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Chapter 14
Pelvis, Hip, and Thigh
Conditions
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Anatomy
Skeletal features of the pelvis, hip, and thigh
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Anatomy (cont’d)
• Pelvis
– Function
• Protects organs
• Transmits loads between trunk and lower
extremity
• Provides site for muscle attachments
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Anatomy (cont’d)
• Pelvis (cont’d)
– 4 fused bones
• Sacrum
• Coccyx
• Innominate bones
• Ilium, ischium, and pubis
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Anatomy (cont’d)
• Pelvis (cont’d)
– SI joint
• Critical link between the two pelvic bones
• Strong ligamentous support
– Sacrococcygeal joint
• Fused line symphysis united by a
fibrocartilaginous disc
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Anatomy (cont’d)
• Pelvis (cont’d)
– Pubic symphysis
• Interpubic disc located between the two joint
surfaces
• Femur
– Weakest at femoral neck
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Anatomy (cont’d)
• Hip Joint
– Head of femur and acetabulum of pelvis
– Ball and socket joint
– Very stable
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Anatomy (cont’d)
• Hip Joint (cont’d)
– Strong ligament support
• Iliofemoral ligament
• Limits hyperextension
• Pubofemoral ligament
• Limits abduction and
hyperextension
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Anatomy (cont’d)
• Hip Joint (cont’d)
– Strong ligament support (cont’d)
• Ischiofemoral ligament
• Limits extension
Ligaments of the pelvis
and hip
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Anatomy (cont’d)
• Femoral Triangle
– Borders
• Inguinal ligament—superior
• Sartorius—lateral
• Adductor longus—medial
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Anatomy (cont’d)
• Femoral Triangle (cont’d)
Femoral triangle
– Contents
• Femoral nerve
• Femoral artery
• Femoral vein
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Anatomy (cont’d)
• Bursae
– Iliopsoas
• Reduces friction between iliopsoas and
articular capsule
– Deep trochanteric bursa
• Provides cushion between greater trochanter
and gluteus maximus at its attachment to
iliotibial tract
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Anatomy (cont’d)
• Bursae (cont’d)
– Gluteofemoral bursa
• Separates gluteus maximus from origin of
vastus lateralis
– Ischial bursa
• Weight-bearing structure during sitting
• Cushions ischial tuberosity where it passes
over gluteus maximus
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Anatomy (cont’d)
• Nerves
– Lumbar plexus
• Femoral nerve
• Obturator nerve
– Sacral plexus
• Sciatic nerve
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Anatomy (cont’d)
• Blood Vessels
– External iliac
• Femoral
• Deep femoral
• Femoral
circumflex
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Kinematics and Major Muscle Actions
Muscles of the pelvis, hip, and thigh. Anterior view
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Kinematics and Major Muscle Actions (cont’d)
Muscles of the pelvis, hip, and thigh. Lateral view
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Kinematics and Major Muscle Actions (cont’d)
Muscles of the pelvis, hip, and thigh. Posterior view
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Kinematics and Major Muscle Actions
(cont’d)
• Hip flexors
– Iliopsoas, pectineus, rectus femoris, sartorius,
and tensor fascia latae
– Two-joint muscles
• Rectus femoris—active during hip flexion and
knee extension
• Sartorius—active during hip flexion and knee
extension
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Kinematics and Major Muscle Actions
(cont’d)
• Hip extensors
– Gluteus maximus and hamstrings (biceps
femoris, semitendinosus, and
semimembranosus)
• Hamstrings—two-joint; hip extension and
knee flexion
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Kinematics and Major Muscle Actions
(cont’d)
• Hip abductors
– Gluteus medius, gluteus minimus
– Active in stabilizing pelvis during single-leg
support and during support phase of walking
and running
• Hip adductors
– Adductor longus, adductor brevis, and adductor
magnus
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Kinematics and Major Muscle Actions
(cont’d)
• Lateral rotators
– Piriformis, gemellus superior, gemellus inferior,
obturator internus, obturator externus, and
quadratus femoris
– Lateral rotation of femur of swinging leg
accommodates lateral rotation of pelvis during
stride
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Kinematics and Major Muscle Actions
(cont’d)
• Medial rotators
– Gluteus minimus
– Tensor fascia latae, semitendinosus,
semimembranosus, gluteus medius, and
adductors
