Transcript Pelvis, Hip, and Thigh Conditions Chapter 17 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins.

Pelvis, Hip, and Thigh Conditions
Chapter 17
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Skeletal Features of Pelvis, Hip, and Thigh
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Pelvis
• Function
– Protects organs
– Transmits loads between trunk and lower
extremity
– Provides site for muscle attachments
• 4 fused bones
– Sacrum
– Coccyx
– Innominate bones
• Ilium, ischium, and pubis
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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
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Bony Structure of Thigh
• Femur
– Weakest at femoral neck
– Angle of inclination
• Angle of depression formed by a line drawn
through the shaft of femur and a line passing
through the long axis of femoral neck
• Approximately 125 in the frontal plane
• 125 coxa valga
• 125 coxa vara
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Bony Structure of Thigh (cont.)
• Femur
– Angle of torsion
• Relationship between femoral head and
femoral shaft in transverse plane
• Approximately 12
• 12 anteversion
• 12 retroversion
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Hip Joint
• Head of femur and acetabulum of pelvis
• Ball and socket joint
• Very stable
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Hip Joint Capsule
• Completely surrounds joint,
attaching to the labrum of the
acetabular socket
• Passes over a fat pad internally
to join to the distal aspect of
femoral neck
• Zona orbicularis
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Ligaments of Hip Joint
• Iliofemoral ligament
– Limits hyperextension
• Pubofemoral ligament
– Limits abduction and
hyperextension
• Ischiofemoral ligament
– Limits extension
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Femoral Triangle
• Borders
– Inguinal ligament—
superior
– Sartorius—lateral
– Adductor longus—medial
• Contents
– Femoral nerves
– Femoral artery
– Femoral vein
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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
• 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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Q-Angle
• Angle between line of
resultant force
produced by
quadriceps and line of
patellar tendon
• Males 13°; females
18°
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Muscles
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Muscles (cont.)
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Muscles (cont.)
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Nerves
• Lumbar plexus
– Femoral nerve
– Obturator nerve
• Sacral plexus
– Sciatic nerve
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Blood Vessels
• External iliac
– Femoral
• F16.10
• Deep
femoral
• Femoral
circumflex
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Kinematics (cont.)
• 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
• Hip extensors
– Gluteus maximus and hamstrings (biceps femoris,
semitendinosus, and semimembranosus)
• Hamstrings—two-joint; hip extension and knee flexion
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Kinematics (cont.)
• 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 (cont.)
• 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
• Medial rotators
– Gluteus minimus
– Tensor fascia latae, semitendinosus,
semimembranosus, gluteus medius, and adductors
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Kinetics
• 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
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Prevention
• Protective equipment
– Hip joint well protected but iliac and pelvis need
protection
– Thigh
• Physical conditioning
• Shoes
– Cushion forces
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Contusions
• Hip pointer
– Mechanism: direct blow to iliac crest
• Common—anterior or lateral portion of crest
• Often from improperly fitting (or absent) hip
pads
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Contusions (cont.)
– 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
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Contusions (cont.)
• 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
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Contusions (cont.)
– 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
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Contusions (cont.)
• 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.)
– 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
– Self-limiting injury
– Maturation—6–12 months
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Contusions (cont.)
• Compartment syndrome
– Neurovascular compression
– Due to uncontrolled internal bleeding and swelling
– S&S
• Progressive, severe pain with passive motion and
isometric contraction of quadriceps
•  pressure → ↓ femoral sensation and motor weakness;
distal pulse and capillary refill may be normal
– Management: ice (no compression); immediate physician
referral
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Bursitis
• Mechanism
– Excessive friction or
shear forces due to
overuse
– Posttraumatic bursitis
from direct blows that
cause bleeding in the
bursa
• Greater trochanteric bursitis
– Influence of Q-angle
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Bursitis (cont.)
– 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
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Bursitis (cont.)
