KIN 191AAdvanced Assessment of Lower

Extremity Injuries

THE PELVIS AND THIGHEVALUATION

INTRODUCTION

• HISTORY• INSPECTION• PALPATION• ROM TESTS• STRESS/STREE TESTS• NEUROGIC TEST• VASCULAR TEST

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HISTORY

• Location of symptoms• Onset of symptoms• Training techniques• Mechanism of injury (etiology)• Prior history (medical conditions)

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Location of Symptoms

• Deep joint pain indicative of joint trauma/injury or may be referred from lumbosacral region

• Anterior hip/groin pain typically associated with hip flexor/adductor muscle strain

• Pain to lateral hip often associated with trochanteric bursitis

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Onset of Symptoms

• Most hip pathologies are overuse/chronic conditions with gradual and insidious onset of symptoms

• Insidious onset – unable to specifically identify one mechanism of injury

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Training Techniques

• Overuse conditions often attributable to– Surface changes– Footwear– Training techniques/skills– Training intensity, frequency and duration

• Tendinitis, bursitis, stress fractures

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Mechanism of Injury

• Direct trauma– Iliac crest – hip pointer– Posterior hip – gluteal contusion

• Eccentric muscle contraction– Muscular strain

• Overuse conditions

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Prior History

• Congenital or developmental hip conditions or abnormalities can alter biomechanics of entire lower extremity– Legg-Calvé-Perthes disease– Slipped capital femoral epiphysis

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INSPECTION• Look for external signs of pathology

– Swelling, discoloration (ecchymosis), deformity

• Leg length discrepancy (true vs. apparent)• Hip angulations

– Angle of inclination (~125 degrees)• > 125° – coxa valga – presents with genu varum• < 125° – coxa vara – presents with genu valgum

– Angle of torsion• > 15° – anteversion – “pigeon toes”• < 15° – retroversion – “duck feet”

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• Pelvic obliquity – iliac crest height not equal bilaterally

• Imaginary line between PSIS (S2 level) bisects SI joints on both sides

• Line across iliac crests crosses spine between L4 and L5 vertebrae

• “Sciatic” nerve lays between ischial tuberosity and greater trochanter

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PALPATION(Medial

Structures)1. Adductor longus2. Adductor magnus3. Adductor brevis

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PALPATION(Anterior

Structures)1. Pubic bone2. ASIS3. AIIS4. Sartorius5. Rectus femoris

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PALPATION(Lateral

Structures)1. Iliac crest2. Tensor fascia latae3. Gluteus medius4. IT band5. Greater trochanter6. Trochanter bursa

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PALPATION(Posterior

Structures)1. Median sacral crests2. PSIS3. Gluteus maximus4. Ischial tuberosity

and bursa5. Sciatic nerve6. Hamstring muscles

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ROM TESTS

• AROM– Flexion (120-130°)– Extension (10-20°)– Adduction (30°)– Abduction (45°)– Internal rotation (45°)– External rotation (50°)

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AROM

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Hip Flexion

• Range of motion - 120~130°• End feel - soft (tissue approximation)• Primary movers

– Iliopsoas, rectus femoris, sartorius• Affected by knee positioning (flexed vs.

extended)– Active by rectus femoris– Passive by hamstring restriction

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Hip Extension

• Range of motion - 10 ~ 20 degrees• End feel - firm (capsular)• Primary movers

– Gluteus maximus, hamstrings

• Affected by knee positioning– Active by hamstrings– Passive by rectus femoris

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Hip Abduction

• Range of motion - ~45°• End feel - firm (capsular)• Primary movers

– Glutues medius, gluteus minimus

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Hip Adduction

• Range of motion - ~30°• End feel - firm (capsular)

– Avoid accessory motions

• Primary movers– Adductor longus/magnus/brevis

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Hip Internal Rotation

• Range of motion - ~45°• End feel - firm (capsular)• Primary movers

– Adductor longus/magnus/brevis– Gluteus medius/minimus

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Hip External Rotation

• Range of motion - 45~50°• End feel - firm (capsular)• Primary movers

– 6 external rotators (piriformis, S.G., I.G., O.E., O.I., Q.F.)

