation disorders, excessive alcohol consumption.
The breakdown or degeneration of what hip structure usually occurs due to repetitive movements such as running or pivoting?
hip labral tear
What are the signs and symptoms of a hip labral tear?
Often asymptomatic, may present with clicking, locking, stiffness, limited ROM,pain in through the groin and hip, limited ROM and feeling of stiffness.
True/False. Surgery is always recommended with hip labral tears to repair.
False; if conservative treatment of ROM exercises focusing on strength and stability and corticosteroid medication does not work within 4 weeks, surgery is then recommended.
What are three common hip problems associated with young athletes?
1. Legg Calve Perthes Disease (avascular necrosis of the femoral head in children 4-10)
2. Slipped Capital Femoral Epiphysis (found mostly in boys 10-17 who are either tall and thin or obese; head slippage can appear posterior and inferior)
3. Snapping Hip Phenomenon (common in young female dancers, gymnasts, and hurdlers; related to structurally narrow pelvis, increased hip abduction and limited lateral rotation)
How can the snapping hip phenomenon be manifested?
1. IT-band moving over greater trochanter resulting in trochanteric bursitis
2. Iliopsoas tendon moving over iliopectineal eminence
3. Iliofemoral ligament moving over femoral head
4. long head of biceps femoris moving over ischial tuberosity
What movements are limited by slipped capital femoral epiphysis?
abduction, flexion, medial rotation
A 15 year old football player complains of pain in his hip off and on during the season. There is increasing hip and knee pain during movement. The athlete has a restriction of hip abduction, flexion, and medial rotation. He is beginning to walk with a limp. What should the athletic trainer be concerned about in this 15 year old and what steps should be taken?
Because of the athlete's age, the trainer should consider the possibility of a growth problem, most likely a slipped capital femoral epiphysis. The trainer must refer the athlete to a physician immediately for X-rays.
A blow to the iliac crest can cause a bruise or hematoma is known as what?
hip pointer contusion
A young patient complains to the athletic trainer that her hip snaps when she stands on one leg. What is the possible cause of this snapping hip?
Likely problem is a strength imbalance of the muscles that help stabilize the hip joint while flexing and rotating; could also be a structurally narrow pelvis, greater than usual ROM of hip abduction, or a restricted ROM during lateral rotation
What is the most common injury of contact sports?
Hip pointer contusion
True/False. A patient that has a hip pointer contusion is unable to rotate the trunk or extend the thigh without pain.
False; unable to rotate the trunk and flex the thigh without pain.
What is the usual recovery time for a hip pointer contusion?
1-3 weeks
True/False. Pelvis rotates along longitudinal axis when running, proportionate to the amount of the arm swing.
What are two injuries that affect the pubic symphysis?
1. Osteitis Pubis - common in distance runners, soccer, football, and wrestling; repetitive stress on pubic symphysis; chronic pain and inflammation; acute case may be from bike seat
2. Athletic Pubalgia - chronic pubic region caused by repetitive stress to pubic symphysis from kicking, twisting, or cutting; pain radiates laterally into adductors and testicles
What motion causes athletic pubalgia? What motion increases pain with athletic pubalgia?
- forced adduction from hyperextended position
-resisted hip flexion, internal rotation, abdominal contraction, resisted hip adduction
Treatment for athletic pubalgia?
Conservative Treatment: 1st week - massage, 2nd week - strengthening of abs, hip flexors, and adductors 3rd, 4th week - running progression
Aggressive Treatment: Cortisone injection or tightening of pelvic wall surgically
True/False. Stress fractures are more common in women than men.
What are three common sites of stress fractures in the hip region?
1. inferior pubic ramus
2. femoral neck
3. subtrochanteric area of femur
Management of what injury includes the following: Rest for 2-5 months, crutch walking for ischium and pubis fractures, x-ray are usually normal for 6-10 weeks and bone scan will be required; swimming can used for training (breast stroke should be avoided)
stress fracture
What type of sports are avulsion fractures common in?
sports with sudden decelerations and accelerations
What are the 3 common sites of avulsion fractures and apophysitis
1. ischial tuberosity
2. AIIS (anterior inferior iliac spine)
3. ASIS (anterior superior iliac spine)
In avulsion fractures and apophysitis, what degree of ROM should be regained before instituting a PRE program?
80 degrees
True/False. Mobilization will not be necessary if injury and subsequent limitation is caused by tightness of ligaments and capsule surrounding the joint.
False; mobilization will be necessary for those conditions
What are two joint mobilization techniques that can be used to restore motion?
anterior glides (increase extensions), posterior glides (increase hip flexion) and rotations
What is the typical progression for regaining strength following an injury to the hip region?
isometric exercises - isotonic strengthening PRE's - isokinetics - PNF strengthening - must also include core strengthening exercises - swimming (non-weight bearing) - walking - jogging - running
What two things increase when neuromuscular control is enhanced?
1. the ability of the kinetic chain to maintain appropriate forces
2. dynamic stabilization increases
True/False. For neuromuscular control, trainer should focus on balance and open kinetic chain activities.
False. balance and closed kinetic chain activities
Name some stretching exercises for the thigh and hip.
supine static hamstring stretch, kneeling quadriceps and hip flexor stretch, sitting piriformis stretch, standing hip abductor stretch, supine gluteal stretch, dynamic forward hip swing gluteal stretch, sitting abductor stretch, supine hip internal and external torator stretch, quadriceps myofascial stretch, standing adductor stretch on stability ball, piriformis myofascial stretch on plyoball, hamstring stretch on a stability ball
What should be immediately done if someone has suffered from a femoral fracture?
treat for shock and verify neurovascular status
What test can be used to test the tightness of the rectus femoris?
Kendall test