Download Chapter 8

Chapter 8
The Pelvis and Thigh
Introduction
Pelvic girdle forms structural base of
support between lower extremity and trunk
Hip articulation – strongest and most
stable joint in the body
– This benefit gained at the expense of ROM
Clinical Anatomy
Bones and Bony Landmarks
– Figures 8-1 and 8-2
– Ilium,
– Ischium
– Pubis
– Sacrum
– Acetabulum
Labrum
Clinical Anatomy
Bones and Bony Landmarks cont.
– Femoral head and neck
Angle of inclination
– Head is angled at 125 degrees in frontal plane
Angle of torsion
– Relationship between head and shaft, 15 degrees
Figures 8-3, 8-4, 8-5
– Greater trochanter
– Lesser trochanter
Clinical Anatomy
Articulations and Ligamentous Support
– Pubic symphysis
Fibrocartilaginous interpubic disc
Small degree of spreading, compression and
rotation between halves of girdle
– Sacroiliac joint (SI joint)
Very study, limited ROM
– Coxofemoral joint (hip joint)
Ball-and-socket
3 degrees of freedom
– Flexion and extension
– Abduction and adduction
– Internal and external rotation
Rom supported by depth of acetabulum, strength
of ligaments, strong muscular support
Joint capsule
– Dense synovial capsule from acetabular rim to distal
femoral neck
– Iliofemoral ligament (Y ligament of Bigelow)
Figure 8-6
AIIS to distal and proximal intertrochanteric line
Reinforces anterior jt capsule and limits
hyperextension
Allows us to stand upright with minimal muscular
activity
– Pubofemoral ligament
Also reinforces anterior capsule
Pubis ramus to intertrochanteric fossa
– Ligamentum teres (ligament of the head of the
femur)
Conduit for medial and lateral circumflex arteries
Little function in stabilizing hip
Figure 8-7
– Inguinal ligament
ASIS to pubic symphysis
Serves to contain soft tissues as they course
anteriorly from trunk to lower extremity
Superior border of femoral triangle
Muscular Anatomy
Table 8-1, pages 276-277
Anterior Musculature
– Quadriceps
– Iliopsoas group
Psoas major, psoas minor, iliacus
Primary hip flexors when knee extended
Figure 8-8
Medial Musculature
– Adductor group
– Gracilis
– Figure 8-9
Lateral Musculature
– Gluteus medius
– Tensor fascia latae
– Figure 8-10
– Trendelenburg’s gait pattern
– Intrinsic muscles form cuff around femoral
head and externally rotate hip
Piriformis, quadratus femoris, obturator internus,
obturator externus, gemellus superior, gemellus
inferior
Figure 8-11
Posterior Musculature
– Gluteus maximus
– hamstrings
Femoral Triangle
Figure 8-12
Formed by:
– Inguinal ligament (superiorly)
– Sartorius (laterally)
– Adductor longus (medially)
Landmark for:
– Femoral nerve, artery and vein
– Femoral pulse
– Lymph nodes
Bursae
3 bursa to decrease friction between
gluteus maximus and adjacent bony
structures
– Trochanteric bursa
Gluteus max – greater trochanter
– Gluteofemoral bursa
Gluteus max – vastus lateralis
– Ischial bursa
Gluteus max – ischial tuberosity
Clinical Evaluation of Pelvis and
Thigh
May necessitate evaluation of lower
extremity, spinal column, and posture
Patient preparedness
Clinician preparedness
Gender issues
Evaluation Map
– Page 280
History
Location of symptoms
– Table 8-2, page 281
Onset
Training techniques
Mechanism of injury
Prior medical conditions
– Legg-Calve-Perthes Disease
– Slipped capital femoral epiphysis
Inspection
Most trauma to area cannot be visualized
Inspection of Hip Angulations
– Angle of inclination
Relationship of femoral head and shaft
Coxa valga
– Increase in angle, may lead to genu varum or lateral
patella
Coxa vara
– Decrease in angle, may lead to genu valgum or squinting
patella
Mechanical advantage of glut medius is reduced
– Angle of torsion
Measured through radiograph