– Sartorius– Gluteus maximus

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PROM

• Flexion

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PROM

• Extension

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PROM

• Abduction Adduction

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PROM

Internal Rotation External Rotation

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Goniometry

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Goniometry

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RROM

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RROM

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RROM

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RROM

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ROM

• SI joint and pubic symphysis have no true range of motion

• Any motion that is present is accessory in nature and minimal

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SPECIAL TESTS

• Thomas test– Evaluates tightness of hip flexors– Thigh and knee position evaluated to differentiate

tightness in iliopsoas vs. rectus femoris

• Trendelenburg’s test/sign– Weakness or neurological injury associated with

gluteus medius– The pelvis lowers on the opposite side of the

affected leg

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Thomas Test

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Trendelenburg’s TestTrendelenburg’s Test

Ligamentous Stress Tests

• No specific stress test for individual ligaments or joint capsule

• Stabilizing structure integrity assessed by end range passive range of motion

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STRESS TESTS

• Pubic symphysis– Translation (secondary to abnormal palpation or

inspection presentation – i.e. elevation or depression)

• SI joint– Compression/distraction– Patrick’s (FABER) test– Gaenslen’s test/sign– Long sit test– SI rocking test

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SI Joint Compression/Distraction

• Compression– Patient supine– “Spread” ASIS – compresses SI joint/s

• Distraction– Side laying – do from both sides– Compress ilium to distract SI joint/s

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SI Compression (A) / Distraction (B) Tests

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Patrick’s (FABER) Test

• Flexion, abduction, external rotation

• Stabilize opposite ASIS and push on crossed knee

• Pain in posterior hip/SI joint area indicative of SI pathology

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Patrick’s (FABER) Test

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Gaenslen’s Test

• Supine on table with involved leg off table side

• Opposite hip fully flexed – involved hip pushed into hyperextension by clinician

• Pain indicative of SI joint dysfunction due to rotational stress to joint

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Gaenslen’s Test

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Long Sit Test

• Evaluative for ilium rotation on sacrum at SI• Clinician’s thumbs on medial malleoli• Patient “sets” pelvis with bridge maneuver and then

performs active long sit• Clinician indicates any change in orientation of

medial malleolus relationship– Involved goes longer to shorter – anterior rotation– Involved goes shorter to longer – posterior rotation

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SI Rocking Test

• Supine on table

• Involved side – hip flexed with flexed knee, involved knee moved toward opposite shoulder and “rocked”

• Pain in SI joint indicative of pathology

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Over’s Test• Used to determine

presence of contracted TFL or IT-band

• Thigh will remain in abducted position, not falling into adduction

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Nobel’s Test• Lying supine the athlete’s

knee is flexed to 90 degrees

• Pressure is applied to lateral femoral condyle while knee is flexed/extended

• Pain at 30 degrees at lateral femoral condyle indicates a positive test

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Renne’s Test• Athlete stands with knee

bent at 30-40˚• Positive response of TFL /

IT band tightness occurs when pain is felt at lateral femoral condyle

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Piriformis Test

• Hip is internally rotated

• Tightness or pain is indicative of piriformis tightness

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Ely’s Test• Used to assess tightness of rectus femoris• Athlete is prone, w/ pelvis stabilized and knee

on the affected side is flexed• If hip on that side extends as the knee is

flexed, rectus femoris is tight

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NEUROVASCULAR TESTS

• Femoral pulse taken in femoral artery at femoral triangle

• Dermatomes/myotomes associated with L1-S2

• Peripheral nerves– Femoral– Obturator– Superior gluteal– Inferior gluteal

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• Femoral nerve– D: None– M: Knee extension

• Obturator nerve– D: None– M: Hip adduction

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• Superior gluteal nerve– D: None– M: Hip abduction

• Inferior gluteal nerve– D: None– M: Hip extension

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