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


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

Chapter 21 The Thigh, Hip, Groin, and Pelvis
Anatomy of the Thigh
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Nerve and Blood Supply
  • Tibial and common peroneal are given rise from
    the sacral plexus which form the largest nerve in
    the body the sciatic nerve complex
  • The main arteries of the thigh are the deep
    circumflex femoral, deep femoral, and femoral
  • The two main veins are the superficial great
    saphenous and the femoral vein

  • The fascia lata femoris is part of the deep
    fascia that invests the thigh musculature
  • Thick anteriorly, laterally and posteriorly but
    thin on the medial side
  • Iliotibial track (IT-band) is located laterally
    serving as the attachment for the tensor fascia
    lata and greater aspect of the gluteus maximum

Functional Anatomy of the Thigh
  • Quadriceps insert in a common tendon to the
    proximal patella
  • Rectus femoris is the only quad muscle that
    crosses the hip
  • Extends knee and flexes the hip
  • Important to distinguish between hip flexors
    relative to injury for both treatment and rehab

  • Hamstrings cross the knee joint posteriorly and
    all except the short of head of the biceps
    crosses the hip
  • Bi-articulate muscles produce forces dependent
    upon position of both knee and hip
  • Position of the knee and hip during movement and
    MOI play important roles and provide information
    to utilize w/ rehab and prevention of hamstring

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 athlete in obvious pain?
  • Is the athlete willing to move the thigh?

Palpation Bony and Soft Tissue
  • Medial and lateral femoral condyles
  • Greater trochanter
  • Lesser trochanter
  • Anterior superior iliac spine (ASIS)
  • Sartorius
  • Rectus femoris
  • Vastus lateralis
  • Vastus medialis
  • Vastus intermedius
  • Semimembranosus
  • Semitendinosus
  • Biceps femoris
  • Adductor brevis, longus and magnus
  • Gracilis
  • Sartorius

Palpation Soft Tissue (continued)
  • Pectineus
  • Iliotibial Band (IT-band)
  • Gluteus medius
  • Tensor fasciae latae

  • Special Tests
  • If a fracture is suspected the following tests
    are not performed
  • Beginning in extension, the knee is passively
  • A normal muscle will elicit full range of motion
    pain free (one w/ swelling or spasm will have
    restricted motion)
  • Active movement from flexion to extension
  • Strong and painful may indicate muscle strain
  • Weak and pain free may indicate 3rd degree or
    partial rupture
  • Muscle weakness against an isometric resistance
    may indicate nerve injury

Prevention of Thigh Injuries
  • Thigh must have maximum strength, endurance, and
    extensibility to withstand strain
  • In collision sports thigh guards are mandatory to
    prevent injuries

Recognition and Management of Thigh Injuries
  • Quadriceps Contusions
  • Etiology
  • Constantly exposed to traumatic blunt blow
  • Contusions usually develop as a result of severe
  • Extent of force and degree of thigh relaxation
    determine depth and functional disruption that
  • Signs and Symptoms
  • Pain, transitory loss of function, immediate
    effusion with palpable swollen area
  • Graded 1-4 superficial to deep with increasing
    loss of function (decreased ROM, strength)

Quad Contusion
  • Management
  • RICE, NSAIDs and analgesics
  • Crutches for more severe cases
  • Aspiration of hematoma is possible
  • Following exercise or re-injury, continued use of
  • Follow-up care consists of ROM, and PRE w/in pain
    free range
  • Heat, massage and ultrasound to prevent myositis

  • General rehab should be conservative
  • Ice w/ gentle stretching w/ a gradual transition
    to heat following acute stages
  • Elastic wrap should be used for support
  • Exercises should be graduated from stretching to
    swimming and then jogging and running
  • Restrict exercise if pain occurs
  • May require surgery of herniated muscle or
  • Once an athlete has sustained a severe contusion,
    great care must be taken to avoid another

  • Myositis Ossificans Traumatica
  • Etiology
  • Formation of ectopic bone following repeated
    blunt trauma (disruption of muscle fibers,
    capillaries, fibrous connective tissue, and
  • Gradual deposit of calcium and bone formation
  • May be the result of improper thigh contusion
    treatment (too aggressive)
  • Signs and Symptoms
  • X-ray shows calcium deposit 2-6 weeks following
  • Pain, weakness, swelling, tissue tension and
    point tenderness w/ decreased ROM
  • Management
  • Treatment must be conservative
  • May require surgical removal due to pain and
    decreased ROM