Box 8-1
Anteverted hips
– Increases greater than 15 degrees result in internal
femoral rotation, squinting patellae and a toe-in gait
Retroverted hips
– Angle less than 15 degrees, femur externally rotates,
resulting in a toe-out position, laterally positioned
patellae
Inspection of Medial Structures
– Adductor group
Inspection of Anterior Structures
– Hip flexors
Inspection of Lateral Structures
– Iliac crest (figure 8-13)
– Nelaton’s line
ASIS to ischial tuberosity
Figure 8-14
Inspection of Posterior Structures
– PSIS
– Gluteus maximus
– Hamstring muscle group (figure 8-15)
– Median sacral crests
Inspection of Leg Length Discrepancy
Palpation
Refer to list of Clinical Proficiencies
Utilize pages 283 - 285
Range of Motion Testing
Limited by bony and soft tissue restraints
Position of knee
– Flexed vs. extended
Table 8-3, page 286 (Muscle actions)
Box 8-2, page 287 (Goniometry)
Active Range of Motion
Flexion and Extension
– Figure 8-17
– 130-150 degrees (range, knee flexed)
– Majority occurs during flexion
– Extending knee limits hip flexion
Adduction and Abduction
– Figure 8-18
– Abduction – 45 degrees
– Adduction – 20-30 degrees
Active Range of Motion
Internal and External Rotation
– Figure 8-19
– ER – 40-50 degrees
– IR – 45 degrees
– Hip flexed vs. extended
Passive Range of Motion
Flexion and Extension
– Flexion
Figure 8-20
End-feel: soft w/knee flexed; firm w/knee extended
Thomas Test
– Box 8-3, page 289
– Extension
Figure 8-21
End-feel: firm w/knee extended and flexed but due
to different structures
Passive Range of Motion
Adduction and abduction
– Figure 8-22
– End-feel: firm
Adduction – due to tension in lateral structures
Abduction – due to tension in medial structures
Internal and external rotation
– Figure 8-23
– End-feel: firm
IR – due to tension in posterior capsule and external hip
rotators
ER – due to tension in anterior capsule and ligament support
– Anteverted vs. retroverted hips
Resisted Range of Motion
Box 8-4, pages 291-292
Trendelenburg’s Test for Gluteus Medius
Weakness
– Box 8-5, page 293
Ligamentous Testing
No specific tests for hip ligaments
Dysfunction is determined through passive
testing of movement
– Hyperextension places iliofemoral,
pubofemoral, and ischiofemoral ligaments on
stretch
Neurologic Testing
Complete lower quarter screening should
be performed
– Pathology involving femoral or sciatic nerve
Piriformis Syndrome
– Impingement of sciatic nerve from spasm of
piriformis muscle
Pathologies and Related Special
Tests
Acute
– Contusions or strains
Chronic
– Improper biomechanics from poor posture, leg
length discrepancies, overuse syndromes
Injury to hip joint is rare
– Potential medical emergency
Muscle Strains
Table 8-4, page 294
Occur secondary to dynamic overload
during eccentric muscle contraction
Commonly injured
– Iliopsoas, quadriceps, adductors, hamstrings
Signs and Symptoms
Bursitis
Onset related to biomechanical factors,
congenital influences, or environmental
conditions, such as prolonged periods of
sitting
Septic infection may be a cause
Bursitis
Trochanteric Bursitis
– Evaluative Findings - Table 8-5, page 295
– May result from a single blow or friction from
IT band
– History of training changes or increased Q
angle may be predisposing factors
– “Snapping Hip” syndrome
Bursitis
Ischial Bursitis
– Evaluative Findings - Table 8-6, page 296
– Movement of buttocks while patient is weightbearing in seated position can irritate this
bursa
Also irritated by prolonged sitting
– Need to rule out hamstring strain or avulsion
of its attachment
– Doughnut padding may help
Bursitis
Iliopsoas Bursitis
– Associated with rheumatoid arthritis or
