Chapter 14 Pelvis, Hip, and Thigh Conditions

Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins

Chapter 14

Pelvis, Hip, and Thigh Conditions

Chapter 14

Pelvis, Hip, and Thigh Conditions


Anatomy Anatomy Skeletal features of the pelvis, hip, and thigh


Anatomy (cont’d)Anatomy (cont’d)

• Pelvis

– Function

• Protects organs

• Transmits loads between trunk and lower extremity

• Provides site for muscle attachments



• Pelvis (cont’d)

– 4 fused bones

• Sacrum

• Coccyx

• Innominate bones

• Ilium, ischium, and pubis




– 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

• Femur

– Weakest at femoral neck



• Hip Joint

– Head of femur and acetabulum of pelvis

– Ball and socket joint

– Very stable



• Hip Joint (cont’d)

– Strong ligament support

• Iliofemoral ligament

• Limits hyperextension

• Pubofemoral ligament

• Limits abduction and hyperextension


Anatomy (cont’d)Anatomy (cont’d)• Hip Joint (cont’d)

– Strong ligament support (cont’d)

• Ischiofemoral ligament

• Limits extension

Ligaments of the pelvis and hip



• Femoral Triangle

– Borders

• Inguinal ligament—superior

• Sartorius—lateral

• Adductor longus—medial



• Femoral Triangle (cont’d)

– Contents

• Femoral nerve

• Femoral artery

• Femoral vein

Femoral triangle



• 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



• Bursae (cont’d)

– 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



• Nerves

– Lumbar plexus

• Femoral nerve

• Obturator nerve

– Sacral plexus

• Sciatic nerve



• Blood Vessels

– External iliac

• Femoral

• Deep femoral

• Femoral circumflex


Kinematics and Major Muscle ActionsKinematics and Major Muscle ActionsMuscles of the pelvis, hip, and thigh. Anterior view


Kinematics and Major Muscle Actions (cont’d)Kinematics and Major Muscle Actions (cont’d)Muscles of the pelvis, hip, and thigh. Lateral view


Kinematics and Major Muscle Actions (cont’d)


Muscles of the pelvis, hip, and thigh. Posterior view




• 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


Kinematics and Major Muscle Actions (cont’d)Kinematics and Major Muscle Actions (cont’d)

PRIMARY ACTION

MUSCLES

Flexion Iliopsoas; rectus femoris; pectineus; sartorius; tensor fasciae latae

Extension Gluteus maximus; biceps femoris; semitendinosus; semimembranosus; adductor magnus

Abduction Gluteus medius; gluteus minimus

Adduction Adductor brevis; adductor magnus; adductor longus; adductor magnus; gracilis

Medial rotation Gluteus minimus; gluteus medius; tensor fasciae latae; semitendinosus; semimembranosus; adductor muscles

Lateral rotation Piriformis; obturator internus; obturator externus; superior gemelli; inferior gemelli; quadratus femoris; gluteus maximus




• Hip joint – movement in 3 planes

– Sagittal

• Flexion and extension

– Frontal

• Abduction and adduction

– Transverse

• Medial rotation and lateral rotation of the femur


Injury PreventionInjury Prevention

• Physical conditioning

– Flexibility

– Strength

• Protective equipment

– Hip joint well protected but iliac and pelvis need protection

– Thigh

• Shoe selection

– Cushion forces


Contusions Contusions

• Hip pointer

– MOI: direct blow to iliac crest

– S&S

• Any trunk movement is painful (incl. coughing, laughing, & breathing)

• Immediate pain, discoloration, spasm, and loss of function

• Unable to rotate trunk or laterally flex the trunk toward injured side.


