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2012-03-25 13:24:42
hip groin thigh injuries

exam 2 sports med hip thigh, groin injuries
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  1. Anatomy of the Thigh Hip and Groin
    • Bones
    • Femur = longest and strongest bone in the body
    • -Proximal end articulates with the acetabulum of the pelvis and makes the hip joint
    • -Distal end articulates with the tibia to form the knee joint.
    • Pelvis = Functions to support the spine and trunk and transfers weight to lower limbs, protects pelvic organs, and is the attachemnt site for trunk and thigh muscles.
  2. Composed of:
    • Two innominate bones
    • -The sacrum
    • -coccyx
    • Femur
    • Pelvic Bones
  3. Pelvic Bone Composition
    • Sacrum and coccyx
    • Illiac Crest
    • Sacroilliac joint
    • Illium
    • Acetabulum (joint location)
    • Ishium (inferior posterior of acetabulum)
    • Pubic bone (inferior anterior of acetabulum)
    • -pubic syphysis (anterior joining of both pelvic bones)
  4. Ligaments in the hip
    • The head of the femur is stabilized in the acetabulum by iliofemoral ligaments and the joint capusle
    • The sacrum is joined to the pelvis via the sacrotuberous and sacrospinal ligaments forming the sacroilliac (SI) joint
  5. Muscles of the Hip--Thigh muscles
    • Quadriceps muscles--Hip flexors
    • Rectus femoris crosses knee joint and hip, so works to flex the hip
    • Sartorius flexes the hip and outwardly rotates the thigh
    • Hamstring muscles--Hip extensors
    • Adductors
    • Gracilis
    • Pectineus
    • Adductor magnus, longus, brevis
  6. Hip Flexion Muscles
    • Cosnist of 4 muscles
    • (Rectus femoris, Sartorius, Illiacus, Psoas)
  7. Hip Extension Muscles
    Hamstrings (Biceps femoris, Semimembranosus, Semitendonosus)
  8. Hip Abductors Muscles
    (Gluteus maximus, Gluteus medius)
  9. Hip Adductors Muscles
    • Tensor fascia lata (TFL)
    • Gracilis
    • Pectineus
    • Adductor magnus
    • Adductor longus
    • Adductor brevis
  10. Hip medial rotation muscle
    Gluteus minimus
  11. Hip lateral rotation muscles
    • Piriformis
    • Superior gemellus
    • Inferior gemellus
    • Obturator internus
    • Obturator externus
    • Quadratus femoris
  12. Evaluating Thigh Hip and Groin Injuries
  13. History
    • What mechanism do you think caused this injury?
    • When did you first notice the pain?
    • Did the pain begin immediately or did it occur gradually over a period of time?
    • Have you had a problem in this area before?
    • Has training intensity changed?
    • Where is your pain?
    • Describe the type of pain. (Sharp, dull, burning, aching)
    • Does the pain radiate down the back or the front of the legs or buttocks
    • When is the pain worst?
  14. Observation
    • Postural asymmetry while standing, one legged, and during ambulation
    • Anterior view are hips even?
    • From the lateral aspect is the pelvis abnormally tilted anteriorly or posteriorly?
    • Patellar alignment
    • Does standing on one leg cause pain in the hip?
    • Observe athlete while walking, bending, and sitting.
  15. Palpation
    • Iliac crest
    • Hip joint
    • Femur
    • Sacrum
    • Coccyx
    • Soft tissues of hip
  16. Special Tests
    • Thomas Test: Looks for tightness in the hip flexors.
    • Straight leg raises: Looks for tightness in the hamstrings/hip extensors, Can also indicate SI joint dysfunction and LBP
  17. Prevention of Injuries to Thigh Hip and Groin
    • Maintain proper flexibiltiy
    • Maintain proper strength in hips/Hamstrings/ Quads
    • Proper core strength
  18. Recognizing Thigh Injuries--Quadriceps Contusions
    • Cause of Injury: Traumatic blows
    • Signs of Injury
    • -Pain
    • -Temporary loss of function
    • -Immediate bleeding in the muscle
  19. Quadriceps Contusions Care Grade 1
    • (mild): usually fairly superficial intramuscular bruise.
