Soft Tissue Injuries of Hip and Thigh

Soft Tissue Injuries of Hip and ThighByRICHA VISHWAKARMAM.P.T. II YEAR(MUSCULOSKELETAL)

Hamstring injury in athletesThe hamstring muscle group consists of three muscles: the semimembranosus, the semitendinosus, and the biceps femoris (long and short heads). These three muscles function during the early stance phase for knee support, during the late stance phase for propulsion of the limb, and during mid swing to control momentum of the extremity.Injury to the hamstrings, whether partial or complete, typically occurs at the myotendinous junction where the eccentric force is concentrated.Mechanism of InjuryThe two most common factors in hamstring injury are lack of adequate flexibility and strength imbalances in the hamstrings (flexor-to-extensor and right-to-left).Other controllable factors such as lack of adequate warm-up, lack of flexibility, overall conditioning, and muscle fatigue should all be corrected to minimize the chance of hamstring injury.large tear of the hamstring muscle group

Radiograph demonstrates an avulsioninjuryof the common hamstring tendon.

ClassificationHamstring injuries are classified in three groups: mild(grade 1), moderate (grade II), and severe (grade III). Grade I strain or "pulled muscle" signifies an overstretching of the muscle resulting in disruption of less than 5% of the structural integrity of the musculotendinous unit. Grade II represents a partial tear with a more significant injury but an incomplete rupture of the musculotendinous unit. Grade III represents a complete rupture of the muscle with severely torn, frayed ends similar to those seen in an Achilles tendon rupture.InvestigationsMRI should be infrequently used. On MRI, acute injuries typically show up as high signal intensity on T2 weighted images as a result of (hemorrhage or edema)within the muscle belly.Chronic muscle injuries are less predictable in appearance.Plain radiographs are of little value unless an avulsion fracture of the ischial tuberosity is suspected. plain films of the pelvis (anteroposterior view of the pelvis that includes the ischial tuberosity) should be taken if an avulsion fracture of the ischial tuberosity is suspected.Signs and Symptoms of Muscle Strains

ManagementSurgery is typically considered only after a complete hamstring avulsion from the ischial tuberosity with a bony avulsion displacement of 2 cm or more.Distal avulsions are treated like proximal avulsions when these occur in isolation (rarely occur).Operative managementModified Clanton, Coupe, Williams, and Brotzman ProtocolPhysiotherapy Management