Contusions (cont’d)Contusions (cont’d)

• Hip pointer (cont’d)

– S&S (cont’d)

• Any trunk movement is painful

• Extreme tenderness

• Abdominal muscle spasm may be present

• Severe injury – unable to walk or bear weight, even with crutches



• Hip pointer (cont’d)

– Management

• Standard acute; rest; protect with hard-shell pad for return to activity

• Severe pain over iliac crest – physician referral



• Quadriceps contusion

– MOI: direct blow

– Common – anterolateral thigh

– S&S

• Pain may be extensive immediately after impact



• Quadriceps contusion (cont’d)

– S&S (cont’d)

• Grade I

• Mild pain and swelling

• Able to walk without a limp

• Passive flexion beyond 90° – painful; resisted knee extension may cause less discomfort.




– S&S (cont’d)

• Grade II

• Can flex the knee between 45 and 90°

• Walks with a noticeable limp

• Grade III

• Unable to bear weight or fully flex the knee.



• Quadriceps Contusion (cont’d)

– Management:

• Standard acute; with knee in maximum flexion

• Hard-shell pad for return to activity

• Physician referral if S&S persist >48 hours




Management of a quadriceps contusion



• Myositis ossificans

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

– Evident on radiograph 3–4 weeks after injury

Myositis ossificans



• Myositis ossificans (cont’d)

– 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


Bursitis Bursitis • MOI

– Excessive friction orshear forces due to overuse

• Greater trochanteric bursitis

– Influence of Q-angle

Bursa of the hips


Bursitis (cont’d)Bursitis (cont’d)

• Greater trochanteric bursitis

– S&S

• Burning or aching over or posterior to greater trochanter

• Aggravated with:

• Hip abduction against resistance

• Hip flexion and extension on weight bearing



• 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

– Do not permit to continue activity until seen by a physician

– Suggest cold to decrease pain and inflammation



• Snapping hip syndrome

– Can result from chronic bursitis

– 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



• Snapping hip syndrome (cont’d)

– Management

• Do not permit to continue activity until seen by a physician

• Suggest cold to decrease pain and inflammation


Hip Sprains and DislocationsHip Sprains and Dislocations

• MOI

– Violent twisting actions

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

• S&S

– Mild/moderate: pain with internal rotation

– Severe: intense pain; inability to move hip

– Position of flexion and internal rotation


Hip Sprains and Dislocations (cont’d)Hip Sprains and Dislocations (cont’d)

• Management

– Mild/moderate—standard acute; physician referral

– Severe—activate EMS; immobilize in position found – do not move; monitor and treat for shock


Hip DislocationsHip Dislocations

Hip dislocations


Strains Strains

• Quadriceps

– Typically rectus femoris

– S&S

• Grade I

• Normal gait, but tightness in the anterior thigh

• Pain with passive knee flexion beyond 90°


Strains (cont’d)Strains (cont’d)

• Quadriceps (cont’d)

– S&S (cont’d)

• Grade II

• Snapping or tearing sensation, followed by immediate pain and loss of function.

• Knee held in extension – protection

• Pain with passive knee flexion; Pain & weakness with knee extension



• Quadriceps (cont’d)

– S&S (cont’d)

• Grade III strains

• Extreme pain

• Ambulation not possible

• Defect in the muscle may be visible

• Resisted knee extension not possible; ROM is severely limited



• 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

– Additional risk factors (Box 14.2)

– Strength imbalance



• Hamstrings (cont’d)

– S&S

• Grade 1

• Tightness and tension

• Pain with passive stretching




– S&S (cont’d)

• Grade II

• Tearing sensation or feeling a “pop,” leading to immediate pain and weakness in knee flexion.




– S&S (cont’d)

• Grade III

• Sharp pain may occur during midstride

• Limps; unable to do heel-strike or fully extend the knee.

