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Pelvis, Hip and Thigh Skeletal Features of Pelvis, Hip, and Thigh Pelvis •Function –Protects organs –Transmits loads between trunk and lower extremity –Provides site for muscle attachments •4 fused bones –Sacrum –Coccyx –Innominate bones (Bilateral) •Ilium, ischium, and pubis Pelvis (cont.) •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 Bony Structure of Thigh • Femur – Weakest at femoral neck Hip Joint • Head of femur and acetabulum of pelvis • Ball and socket joint • Very stable Femoral Triangle • Borders – Inguinal ligament—superior – Sartorius—lateral – Adductor longus—medial • Contents – Femoral nerves – Femoral artery – Femoral vein Q-Angle • Angle between line of resultant force produced by quadriceps and line of patellar tendon • Males 13°; females 18° Nerve and Blood Supply • Nerves – Lumbar plexus • Femoral nerve • Obturator nerve – Sacral plexus • Sciatic nerve • Blood Supply – External iliac • Femoral – Deep femoral – Femoral circumflex Kinematics • ROM – – – – – – Hip Flexion Hip Extension Hip Abduction Hip Adduction Medial Rotation Lateral Rotation • Body weight places compression on hip, as does tension in hip muscles • Forces are less during standing than with running and walking – Forces translated through the lower extremity; result ↑ compression on hip Prevention • Protective equipment – Hip joint well protected but iliac and pelvis need protection – Thigh • Physical conditioning • Shoes – Cushion forces Contusions • Hip pointer – Mechanism: direct blow to iliac crest • Common—anterior or lateral portion of crest • Often from improperly fitting (or absent) hip pads – S&S • Point tenderness; swelling; ecchymosis • Individual prefers slightly forward flexed position to relieve tension of abdominals and iliopsoas • Antalgic gait with shortened swing phase • ↑ pain with active trunk flexion and active hip flexion • Pain with coughing, laughing, breathing • Abdominal muscle spasm – Management: standard acute; rest; protect with hard-shell pad for return to activity Contusions (Cont’d) • Quadriceps contusion – Mechanism: direct blow – Common – anterolateral thigh – S&S • Transitory loss of function • With continued play, progressively stiffer and unresponsive • ↑ pain with active knee extension and hip flexion • Limited AROM due to pain; knee flexion limited actively and passively – Management: • Standard acute; with knee in maximum flexion • Hard-shell pad for return to activity • Physician referral if myositis ossificans or compartment syndrome is suspected Bursitis • Greater trochanteric bursitis – Influence of Q-angle – Effect of IT Band – S&S • Burning or aching over or posterior to greater trochanter • Aggravated with: – Hip abduction against resistance – Hip flexion and extension on weight bearing • Referred pain—lateral aspect of the thigh • Bursitis management – Standard acute; deep friction massage; NSAIDs; stretching program for involved muscle – On-going prevention: biomechanical analysis; technique analysis Hip Sprains and Dislocations • Mechanism – 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 • Management – Mild/moderate—standard acute – Severe—activate EMS; immobilize in position found; assess distal vascular integrity; monitor and treat for shock; NPO Strains • Mechanism – Explosive movements – Tensile stress from overstretching • Muscles – Quadriceps • Typically rectus femoris – 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 • Strength imbalance • S&S – – – – Point tender with palpable spasm Possible palpable defect/divot Ecchymosis may or may not be present Pain with AROM; pain with PROM (muscles placed on stretch) Strains (Cont’d.) • Piriformis strain – In some individuals, sciatic nerve passes through or above piriformis, subjecting nerve to compression from trauma, hemorrhage, or spasm – S&S • History of prolonged sitting, overuse, recent ↑ in activity, or buttock trauma • Dull ache in midbuttock—worse at night • Numbness or weakness may extend down posterior leg • Predisposing factors – – – – Beginning of season – too much too soon Fatigue History of strains; reinjury common Restricted flexibility of involved muscle group • Management: standard acute; restrict weight bearing if unable to assume normal gait Venous disorders – Direct blow may damage a vein causing – Thrombophlebitis Superficial thrombophlebitis (ST) Deep venous thrombosis (DVT) – S&S • ST—acute, red, hot, palpable, tender cord in course of a superficial vein • Extension of ST to deep veins—via proximal long and short saphenous veins to common femoral and popliteal veins, respectively – Management: anticoagulant therapy; external support (e.g., compression stockings); therapeutic exercise Femoral Fracture • Mechanism – Tremendous impact forces – Direct compressive forces • Potential for neurovascular damage • S&S – Previous history of femoral stress fracture ↑ risk of complete fracture – Extreme pain and inability/unwillingness to move involved side – Shock – Neck • Individual supine, lower extremity in external rotation and abduction; appears shortened compared with other side – Shaft • 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) Assessment • • • • History Observation/inspection Palpation Physical examination tests ROM • • • • AROM AAROM PROM RROM ROM (cont.) ROM (cont.) ROM (cont.) Stress Tests • Sacroiliac compression and distraction test • “Squish” test • Sacroiliac rocking test Stress Tests • Approximation test • Patrick’s (FABER) test Special Tests • Leg length measurement – Anatomic – Apparent Special Tests (cont.) • Thomas Test for flexion contractures Special Tests (cont.) • Straight leg raising (Lasegue's) test • Trendelenburg test Special Tests (cont.) • Piriformis test • Ober’s test