  • Quadriceps Muscle Strain
  • Etiology
  • Sudden stretch when athlete falls on bent knee or
    experiences sudden contraction
  • Associated with weakened or over constricted
  • Signs and Symptoms
  • Peripheral tear causes fewer symptoms than deeper
  • Pain, point tenderness, spasm, loss of function
    and little discoloration
  • Complete tear may live athlete w/ little
    disability and discomfort but with some deformity

  • Management
  • RICE, NSAIDs and analgesics
  • Manage swelling, compression, crutches
  • With increased healing, progress to isometrics
    and stretching
  • Neoprene sleeve may provide some added support

  • Hamstring Muscle Strains
  • (second most common thigh injury)
  • Etiology
  • Multiple theories of injury
  • Hamstring and quad contract together
  • Change in role from hip extender to knee flexor
  • Fatigue, posture, leg length discrepancy, lack of
    flexibility, strength imbalances
  • Signs and Symptoms
  • Muscle belly or point of attachment pain
  • Capillary hemorrhage, pain, loss of function and
    possible discoloration
  • Grade 1 - soreness during movement and point
    tenderness (lt20 of fibers torn)
  • Grade 2 - partial tear, identified by sharp snap
    or tear, severe pain, and loss of function (lt70
    of fiber torn)

  • Signs and Symptoms (continued)
  • Grade 3 - Rupturing of tendinous or muscular
    tissue, involving major hemorrhage and
    disability, edema, loss of function, ecchymosis,
    palpable mass or gap
  • gt70 muscle fiber tearing
  • Management
  • RICE, NSAIDs and analgesics
  • Grade I - dont resume full activity until
    complete function restored
  • Grade 2 and 3 should be treated conservatively w/
    gradual return to stretching and strengthening in
    later stages of healing

  • Management (continued)
  • Modalities and isometrics need to gradually be
    introduced during healing process
  • When soreness is eliminated, isotonic leg curls
    can be introduced (focus on eccentrics)
  • Recovery may require months to a full year
  • Greater scaring greater recurrence of injury

  • Acute Femoral Fractures
  • Etiology
  • Generally involving shaft and requiring a great
    deal of force
  • Occurs in middle third due to structure and point
    of contact
  • Signs and Symptoms
  • Pain, swelling, deformity
  • Muscle guarding, hip is adducted and ER
  • Leg with fx may also be shorter
  • Management
  • Treat for shock, verify neurovascular status,
    splint before moving, reduce following X-ray
  • Analgesics and ice
  • Extensive soft tissue damage will also occur as
    bones will displace due to muscle force

  • Femoral Stress Fractures
  • Etiology
  • Overuse (10-25 of all stress fractures)
  • Excessive downhill running or jumping activities
  • Often seen in endurance athletes
  • Signs and Symptoms
  • Persistent pain in thigh/groin
  • X-ray or bone scan will reveal fracture
  • Walk with antalgic gait (abduction lurch)
  • Positive Trendelenburgs sign
  • Management
  • Prognosis will vary depending on location
  • Fx lateral to femoral neck tend to be more
  • Shaft and medially located fractures tend to heal
    well with conservative management

Anatomy of the Hip, Groin and Pelvic Region
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Functional Anatomy
  • Pelvis moves in three planes through muscle
  • Anterior tilting changes degree of lumbar
    lordosis, lateral tilting changes degree of hip
  • Hip is a true ball and socket joint w/ intrinsic
  • Hip also moves in all three planes, particularly
    during gait (bodys relative center of gravity)

  • Tremendous forces occur at the hip during varying
    degrees of locomotion
  • Muscles are most commonly injured in this region
  • Numerous injuries attach in this region and
    therefore injury to one can be very disabling and
    difficult to distinguish

Assessment of the Hip and Pelvis
  • Bodys center of gravity is located just anterior
    to the sacrum
  • Injuries to the hip or pelvis cause major
    disability in the lower limbs, trunk or both
  • Low back may also become involved due to
  • History
  • Onset (sudden or slow?)
  • Previous history?
  • Mechanism of injury?
  • Pain description, intensity, quality, duration,
    type and location?

