Chapter 21: The Thigh, Hip, Groin, and Pelvis

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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

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Anatomy of the Thigh

• Review

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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

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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

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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

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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

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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?

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Palpation Bony Tissue

• Medial and lateral femoral condyles
• Greater trochanter
• Lesser trochanter
• Anterior superior iliac spine (ASIS)

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Palpation Soft Tissue

• Sartorius
• Rectus femoris
• Vastus lateralis
• Vastus medialis
• Vastus intermedius
• Semimembranosus
• Semitendinosus
• Biceps femoris

• Adductor brevis, longus, and magnus
• Gracilis
• Sartorius
• Pectineus
• Iliotibial Band (IT-band)
• Gluteus medius
• Tensor fasciae latae

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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

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Prevention of Thigh Injuries

• Maximum strength
• Endurance
• Flexibility
• In collision sports, thigh guards are mandatory
  to prevent injuries

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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

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Thigh Injuries Quadriceps Contusions

• Management
• RICE
• NSAIDs 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

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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

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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 SS than
  deeper strain
• Complete tear results in deformity
• Athlete displays little disability and discomfort

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Thigh Injuries Quadriceps Muscle Strain

• Management
• RICE
• NSAIDs and analgesics
• Manage swelling
• Compression, crutches
• Stretching
• PRE strengthening exercises
• Neoprene sleeve for added support

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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

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Thigh Injuries Hamstring Muscle Strains

• Signs and Symptoms
• Pain in muscle belly or point of attachment
• Capillary hemorrhage
• Ecchymosis
• Grade 1
• Pain with movement
• Point tenderness
• lt20 of fibers torn

• Grade 2
• Partial tear
• lt70 of fibers torn
• Sharp snap or tear
• Severe pain
• Loss of function
• Grade 3
• Rupture of tendinous or muscular tissue
• gt70 muscle fiber tearing
• Severe hemorrhage
• Disability
• Edema
• Loss of function
• Ecchymosis
• Palpable mass or gap

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Thigh Injuries Hamstring Muscle Strains

• Management
• RICE,
• NSAIDs 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

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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

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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 Trendelenburgs 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

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Anatomy of the Hip, Groin, and Pelvic Region

• Review

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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

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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?

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Assessment of the Hip and Pelvis

• Observation
• Symmetry - hips, pelvis tilt (anterior/posterior)
• Lordosis or flat back
• Lower limb alignment
• Knees, patella, feet
• Pelvic landmarks
• ASIS, PSIS, iliac crest
• Standing on one leg
• Pubic symphysis pain or drop to one side
• Ambulation

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Palpation Bony Tissue

• Iliac crest
• Anterior superior iliac spine (ASIS)
• Anterior inferior iliac spin (AIIS)
• Posterior superior iliac spine (PSIS)

• Pubic symphysis
• Ischial tuberosity
• Greater trochanter
• Femoral neck
• Poster inferior iliac spine (PIIS)

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Palpation Soft Tissue

• Rectus femoris
• Sartorius
• Iliopsoas
• Inguinal ligament
• Gracilis
• Adductor magnus, longus brevis
• Pectineus

• Gluteus maximus, medius minimus
• Piriformis
• Hamstrings
• Tensor fasciae latae
• Iliotibial Band

Major regions of concern are the groin, femoral
triangle, sciatic nerve, and lymph nodes
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Special Tests

• Functional Evaluation
• PROM, AROM, RROM
• Hip adduction and abduction
• Hip flexion and extension
• Hip internal and external rotation

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Special Tests Hip Flexor Tightness

• Kendall test
• Test for rectus femoris tightness

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Special Tests Hip Flexor Tightness

• Thomas test
• Test for hip contractures

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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

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Special Tests Hip and Sacroiliac Joint

• Gaenslens Test
• Test forces SI joint into extension
• Hyperextension on the affected side increases pain

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Special Tests Tensor Fasciae Latae and
Iliotibial Band

• Rennes test
• Athlete stands with knee bent at 30 - 40 degrees
• Pain at lateral femoral condyle indicates tensor
  fasciae latae tightness

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Special Tests Tensor Fasciae Latae and
Iliotibial Band

• Nobels 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

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Special Tests Tensor Fasciae Latae and
Iliotibial Band

• Obers Test
• Used to determine presence of contracted TFL or
  IT-band
• Thigh will remain in abducted position

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Special Tests Tensor Fasciae Latae and
Iliotibial Band

• Trendelenburgs 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)

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Special Tests Piriformis

• Piriformis Test
• Hip is internally rotated
• Tightness or pain is indicative of piriformis
  tightness

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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

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Leg Length Discrepancy Measures
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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

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Hip and Groin Injuries

• Groin Strain (continued)
• Management
• RICE
• NSAIDs 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

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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

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Hip and Groin Injuries

• Trochanteric Bursitis (continued
• Management
• RICE
• NSAIDs and analgesics
• ROM and PRE exercises for hip abductors and
  external rotators
• Phonophoresis
• Evaluate biomechanics and Q-angle
• Runners should avoid inclined surfaces

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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 SS to stress fracture

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Hip and Groin Injuries

• Sprains of the Hip Joint (continued)
• Management
• RICE
• NSAIDs 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

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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

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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

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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 non-traumatic conditions (ie steroids, blood
  coagulation disorders)
• Signs and Symptoms
• Possibly no SS 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

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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 bearingROM 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

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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

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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

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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

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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
• Rest and non-weight bearing may prevent further
  slippage
• Major slippage results in displacement
• Requires surgery
• If condition goes undetected or if surgery fails,
  severe problems will result

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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

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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

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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

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Pelvic Injuries

• Contusion (hip pointer) continued
• Management
• RICE for at least 48 hours
• NSAIDs,
• Bed rest 1 - 2 days
• Referral must be made for X-ray
• Modailities
• Ice massage, ultrasound, occasionally steroid
  injection
• Recovery lasts 1 - 3 weeks

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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, NSAIDs, and gradual return to activity

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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

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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

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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

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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

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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

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Pelvic Injuries

• Avulsion Fractures and Apophysitis (continued)
• Management
• X-ray required for diagnosis
• RICE, NSAIDs, 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

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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

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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

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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

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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