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Kinematics and Major Muscle Actions (cont’d)
PRIMARY
ACTION
MUSCLES
Flexion
Iliopsoas; rectus femoris; pectineus; sartorius;
tensor fasciae latae
Extension
Gluteus maximus; biceps femoris; semitendinosus;
semimembranosus; adductor magnus
Abduction
Gluteus medius; gluteus minimus
Adduction
Adductor brevis; adductor magnus; adductor
longus; adductor magnus; gracilis
Medial rotation
Gluteus minimus; gluteus medius; tensor fasciae
latae; semitendinosus; semimembranosus; adductor
muscles
Lateral rotation
Piriformis; obturator internus; obturator externus;
superior gemelli; inferior gemelli; quadratus
femoris; gluteus maximus
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Kinematics and Major Muscle Actions
(cont’d)
• Hip joint – movement in 3 planes
– Sagittal
• Flexion and extension
– Frontal
• Abduction and adduction
– Transverse
• Medial rotation and lateral rotation of the
femur
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Injury Prevention
• Physical conditioning
– Flexibility
– Strength
• Protective equipment
– Hip joint well protected but iliac and pelvis need
protection
– Thigh
• Shoe selection
– Cushion forces
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Contusions
• Hip pointer
– MOI: direct blow to iliac crest
– S&S
• Any trunk movement is painful (incl.
coughing, laughing, & breathing)
• Immediate pain, discoloration, spasm, and
loss of function
• Unable to rotate trunk or laterally flex the
trunk toward injured side.
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Contusions (cont’d)
• Hip pointer (cont’d)
– S&S (cont’d)
• Any trunk movement is painful
• Extreme tenderness
• Abdominal muscle spasm may be present
• Severe injury – unable to walk or bear weight,
even with crutches
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Contusions (cont’d)
• Hip pointer (cont’d)
– Management
• Standard acute; rest; protect with hard-shell
pad for return to activity
• Severe pain over iliac crest – physician
referral
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Contusions (cont’d)
• Quadriceps contusion
– MOI: direct blow
– Common – anterolateral thigh
– S&S
• Pain may be extensive immediately after
impact
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Contusions (cont’d)
• Quadriceps contusion (cont’d)
– S&S (cont’d)
• Grade I
• Mild pain and swelling
• Able to walk without a limp
• Passive flexion beyond 90° – painful;
resisted knee extension may cause less
discomfort.
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Contusions (cont’d)
• Quadriceps contusion (cont’d)
– S&S (cont’d)
• Grade II
• Can flex the knee between 45 and 90°
• Walks with a noticeable limp
• Grade III
• Unable to bear weight or fully flex the knee.
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Contusions (cont’d)
• Quadriceps Contusion (cont’d)
– Management:
• Standard acute; with knee in maximum
flexion
• Hard-shell pad for return to activity
• Physician referral if S&S persist >48 hours
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Contusions (cont’d)
• Quadriceps contusion (cont’d)
Management of a quadriceps contusion
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Contusions (cont’d)
• Myositis ossificans
Myositis ossificans
– Develops secondary to
single significant blow
or repetitive blows to
same area
– Evident on radiograph
3–4 weeks after injury
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Contusions (cont’d)
• Myositis ossificans (cont’d)
– S&S
• Warm, firm, swollen thigh; 2–4 cm larger
• Palpable, painful mass may limit
passive knee flexion to 20–30°
• Active quadriceps contractions and
straight leg raises—difficult
– Management: standard acute; physician referral
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Bursitis
• MOI
Bursa of the hips
– Excessive friction or
shear forces due to overuse
• Greater trochanteric bursitis
– Influence of Q-angle
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Bursitis (cont’d)
• Greater trochanteric bursitis
– S&S
• Burning or aching over or
posterior to greater trochanter
• Aggravated with:
• Hip abduction against resistance
• Hip flexion and extension on weight bearing
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Bursitis (cont’d)
• Iliopsoas bursitis
– Pain medial and anterior to joint; cannot be
easily palpated
–  pain with passive hip rotation; resisted hip
flexion, abduction, and external rotation
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Bursitis (cont’d)
• Ischial bursitis
– Pain aggravated by prolonged sitting and uphill
running,
– Point tenderness directly over ischial tuberosity
–  pain with passive and resisted hip extension
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Bursitis (cont’d)