    • -Superficial Contusion
    • --Mild hemorrage
    • --Minimal pain
    • --No swelling
    • --Mild point tenderness with no restriction of the ROM
    • -Deeper 1st degree contusion
    • --Pain
    • --Mild swelling
    • --TTP
    • --Knee flexion less or equal to 90 degree
    • walk it off, stretch, and RTP
    • ice
  20. Grade II (moderate) Quad Contusion
    • -Moderate intesity
    • --Pain
    • --Swelling
    • --Knee Flexion < 90 degrees
    • --Athlete walks with a limp
    • --no RTP
  21. Quad Contusions--Grade III (severe)
    • Major Disability
    • Herniation of the muscle through the fascia can occur (bump on thigh)
    • Deep intramuscular hematoma (bleed within muscle)
    • Pain is severe
    • Swelling is severe and can lead to a hematoma
    • Knee flexion is limited to 45-90 degrees
    • The athlete has an obvious limp
    • Recognizing Thigh Injuries
  22. Care of Quad Contusions
    • Ice and Compression with the knee flexed
    • Gentle static stretch when tolerable
    • Crutch walking if a limp is present
    • Protective padding
    • Quad sets
  23. Recognizing Thigh Injuries--Myositis Ossificans
    • Myositis Ossificans traumatica = ectopic bone formation within the muscle
    • Cause of injury
    • --Severe blow or repeated blows to the thigh
    • --Attempting to run off a Quad injury
    • --Too vigorous treatment of a contusion
  24. Myositis Ossificans--Signs of Injury
    • Disruption of muscle fibers, blood vessels, connective tissue, and periosteum of femur
    • Acute inflammation
    • Formation of bone may be noted on x-ray 2-4 weeks after injury
  25. Myositis Ossificans--Care
    • VERY Conservative treatment
    • Removal of bone formation after 1 year
    • Recurrent Myositis Ossificans can indicate a problem with blood clotting.
  26. Recognizing Thigh Injuries--Quadriceps Muscle Strain Cause of Injury
    • --Sudden stretch e.g. falling on a bent knee
    • --Sudden contraction: Jumping in volleyball or kicking in soccer.
  27. Quadriceps Muscle Strain-Signs of Injury of Peripheral tear
    • --Mild point tenderness
    • --Mild to no bleeding
  28. Quadriceps Muscle Strain- Signs of Injury of Partial muscle tear
    • --Mild to Moderate Pain
    • --Mild bleeding
  29. Quadriceps Muscle Strain--Signs of injury of Deep tear
    • --Lots of pain
    • --TTP
    • --Spasm
    • --Loss of function
    • --Little discoloration
  30. Quadriceps Muscle Strain--Signs of Injury of Complete tear
    • --Little disability
    • --Little discomfort
    • --Deformity of anterior thigh
    • --Recognizing Thigh Injuries
  31. Quadriceps Muscle Strain--Care
    • Rest
    • Cold application
    • Pressure
    • Neoprene sleeve
  32. Hamstring Muscle Strains Facts
    • This muscle group has the highest incidence of strain.
    • Hamstrings should have 60-75% of strength of the Quads
  33. Hamstring Muscle Strains--Cause of Injury
    • Quick change of function from stabilization to extension of the hip
    • Muscle fatigue
    • Sciatic nerve irritation
    • Faulty posture
    • Leg- length discrepancy
    • Tight hamstrings
    • Improper form
    • Muscle strength imbalance
  34. Hamstring Strains--Signs of Injury (Grades I-III)
    • Grade I
    • --Muscle soreness on movement
    • --TTP
    • Grade II
    • --Sudden snap or tear of the muscle
    • --Severe pain
    • --Loss of function of knee flexion
    • --Palpable defect in the muscle
    • Grade III
    • --Major hemorrhage
    • --Disability
    • --Palpable, and sometimes visual, defect
  35. Hamstring Strains--Care
    • RICE
    • Decreased Activity
    • Avoid ballistic and explosive stretching
    • Hamstring strains tend to reoccur because they heal with inelastic fibrous scar tissue.
    • The greater the injury the greater the incidence of recurrence.
  36. Acute Femoral Fracture--Cause of Injury
    • Typically occur in the shaft
    • Caused by great force
    • Falling from a great height
    • Direct hit
  37. Acute Femoral Fracture--Signs of Injury
    • Shock
    • Extreme pain
    • Deformity with the thigh rotated outward
    • A shortened thigh, cause by bone displacement
    • Swelling of soft tissues
  38. Acute Femoral Fracture--Care
    Immediate EMS assistance and referral to ER
  39. Stress Fracture of the Femur--Cause of Injury
    • Increase in popularity of jogging and mileage
    • Females who are amenorrheic (inconsistent/ no period)
  40. Stress Femoral Fracture--Signs of Injury
    • Constant pain
    • Usually located in the neck of the femur
  41. Stress Femoral Fracture--Care
    • Rest
    • Limited weight bearing
  42. Dislocated Hip Joint--Cause of Injury
    • Traumatic force along the axis of the femur
    • Falling on the side (usually w/knee bent)
  43. Disclocated Hip Joint--Signs of Injury
    • Thigh is flexed, adducted and internally rotated
    • Dislocated Hip Joint--Care
    • --Immediate EMS action
    • --Immobilization (bed rest) for 2 weeks
    • --Crutch walking for 1 month or longer
    • Complications
    • --Muscle paralysis due nerve injury
    • --Degeneration of femoral head
  44. Piriformis Syndrome--Cause of Condition
    • The sciatic nerve becomes compressed by irritation or tightness and spasm of the piriformis muscle.
    • This is NOT sciatica. Sciatica is caused by a herniated lumbar disc pressing on the nerve.
  45. Periformis Sybdrome--Signs of Condition
    • Pain
    • Numbness and tingling in the butt that can run down into the knee and foot.