  • 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 on one side
  • Ambulation
  • Walking, sitting - pain will result in movement

Palpation Bony
  • 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

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, lymph nodes
Special Tests
  • Functional Evaluation
  • ROM, strength tests
  • Hip adduction, abduction, flexion, extension,
    internal and external rotation
  • Tests for Hip Flexor Tightness
  • Kendall test
  • Test for rectus femoris tightness
  • Thomas test
  • Test for hip contractures

Kendalls Test
Thomas Test
Femoral Anteversion (A) and Retroversion (B)
  • Relationship between neck and shaft of femur
  • Normal angle is 15 degrees anterior to the long
    axis of the femur and condyles
  • Internal rotation in excess of 35 degrees is
    indicative of anteversion, 45 degrees of external
    rotation is an indicator of retroversion

Test for Hip and Sacroiliac Joint
  • Patrick Test (FABER)
  • Detects pathological conditions of the hip and SI
  • Pain may be felt in the hip or SI joint

  • Gaenslens Test
  • Test works to push SI joint into extension
  • Test is positive if hyperextension on affected
    side increases pain

Testing the Tensor Fasciae Latae and Iliotibial
  • Rennes test
  • Athlete stands w/ knee bent at 30 - 40
  • Positive response of TFL tightness occurs when
    pain is felt at lateral femoral condyle

  • Nobels Test
  • Lying supine the athletes knee is flexed to 90
  • Pressure is applied to lateral femoral condyle
    while knee is extended
  • Pain at 30 degrees at lateral femoral condyle
    indicates a positive test

  • Obers Test
  • Used to determine presence of contracted TFL or
  • Thigh will remain in abducted position, not
    falling into adduction

Trendelenburgs Test - Iliac crest on unaffected
side should be higher when standing on one leg -
Test is positive when affected side is higher
indicating weak abductors (glut medius)
  • Piriformis Test
  • Hip is internally rotated
  • Tightness or pain is indicative of piriformis

  • Elys 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
  • Measuring Leg Length Discrepancy
  • With inactive individual, difference of more
    that 1 may produce symptoms
  • Active individuals may experience problems w/ as
    little 3mm (1/8) difference
  • Can cause cumulative stresses to lower limbs,
    hips, pelvis or low back

  • True or anatomical
  • Shortening may be equal throughout limb or
    localized w/in femur or lower leg
  • Measurement taken from medial malleolus to ASIS
  • Apparent or functional
  • Result of lateral pelvic tilt or from a flexion
    or adduction deformity
  • Measurement is taken from umbilicus to medial

Leg Length Discrepancy Measures
Recognition and Management of Specific Hip,
Groin, and Pelvic Injuries
  • Groin Strain
  • Etiology
  • One of the more difficult problems to diagnose
  • Injury to one of the muscles in the regions
    (generally adductor longus)
  • Occurs from running , jumping, twisting w/ hip
    external rotation or severe stretch
  • Signs and Symptoms
  • Sudden twinge or tearing during active movement
  • Produce pain, weakness, and internal hemorrhaging

  • Groin Strain (continued)
  • Management
  • RICE, NSAIDs and analgesics for 48-72 hours
  • Determine exact muscle or muscles involved
  • Rest is critical daily whirlpool and
    cryotherapy, moving into ultrasound
  • Delay exercise until pain free
  • Restore normal ROM and strength -- provide
    support w/ wrap

  • Trochanteric Bursitis
  • Etiology
  • Inflammation at the site where the gluteus medius
    inserts or the IT-band passes over the trochanter
  • Signs and Symptoms
  • Complaint of lateral hip pain that may radiate
    down the leg
  • Palpation reveals tenderness over lateral aspect
    of greater trochanter
  • IT-band and TFL tests should be performed

  • Management
  • RICE, NSAIDs and analgesics
  • ROM and PRE directed toward hip abductors and
    external rotators
  • Phonophoresis if pain doesnt respond in 3-4 days
  • Must look at biomechanics and Q-angle
  • Runners should avoid inclined surfaces

  • Sprains of the Hip Joint
  • Etiology
  • Due to substantial support, any unusual movement
    exceeding normal ROM may result in damage
  • Force from opponent/object or trunk forced over
    planted foot in opposite direction
  • Signs and Symptoms
  • Signs of acute injury and inability to circumduct
  • Similar S S to stress fracture
  • Pain in hip region, w/ hip rotation increasing

  • Management
  • X-rays or MRI should be performed to rule out fx
  • RICE, NSAIDs and analgesics
  • Depending on severity, crutches may be required
  • ROM and PRE are delayed until hip is pain free