• Pain and muscle weakness with active knee flexion



• Adductors

– Quick changes of direction, and explosive propulsion and acceleration

– Strength imbalance



• Adductors (cont’d)

– S&S

• An initial “twinge” or “pull” of the groin muscles, and is unable to walk because of the intense, sharp pain

• As the condition worsens, increased pain, stiffness, and weakness in hip adduction and flexion



• Adductors (cont’d)

– S&S (cont’d)

• Running straight ahead or backward may be tolerable, but any side-to-side movement leads to more discomfort and pain

• Pain with passive stretching with the hip extended, abducted, and externally rotated

• Pain with resisted hip adduction



• Predisposing factors

– Beginning of season – too much too soon

– Fatigue

– History of strains; reinjury common

– Restricted flexibility of involved muscle group



• Management:

• Grade 1 – standard acute; If symptoms persist > 2-3 days, physician referral

• Grade 2 or 3 – standard acute; physician referral


Vascular and Neural DisordersVascular and Neural Disorders

• Legg-Calvé-Perthes disease

– Avascular necrosis of proximal femoral epiphysis

– Seen especially in males ages 3–8

– Osteochondrosis of femoral head


Vascular and Neural DisordersVascular and Neural Disorders

• Legg-Calvé-Perthes disease (cont’d)

– S&S

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

• Pain is generally activity related

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


Vascular and Neural Disorders (cont’d)Vascular and Neural Disorders (cont’d)

• Legg-Calvé-Perthes disease

– Management

• Do not permit to continue activity until seen by a physician


Hip FracturesHip Fractures

• Avulsion fractures

– Due to rapid, sudden acceleration and deceleration

– Apophyseal sites

• ASIS with displacement of sartorius

• AIIS with rectus femoris displacement

• Ischial tuberosity with hamstrings displacement

• Lesser trochanter with iliopsoas displacement


Hip Fractures (cont’d)Hip Fractures (cont’d)

• Avulsion fractures (cont’d)

– 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



• Avulsion fractures (cont’d)

– Management: fit with crutches; immediate physician referral



• Slipped capital femoral epiphysis

– Boys ages 12–15

– Femoral head slips at epiphyseal plate—displaces inferiorly and posteriorly

Slipped capital femoral epiphysis



• Slipped capital femoral epiphysis (cont’d)

– S&S

• Early S&S often undetected other than diffuse knee pain

• Later stages

• More comfortable holding leg in slight flexion



• Slipped capital femoral epiphysis (cont’d)

• Later stages

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

• Unable to rotate the femur internally or stand on one leg.

– Management: Do not permit to continue activity until seen by a physician



• Stress fractures

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

– Risk factors



• Stress fractures (cont’d)

– 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



• Stress fractures (cont’d)

– S&S (cont’d)

• ↑ pain on extremes of hip rotation, abduction lurch

• Inability to stand on involved leg

– Management: Do not permit to continue activity until seen by a physician


Sacral and Coccygeal FracturesSacral 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 Shaft FractureFemoral Shaft Fracture

• MOI

– Tremendous impact forces

– Direct compressive forces

• Potential for neurovascular damage


Femoral Shaft Fracture (cont’d)Femoral Shaft Fracture (cont’d)

• S&S

– Severe pain and a total loss of functions

– Swelling at fracture site

– Present with the thigh externally rotated

– Shortened limb deformity


Femoral Shaft Fracture (cont’d)Femoral Shaft Fracture (cont’d)

• Management

– Activate emergency plan, including summoning of EMS

– Do not attempt to immobilize

– Assess and treat for shock as necessary


Femoral Fractures (cont’d)Femoral Fractures (cont’d)

• S&S

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

– Extreme pain and inability/unwillingness to move involved side

– Shock



• S&S (cont’d)

– Neck

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

– Shaft

• Limb appears shortened; thigh appears externally rotated



• 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


Coach and Onsite AssessmentCoach and Onsite Assessment

• S &S that require activation of emergency plan, including summoning EMS

– Obvious deformity suggesting a dislocation or fracture

– Significant loss of motion or loss of function

– Palpable defect in a muscle

– Severe joint disability that may be evident by a noticeable limp


Coach and Onsite Assessment (cont’d)Coach and Onsite Assessment (cont’d)

• S &S that require activation of emergency plan, including summoning EMS

– Excessive soft tissue swelling, particularly in the quadriceps

– Abnormal cutaneous sensations or an absent or weak pulse

• Refer to Application Strategy 14.2

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Chapter 14 Pelvis, Hip, and Thigh Conditions