• Bursitis management
– Do not permit to continue activity until seen by
a physician
– Suggest cold to decrease pain and inflammation
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Bursitis (cont’d)
• Snapping hip syndrome
– Can result from chronic bursitis
– S&S
• Snapping sensation heard or felt during hip
motion, especially with lateral rotation and
flexion while balancing on one leg
• Iliopsoas bursa affected—snapping in medial
groin
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Bursitis (cont’d)
• Snapping hip syndrome (cont’d)
– Management
• Do not permit to continue activity until seen
by a physician
• Suggest cold to decrease pain and
inflammation
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Hip Sprains and Dislocations
• MOI
– 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
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Hip Sprains and Dislocations (cont’d)
• Management
– Mild/moderate—standard acute; physician
referral
– Severe—activate EMS; immobilize in position
found – do not move; monitor and treat for
shock
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Hip Dislocations
Hip dislocations
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Strains
• Quadriceps
– Typically rectus femoris
– S&S
• Grade I
• Normal gait, but tightness in the anterior
thigh
• Pain with passive knee flexion beyond 90°
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Strains (cont’d)
• Quadriceps (cont’d)
– S&S (cont’d)
• Grade II
• Snapping or tearing sensation, followed by
immediate pain and loss of function.
• Knee held in extension – protection
• Pain with passive knee flexion; Pain &
weakness with knee extension
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Strains (cont’d)
• Quadriceps (cont’d)
– S&S (cont’d)
• Grade III strains
• Extreme pain
• Ambulation not possible
• Defect in the muscle may be visible
• Resisted knee extension not possible; ROM
is severely limited
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Strains (cont’d)
• 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
– Additional risk factors (Box 14.2)
– Strength imbalance
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Strains (cont’d)
• Hamstrings (cont’d)
– S&S
• Grade 1
• Tightness and tension
• Pain with passive stretching
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Strains (cont’d)
• Hamstrings (cont’d)
– S&S (cont’d)
• Grade II
• Tearing sensation or feeling a “pop,”
leading to immediate pain and weakness in
knee flexion.
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Strains (cont’d)
• Hamstrings (cont’d)
– S&S (cont’d)
• Grade III
• Sharp pain may occur during midstride
• Limps; unable to do heel-strike or fully
extend the knee.
• Pain and muscle weakness with active knee
flexion
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Strains (cont’d)
• Adductors
– Quick changes of direction, and explosive
propulsion and acceleration
– Strength imbalance
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Strains (cont’d)
• Adductors (cont’d)
– S&S
• An initial “twinge” or “pull” of the groin
muscles, and is unable to walk because of the
intense, sharp pain
• As the condition worsens, increased pain,
stiffness, and weakness in hip adduction and
flexion
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Strains (cont’d)
• Adductors (cont’d)
– S&S (cont’d)
• Running straight ahead or backward may be
tolerable, but any side-to-side movement
leads to more discomfort and pain
• Pain with passive stretching with the hip
extended, abducted, and externally rotated
• Pain with resisted hip adduction
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Strains (cont’d)
• Predisposing factors
– Beginning of season – too much too soon
– Fatigue
– History of strains; reinjury common
– Restricted flexibility of involved muscle group
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Strains (cont’d)
• Management:
• Grade 1 – standard acute; If symptoms
persist > 2-3 days, physician referral
• Grade 2 or 3 – standard acute; physician
referral
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Vascular and Neural Disorders
• Legg-Calvé-Perthes disease
– Avascular necrosis of proximal femoral epiphysis
– Seen especially in males ages 3–8
– Osteochondrosis of femoral head
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Vascular and Neural Disorders
• Legg-Calvé-Perthes disease (cont’d)
– S&S
• Gradual onset of limp and mild hip
or knee pain of several months in duration
• Pain is generally activity related
•  ROM in hip abduction, extension,
and external rotation due to spasm in hip
flexors and adductors
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Vascular and Neural Disorders (cont’d)
• Legg-Calvé-Perthes disease