  • Dislocated Hip
  • Etiology
  • Rarely occurs in sport
  • Result of traumatic force directed along the long
    axis of the femur (posterior dislocation w/ hip
    flexed and adducted and knee flexed)
  • Signs and Symptoms
  • Flexed, adducted and internally rotated hip
  • Palpation reveals displaced femoral head
  • Serious pathology
  • Soft tissue, neurological damage and possible fx
  • Management
  • Immediate medical care (blood and nerve supply
    may be compromised)
  • Contractures may further complicate reduction
  • 2 weeks immobilization and crutch use for at
    least one month

  • Avascular Necrosis
  • Etiology
  • Result of temporary or permanent loss of blood
    supply to proximal femur
  • Can be caused by traumatic conditions (hip
    dislocation disruption of circumflex artery),
    or non-traumatic circumstances (steroids, blood
    coagulation disorders, excessive alcohol use
    compromising blood vessels)
  • Signs and Symptoms
  • Early stages - possibly no SS
  • Joint pain w/ weight bearing progressing to pain
    at times of rest
  • Pain gradually increases (mild to severe)
    particularly as bone collapse occurs
  • May limit ROM
  • Osteoarthritis may develop
  • Progression of SS can develop over the course of
    months to a year

  • Avascular Necrosis (continued)
  • Management
  • Must be referred for X-ray, MRI or CT scan
  • Must work to improve use of joint, stop further
    damage and ensure survival of bone and joint
  • Most cases will ultimately require surgery to
    repair joint permanently
  • Conservative treatment involves ROM exercises to
    maintain ROM electric stim for bone growth
    non-weight bearing if caught early
  • Medication to treat pain, reduce fatty substances
    reacting w/ corticosteroids or limit blood
    clotting in the presence of clotting disorders
    may limit necrosis

Hip Problems in the Young Athlete
  • Legg Calve-Perthes Disease (Coxa Plana)
  • Etiology
  • Avascular necrosis of the femoral head in child
    ages 4-10
  • Trauma accounts for 25 of cases
  • Articular cartilage becomes necrotic and flattens
  • Signs and Symptoms
  • Pain in groin that can be referred to the abdomen
    or knee
  • Limping is also typical
  • Varying onsets and may exhibit limited ROM

Legg-Calve-Perthes Disease (continued)
  • Management
  • Bed rest to alleviate synovitis
  • Brace to avoid direct weight bearing
  • With early treatment and the head may re-ossify
    and revascularize
  • Complication
  • If not treated early, will result in ill-shaping
    and develop into osteoarthritis in later life

  • Slipped Capital Femoral Epiphysis
  • Etiology
  • Found mostly in boys ages 10-17 who are
    characteristically tall and thin or obese
  • May be growth hormone related
  • 25 of cases are seen in both hips, trauma
    accounts for 25
  • Head slippage on X-ray appears posterior and

  • Signs and Symptoms
  • Pain in groin that comes on over weeks or months
  • Hip and knee pain during passive and active
  • Limitations of abduction, flexion, medial
    rotation and presents with a limp
  • Management
  • W/ minor slippage, rest and non-weight bearing
    may prevent further slippage
  • Major displacement requires surgery
  • If undetected or surgery fails severe problems
    will result

  • The Snapping Hip Phenomenon
  • Etiology
  • Common in young female dancers, gymnasts,
  • Habitual movement predispose muscles around hip
    to become imbalanced (lateral rotation and
  • Related to structurally narrow pelvis, increased
    hip abduction and limited lateral rotation
  • Hip stability is compromised
  • Signs and Symptoms
  • Pain w/ balancing on one leg, possible
  • Management
  • Focus on cryotherapy and ultrasound to stretch
    musculature and strengthen weak musculature in
    hip region

Pelvic Conditions
  • Athletes can suffer serious, acute and chronic
    injuries to the pelvic region
  • Pelvis rotates along longitudinal axis when
    running, proportionate to the amount of arm swing
  • Also tilts as legs engage support and nonsupport
  • Combination of motion causes shearing and changes
    in lordosis throughout activity