osteoarthritis of hip
– Signs and symptoms
Pain in anterior hip
Palpable mass in groin or inguinal ligament
“snapping hip” syndrome
– Treatment includes strengthening hip rotators
Degenerative Hip Changes
Due to age, repetitive trauma, acute trauma, or
improper arrangements of hip
– Degeneration of articular surfaces of femur and
acetabulum
– Arthritis, osteochondritis dissecans, acetabular
labrum tears, avascular necrosis
Signs and symptoms
–
–
–
–
Pain, referred to low back, anterior thigh, knee
Loss of motion in all planes, decrease strength
Hip Scouring, Box 8-6, page 297
Radiographic evaluation
Piriformis Syndrome
Sciatic nerve passes under or through the
piriformis muscle as nerve travels across
posterior pelvis
Spasm or hypertrophy of muscle places
pressure on sciatic nerve
Six times more common in women
Relatively undefined and confusing
– Mimics lumbar nerve root impingement and
intervertebral disk disease
Piriformis Syndrome
Evaluative Findings
– Table 8-7, page 298
Straight leg raise, passive hip internal
rotation resisted external rotation with
patient seated, and resisted hip abduction
may produce symptoms
– Figure 8-24
Treatment includes stretching and
strengthening or surgical release
On-Field Evaluation of Pelvis and
Thigh Injuries
Trauma to coxofemoral joint is rare
– Protection from padding
More commonly, strains, contusions,
sprains of SI joint
Note position of athlete
– If leg is moving, rule out dislocation
– Fixed, immobile awkward position may
indicate dislocation
On-Field Evaluation of Pelvis and
Thigh Injuries
After ruling out dislocation or subluxation
and femoral fracture – AROM
Weight-bearing status
– Removal from field
Initial Evaluation and Management
of On-Field Injuries
Iliac Crest Contusion (hip pointer)
– Evaluative Findings, Table 8-8, page 299
– Disproportionate amount of pain, swelling,
and loss of function
– Recognition and immediate management of
pain reduces time lost due to injury
– Treatment
Ice, padding, reduced activity, crutches, if
necessary
Initial Evaluation and Management
of On-Field Injuries
Quadriceps Contusion
– As severity of impact increases, so does the
proportion of muscle fiber death
– Can result in decreased force during knee
extension
Associated pain and spasm may limit flexion
– Gross discoloration, painful to touch,
intramuscular hematoma gives hardened feel,
increase in girth of muscle
Overtime, atrophy may occur
– Risk of myositis ossificans is increased when
effusion of knee joint occurs
Figure 8-25
– First 24 hours following injury are critical
– Pain during AROM, or weakness during MMT
= removal from activity
Ice applied in flexion
Maintaining ROM decrease possibility of myositis
ossificans formation
Figure 8-26
Hip Dislocation
– Rare
– Medical emergency
– Majority involve posterior displacement of
femoral head
Fractures to femoral neck and acetabulum
– Most occur when hip is in flexion and
adduction and axial force is placed on femur,
displacing it posteriorly and causing head to
be driven through posterior capsule
Signs and Symptoms
– Immediate pain within joint and buttocks
– Sensation of “giving out”
– Femur and lower leg positioned in internal
rotation and adduction
Figure 8-27
– AROM is impossible
– No attempt to reduce
– Sensory and vascular check
Immediate immobilization and
transportation to emergency facility
Reduction under anesthesia
Femoral Fracture
Torsional or shear force to shaft
Relatively rare
– “weak link” principle
Immediate loss of function, pain, deformity,
easily recognizable
Stress fracture
– Shaft and neck, difficult to diagnosis
Similar s/s to hip flexor strain or tendinitis
– Treatment