– Management
• Do not permit to
continue activity until
seen by a physician
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Hip Fractures
• Avulsion fractures
– Due to rapid, sudden acceleration and deceleration
– Apophyseal sites
• ASIS with displacement of sartorius
• AIIS with rectus femoris displacement
• Ischial tuberosity with hamstrings displacement
• Lesser trochanter with iliopsoas displacement
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Hip Fractures (cont’d)
• Avulsion fractures (cont’d)
– S&S
• Sudden, acute, localized pain—may radiate
down muscle
• Swelling and discoloration
• Palpable gap between tendon attachment and
bone
•  pain with AROM, PROM, RROM of involved
muscle
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Hip Fractures (cont’d)
• Avulsion fractures (cont’d)
– Management: fit with crutches; immediate
physician referral
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Hip Fractures (cont’d)
• Slipped capital femoral
epiphysis
Slipped capital femoral epiphysis
– Boys ages 12–15
– Femoral head slips at
epiphyseal plate—
displaces inferiorly and
posteriorly
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Hip Fractures (cont’d)
• Slipped capital femoral epiphysis (cont’d)
– S&S
• Early S&S often undetected other than diffuse
knee pain
• Later stages
• More comfortable holding leg in slight
flexion
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Hip Fractures (cont’d)
• Slipped capital femoral epiphysis (cont’d)
• Later stages
• Unable to touch the abdomen with the thigh
because the hip externally rotates with
flexion
• Unable to rotate the femur internally or
stand on one leg.
– Management: Do not permit to continue activity
until seen by a physician
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Hip Fractures (cont’d)
• Stress fractures
– Pubis, femoral neck, and proximal one-third of
femur
– Risk factors
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Hip Fractures (cont’d)
• Stress fractures (cont’d)
– S&S
• Diffuse or localized aching pain in anterior
groin or thigh during weight-bearing activity,
relieved with rest
• Night pain
• Antalgic gait may be present
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Hip Fractures (cont’d)
• Stress fractures (cont’d)
– S&S (cont’d)
• ↑ pain on extremes of hip rotation, abduction
lurch
• Inability to stand on involved leg
– Management: Do not permit to continue activity
until seen by a physician
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Sacral and Coccygeal Fractures
• Rare in sports
• Direct blow to area due to fall on buttock
• S&S: extremely painful; unable to sit
• Management: immediate referral to a physician
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Femoral Shaft Fracture
• MOI
– Tremendous impact forces
– Direct compressive forces
• Potential for neurovascular damage
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Femoral Shaft Fracture (cont’d)
• S&S
– Severe pain and a total loss of functions
– Swelling at fracture site
– Present with the thigh externally rotated
– Shortened limb deformity
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Femoral Shaft Fracture (cont’d)
• Management
– Activate emergency plan, including summoning
of EMS
– Do not attempt to immobilize
– Assess and treat for shock as necessary
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Femoral Fractures (cont’d)
• S&S
– Previous history of femoral stress fracture ↑ risk
of complete fracture
– Extreme pain and inability/unwillingness to
move involved side
– Shock
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Femoral Fractures (cont’d)
• S&S (cont’d)
– Neck
• Individual supine, lower extremity in external
rotation and abduction; appears shortened
compared with other side
– Shaft
• Limb appears shortened; thigh appears
externally rotated
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Femoral Fractures (cont’d)
• 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)
– NPO—possible surgical intervention
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Coach and Onsite Assessment
• S &S that require activation of emergency plan,
including summoning EMS
– Obvious deformity suggesting a dislocation or
fracture
– Significant loss of motion or loss of function
– Palpable defect in a muscle
– Severe joint disability that may be evident by a
noticeable limp
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Coach and Onsite Assessment (cont’d)
• S &S that require activation of emergency plan,
including summoning EMS
– Excessive soft tissue swelling, particularly in the
quadriceps
– Abnormal cutaneous sensations or an absent or
weak pulse
• Refer to Application Strategy 14.2
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