  • Contusion (hip pointer)
  • Etiology
  • Contusion of iliac crest or abdominal musculature
  • Result of direct blow (same MOI for iliac crest
    fx and epiphyseal separation
  • Signs and Symptoms
  • Pain, spasm, and transitory paralysis of soft
  • Decreased rotation of trunk or thigh/hip flexion
    due to pain
  • Management
  • RICE for at least 48 hours, NSAIDs,
  • Bed rest 1-2 days
  • Referral must be made, X-ray
  • Ice massage, ultrasound, occasionally steroid
    injection Recovery lasts 1-3 weeks

  • Osteitis Pubis
  • Etiology
  • Seen in distance runners
  • Repetitive stress on pubic symphysis and adjacent
  • Signs and Symptoms
  • Chronic pain and inflammation of groin
  • Point tenderness on pubic tubercle
  • Pain w/ running, sit-ups and squats
  • Acute case may be the result of bicycle seat
  • Management
  • Rest, NSAIDs and gradual return to activity

  • Athletic Pubalgia
  • Etiology
  • Chronic pubic region pain caused by repetitive
    stress to pubic symphysis from kicking, twisting,
    or cutting
  • Forced adduction, from hyperextended position,
    creates shearing forces that are transmitted
    through pubic symphysis to insertion of rectus
    abdominus, hip adductors and conjoined tendon
  • Result in microtears of tranversalis abdominis
    fascia, aponeurosis of obliques, or conjoined
  • Create weakening of anterior wall and inguinal
  • Signs and Symptoms
  • No presence of hernia
  • Chronic pain during exertion, sharp and burning
    that laterally radiates into adductors and

  • Signs and Symptoms (continued)
  • Point tenderness on pubic tubercle
  • Pain increased w/ resisted hip flexion, internal
    rotation, abdominal contraction, resisted hip
    adduction (adductors not painful adductor
  • Management
  • Conservative treatment (even though rarely
  • Massage, stretching after 1 week of surrounding
  • 2 weeks, strengthening of abs and hip flexors and
  • 3-4 weeks begin running progression
  • Aggressive treatment involves cortisone injection
    or tightening of pelvic wall surgically

  • Stress Fractures
  • Etiology
  • Seen in distance runners - repetitive cyclical
    forces from ground reaction force
  • More common in women than men
  • Common site include inferior pubic ramus, femoral
    neck and subtrochanteric area of femur
  • Signs and Symptoms
  • Groin pain, w/ aching sensation in thigh that
    increases w/ activity and decreases w/ rest
  • Standing on one leg may be impossible
  • Deep palpation results in point tenderness
  • May be caused by intense interval or competitive

  • Stress Fractures (continued)
  • Management
  • 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 be used for training -- breast
    stroke should be avoided

  • Avulsion Fractures and Apophysitis
  • Etiology
  • Traction epiphysis (bone outgrowth)
  • Common sites include ischial tuberosity, AIIS,
    and ASIS
  • Avulsions seen in sports w/ sudden accelerations
    and decelerations
  • Signs and Symptoms
  • Sudden localized pain w/ limited movement
  • Pain, swelling, point tenderness
  • Muscle testing increases pain

  • Avulsion Fractures and Apophysitis
  • Management
  • X-ray
  • If uncomplicated, RICE, NSAIDs, crutch toe-touch
  • After control pain and inflammation, 2-3 weeks of
    gradual stretching
  • When 80 degrees of ROM have been regained a PRE
    program should be instituted.
  • With full return of ROM and strength athlete can
    return to play

Thigh and Hip 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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  • Will be necessary if injury and subsequent
    limitation is caused by tightness of ligaments
    and capsule surrounding the joint
  • Use to re-establish appropriate arthrokinematics
  • Series of glides (anterior and posterior) and
    rotations can be used to restore motion

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  • Progression should move from isometric exercises
    until muscle can be fully contracted to isotonic
    strengthening PREs and on into isokinetics
  • PNF strengthening should then be incorporated to
    enhance functional activity

Strength (Continued)
  • Active exercise should occur in pain free ranges
    -- in an effort not to aggravate condition
  • Exercises for the core must also be included
  • Develop optimal levels of functional strength and
    dynamic stabilization

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Neuromuscular Control
  • Establish through combination of appropriate
    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

Balance Shoe for Neuromuscular Control
Functional Progression and Return to Activity
  • Begin in pool, non-weight bearing
  • Depending on activity, progression of walking, to
    jogging, to running and more difficult agility
    tasks can occur
  • Before returning to play, athlete should
    demonstrate pain free function, full ROM,
    strength, balance and agility