• Iliopsoas bursitis
– Pain medial and anterior to joint; cannot be easily
palpated
–  pain with passive hip rotation; resisted hip flexion,
abduction, and external rotation
• 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.)
• Bursitis management
– Standard acute; deep friction massage; NSAIDs;
stretching program for involved muscle
– On-going prevention: biomechanical analysis;
technique analysis
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Bursitis (cont.)
• Snapping hip syndrome
– Causes: intra- and extra-articular (refer to Box 15.2)
– Types
• External—IT band or gluteus maximus snapping over
greater trochanter during hip flexion → trochanteric
bursitis
• Internal—iliopsoas snaps over structures deep to
musculotendinous unit (e.g., iliopsoas bursa)
• Intra-articular—lesions of the joint (e.g., labral tear)
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Bursitis (cont.)
– 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
– Management: NSAIDs; rehabilitation program to address
specific deficits
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Hip Sprains and Dislocations
• Mechanism
– Violent twisting actions
– With hip and knee flexed to 90°, force through
shaft of femur
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Hip Sprains and Dislocations (cont.)
• 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
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Hip Dislocation
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Strains
• Mechanism
– Explosive movements
– Tensile stress from overstretching
• Muscles
– Quadriceps
• Typically rectus femoris
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Strains (cont.)
– 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
– Adductors
• Common with quick change of direction and explosive
propulsion and acceleration
• Strength imbalance
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Strains (cont.)
• 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)
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Strains (cont.)
• Piriformis strain
– In some individuals, sciatic nerve passes
through or above piriformis, subjecting
nerve to compression from trauma,
hemorrhage, or spasm
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Strains (cont.)
– 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
• ↑ pain or weakness during:
• Passive hip flexion, adduction, and internal rotation
• Active hip external rotation
• Resisted hip external rotation
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Strains (cont.)
• 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
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Vascular and Neural Disorders
• Legg-Calvé-Perthes disease
– Avascular necrosis of proximal
femoral epiphysis
– Seen esp in males ages 3–8
– Osteochondrosis - femoral head
– S&S
• Gradual onset of limp and
mild hip
or knee pain of several
months in duration
• Pain -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.)
• Venous disorders
– Direct blow may damage a vein causing
• Thrombophlebitis

Superficial thrombophlebitis (ST)

Deep venous thrombosis (DVT)
• Phlebothrombosis
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Vascular and Neural Disorders (cont.)
– 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
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Vascular and Neural Disorders (cont.)
• Toxic synovitis of hip
– Transient inflammatory condition
– Painful hip joint with an antalgic gait
– Management: physician referral
• Obturator nerve entrapment
– Possible causes: pelvic tumors, obturator hernias, or
pelvic and proximal femoral fractures
– S&S: exercise-induced medial thigh pain; described
as vague groin or medial knee pain
– Management: physician referral
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Hip Fractures
• Avulsion fractures
– Apophyseal sites
• ASIS with displacement of sartorius
• AIIS with rectus femoris displacement
• Ischial tuberosity with hamstrings displacement
• Lesser trochanter with iliopsoas displacement
– Due to rapid, sudden acceleration and deceleration
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Hip Fractures (cont.)
– 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
– Management: immobilize with elastic bandage; fit with
crutches; immediate physician referral
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Hip Fractures (cont.)
• Slipped capital femoral
epiphysis
– Boys ages 12–15
– Femoral head slips at
epiphyseal plate—
displaces inferiorly and
posteriorly relative to
femoral neck
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Hip Fractures (cont.)
– S&S
• Early stages—diffuse knee pain
• Later stages
• More comfortable holding leg in slight flexion
• Unable to touch abdomen with thigh because hip
externally rotates with flexion
• Unable to rotate femur internally or stand on one leg
– Management: fit with crutches; physician referral
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Hip Fractures (cont.)
• Stress fractures
– Pubis, femoral neck, and proximal one-third of
femur
– Risk factors
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Hip Fractures (cont.)