Phase 1:Acute

Phase 2: Sub acute

Phase 3: Remodelling

Phase 4: Functional

Phase 5: return to compitition

QUADRICEPS STRAINSQuadriceps tears or strains are typically caused by indirect trauma. The patient complains of a feeling of a "pulled" muscle, the mechanism often occurs by the patient missing a soccer ball and striking the ground Violently with forced stretching of the contracting quadriceps muscle.Risk factors:-Risk factors for quadriceps strains (or tears) include inadequate stretching, inadequate warm-up before vigorous exercise, and muscle imbalance of the lower extremity.Signs and symptomes:The patient typically complains of a "pulled" thigh. Examination typically reveals tenderness on palpation of the rectus femoris (strain) or defect (tear). This is usually found in the muscle belly. Because the rectus femoris is the only quadriceps that crosses the hip joint, extending the hip with the knee flexed causes more discomfort than flexing the hip with the knee extended. This extended hip maneuver causes pain because of its isolation of the rectus femoris.Treatment of Quadriceps Strains (or Tears)RICE. NSAIDs if not contraindicated. Crutches in a touch-down or partial weight-bearing (painless) fashion. Hold all lower extremity athletic participation. Avoid SLR in early rehabilitation because of increased stress on the torn rectus femoris.Acute phaseGoals Regain normal gait. Regain normal knee and hip motion. Usually intermediate phase begins 3-10 days post injury, depending on severity of injury.Intermediate phaseExercises Initiate a gentle quadriceps and hamstring stretching program. PNF patterns. Aquatic rehabilitation program in deep water with flotation belt. Cycling with no resistanceTerminal knee extension exercises. Increase aquatic program (deep-water running [DWR]). Begin knee extension with light weights, progress. SLR, quad sets progressing to PRE (progressive resistance exercises) with 1- to 5-pound weight on the ankle.Return of function phaseIncrease low-impact exercises to progress endurance and strength: Progress bicycle resistance and intensity of workout. Elliptical trainer. Thera-bands for hip flexion, extension, abduction, adduction. Walking progression to jogging (painless). 30-degree mini-squats (painless). Initiate sport-specific drills and agility training. Isokinetic equipment (at higher speeds) with patient supine.ADDUCTOR STRAINThe commonly accepted definition of a groin strain focuses on injury to the hip adductors and includes the iliopsoat, rectus femoris, and sartorius musculotendinous units.Risk factorsContact sportsObesityPoor muscle conditioningInflexibilitySports that require quick startsSign and symptomesAcute pain over proximal muscles of medial thigh region SwellingOccasional bruisingAfter Groin (Adductor) StrainActivity Relative rest from athletic injury until patient is asymptomatic and rehabilitation protocol complete. Avoid lateral movements, pivoting, twisting, reverse of direction. Initiate PRICE regimen (protection, rest, ice, compression,elevation above heart).Phase 1: Immediate post injuryCrutches Employ crutches weight-bearing as tolerated until patient walks with a normal, nonantalgic gaitModalities Cryotherapy postexercise. Pulsed ultrasound. Electric stimulationExercises Aquatic deep-water pool running. Stationary bicycling with no resistance. Active ROM exercises of hip Flexion, extension, abduction, gentle adduction. Isometric exercises Hip adduction. Hip abduction. Hip flexion. Hip extension. SLR, quad sets.Criteria for Progression to Phase 2 Minimal to no pain on gentle groin stretching. Good, painless gait. Swelling minimal.Progressive Resistance Exercises (1- to 5-pound weight) Hip abduction, adduction, flexion, extension. SLR.Continue modalities (ultrasound, moist heat).Proprioceptive exercises.Initiate gentle groin stretchesPhase 2: intermediate phaseWall groin stretch . Groin stretch . Straddle groin and hamstring stretch . Side-straddle groin/hamstring stretch Hamstring stretches. Passive rectus femoris stretch. Passive hip flexor stretch. Progress stationary bicycling resistance. DWR in pool. PNF patterns.Jogging/ runningBox drill.Protective wrapping or commercial hip spica type protection.Bursitis & Tendinitis around hipTrochanteric bursitis:Pain over the lateral aspect of the hip & thigh may be due to local trauma or overuse resuting in inflammation of the trochanteric bursa which lies deep to the tensor fascia lata.Gluteus medius tendinitis:Acute tendinitis may cause pain and localized tenderness just behind the greater trochanter. Perticularly seen in dancers and athletes.Adductor longus strain or tendinitis:Adductor muscle strains are a common injury in sports that involve sudden changes of direction. Often seen in footballers and athletes. The patient complains of pain in the groin and tenderness can be localized to the adductor longus origin.Iliopsoas bursitis:Pain in the anterior thigh and groin may be due to an iliopsoas bursitis. The condition may arise from synovitis of hip as hip joint and bursa are interconnected. The most typical feature is a sharp pain on adduction and internal rotation of the hip.Snapping hip pain:Snapping hip is a disorder in which the patient complains of the hip jumping out of place or catching during walking. The snapping is caused by a thickened band in the gluteus maximus aponeurosis flipping over the greater trochanter.In the swing phase of walking the band moves anteriorly than in the stance phase as the Gmax contracts and pulls the hip into extension, the band flips back across the trochanter causing an audible snap.Often if discomfort is marked the band can be either divided or lenghthened by a z-plasty.Treatement of other tendinitis and bursitis include rest and local anesthetic and corticosteroid injection.Management Controll inflammation and promote healing- by not stressing the involved tissue. and the patient avoid the provoking activity; and if necessary, decrease the amount and time walking or use an assistive device.

Develop Support in Related Areas-Initiate exercises to develop neuromuscular control for alignment of the pelvis and hip.Protection phaseDevelop a Balance in Length and Strength of the Hip Muscles.Stretch any muscles that are restricting motion with gentle, progressive neuromuscular inhibition techniques.Instruct the patient to do self-stretching with proper stabilization to ensure that the stretches are performed safely and effectively.Begin developing neuromuscular control to train the involved muscles to contract and control alignment of the femur. Initially, the emphasis is on control, not strengthening.Controlled motion phaseOnce the patient is aware of proper muscle control and is able to maintain alignment, progress to strengthening the weakened muscles through the range.Muscles not directly injured should be stretched and strengthened if they are contributing to asymmetrical forces. The patient may not have sufficient trunk coordination or strength, which may be contributing to the overuse because of compensations in the hip.Apleys system of orthopedics and fracture.Clinical orthopedic rehabilitation.Therapeutic exercise.referenceThank you