– 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
• Pain with deep palpation in inguinal
• ↑ pain on extremes of hip rotation
• + Trendelenburg sign
– Management: physician referral
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Hip Fractures (cont.)
• Osteitis pubis
– Continued stress on pubic symphysis
• From repeated overload of the adductor muscles
• From repetitive running activities
– S&S
• Gradual onset of pain in the adductor musculature,
aggravated by kicking, running, and pivoting on one leg
•  pain with sit-ups and abdominal strengthening
exercises
• Pain may radiate distally into groin or medial thigh
– Management: standard acute—treat symptoms
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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 Fractures
• Mechanism
– Tremendous impact forces
– Direct compressive forces
• Potential for neurovascular damage
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Femoral Fractures (cont.)
• 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
• Limb appears shortened; thigh appears externally rotated
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Femoral Fractures (cont.)
• 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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Assessment
• History
• Observation/inspection
– Contranutation and nutation
• Palpation
• Physical examination tests
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Observation
• Contranutation at the SI joint
– Indicates anterior torsion of joint, or posterior
rotation of sacrum on ilium on one side
• Nutation
– Backward rotation of ilium on sacrum
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Range of Motion (ROM)
• Active range of motion (AROM)
– Hip
• Flexion
• Extension
• Abduction
• Adduction
• Lateral rotation
• Medial rotation
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ROM (cont.)
– Knee
• Flexion
• Extension
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ROM (cont.)
• Normal ranges
– Hip flexion (110–120°) with knee flexed
– Hip extension (10–15°)
– Abduction (30–50°)
– Adduction (30°)
– Lateral rotation (40–60°)
– Medial rotation (30–40°)
– Knee flexion (0–135°)
– Knee extension (0–15°)
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ROM (cont.)
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ROM (cont.)
• Passive range of motion (PROM)
– Normal end feel
• Hip flexion and adduction—tissue
approximation
• Hip extension, abduction, and medial and
lateral rotation—tissue stretch
– Passive movements at pelvic joint also stress
the ligamentous structures
• Sacroiliac compression and distraction
test
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ROM (cont.)
• RROM
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ROM (cont.)
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ROM (cont.)
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Stress Tests
• Sacroiliac compression
and distraction test
• “Squish” test
• Sacroiliac rocking test
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Stress Tests
• Approximation test
• Patrick’s (FABER) test
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Special Tests
• Leg length
measurement
– Anatomic
– Apparent
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Special Tests (cont.)
• Thomas Test for
flexion contractures
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Special Tests (cont.)
• Gaenslen’s test
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Special Tests (cont.)
• Kendall test for rectus
femoris contracture
• Hamstring contracture
test
• 90° – 90° straight leg
raising test
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Special Tests (cont.)
• Straight leg raising
(Lasegue's) test
• Trendelenburg test
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Special Tests (cont.)
• Piriformis test
• Long sitting test
• Ober’s test
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Special Tests (cont.)
• Sign of the buttock
test
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Neurologic Tests
• Myotomes
–
Hip flexion—L1, L2
–
Knee extension—L3
–
Ankle dorsiflexion—L4
–
Toe extension—L5
–
Ankle plantarflexion, foot eversion, or hip extension—S1
–
Knee flexion—S2
• Reflexes
–
No specific reflexes to test the pelvic or hip area
–
Lower extremity reflexes
• Patella—L3, L4
• Achilles tendon—S1
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Neurologic Tests (cont.)
• Dermatomes
• F16.35
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Neurologic Tests (cont.)
• Cutaneous patterns
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Rehabilitation
• Restoration of motion
– Refer to Field Strategies 16.1 and 17.1
• Restoration of proprioception and balance
– Closed-chain exercises
• Muscular strength, endurance, and power
– Open-chain exercises
– PNF-resisted exercises
• Cardiovascular fitness
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