    • Pain can worsen if they are seated for long periods of time/climbing stairs/running/walking
  46. Periformis Syndrome--Care
    • Stretching
    • Massage
    • NSAIDs
    • Corticosteroid injection
    • Rest
  47. Cam and Pincer Lesions (femoralacetabular impingment)--Cause of Condition
    • Condition caused by an abnormally shaped femoral head, accetabulum or both.
    • Common in hockey players and Soccer players
    • Diagnosis is one of exclusion--chronic hip injuries
    • Treatment is surgery to correct the abnormality
    • Cam=abnormal shaped femoral head
    • Pincer=abnormal shaped acetabulum
  48. Groin Strain--Cause of Injury
    • Overextension of the groin musculature
    • Running, jumping, twisting w/external rotation
    • Usually occurs in early part of the season due to poor conditioning
  49. Groin Strain--Signs of Injury
    • Sudden twinge of feeling of tearing during movement
    • Pain
    • Weakness
    • Internal bleeding
    • --test with sit-ups to determine strain or hernia.
    • Groin Strain--Care
    • Intermittent ice
    • Pressure wrap
    • Rest for 48-72 hours
    • Spica bandage
    • Severe groin pain should be referred to Dr. for medical attention to R/O pelvic fx
  50. Athletic Pubalgia/ Sports Hernia--Cause of Injury
    • Repetitive movement and trauma especially hip flexion
    • Weak abdominal muscles and pelvic floor muscles
    • Tight adductors
  51. Athletic Pubalgia/Sports Hernia--Signs of Injury
    • Pain during activity usually with hip flexor and trunk twisting
    • Pain is diffuse and hard to pinpoint but usually refers to the adductors
  52. Athletic Pubalgia/ Sports Hernia--Care
    • Usually diagnosed via process of elimination
    • Surgical repair of hernia as well as possible adductor release
  53. Hip Joint Problems in the Adolescent Athlete
    • Slipped Capital Femoral Epiphysis
    • Legg-Perthes disease (Coxa Plana)
  54. Legg-Perthes disease (Coxa Plana)
    • Loss of blood circulation to the articular head of the femur.
    • Usually occurs in children ages 3-12 and in boys more often than girls.
    • The articular cartilage will die and becomes flattened. (Avascular Necrosis)
  55. Signs of Coxa Plana
    • C/O Pain in the groin that can refer to abdomen or knee
    • Usually comes slowly over time
    • Exam may show limited hip movement and pain
  56. Coxa Plana--Care
    • Complete bed rest
    • Special Brace
    • If treated properly head of femur will revascularize and retain it's normal shape
  57. Coxa Plana--Complications
    • Osteoarthritis in later life
    • Hip Joint Problems in the Adolescent Athlete
  58. Slipped Capital Femoral Epiphysis
    • Condition in which the epiphysis of the femur slips backward off of the femoral head.
    • Usually due to weakness in the growth plate
    • Usually occurs in boys 10-17
    • Caused by rapid growth
    • Might be related to effects of growth hormone
    • ? of the cases both hips are affected
  59. Slipped Capital Femoral Epiphysis--Signs of Condition
    • Pain in the groin area
    • During advanced stage major limitations of movement occur
  60. Slipped Capital Femoral Epiphysis--Care
    • Minor displacement = no weight bearing
    • Major displacement = corrective surgery
  61. Slipped Capital Femoral Epiphysis--Complications
    Severe hip problems may occur later in life
  62. Iliac Crest Contusion (Hip Pointer)--Cause of Injury
    Blow to the iliac crest
  63. Iliac Crest Contusion (Hip Pointer)--Signs of Injury
    • Immediate pain
    • Muscle guarding
    • Transitory paralysis of soft structures
  64. Iliac Crest Contusion (Hip Pointer)--Care
    • Cold and pressure
    • Bed rest in severe cases
    • Referral to Dr. for X-rays
    • Padding for RTP
  65. Osteitis Pubis--Cause of Injury
    • chronic inflammation of pubic symphysis
    • Running
  66. Osteitis Pubis--Signs of Injury
    • Pain in groin region and in the pubic symphysis
    • TTP on pubic tubercle
    • Pain with running sit-ups and squats
  67. Osteitis Pubis--Care
    • Rest
    • NSAIDs
    • Gradual return to activity
  68. Acute Fracture of the Pelvis--Cause of Injury
    Direct trauma
  69. Acute Fracture of the Pelvis--Signs of Injury
    • Severe pain
    • Loss of function
    • Shock
  70. Acute Fracture of Pelvis--Care
    • Treat for shock
    • Initiate EMS or refer to Dr.
  71. Stress Fracture of Pelvis--Cause of Injury
    Repetitive abnormal overuse forces
  72. Stress Fractue of Pelvis--Signs of Injury
    • Groin pain
    • Aching sensation in the thigh that increases with activity and decreases with rest
  73. Stress Fracture of Pelvis--Care
    • Refer to Dr. for X-ray
    • Rest for 2-5 months
  74. Avulsion Fracture--Cause of Injury
    • Intense forces of the muscle pulls a small piece of the bone away from it's insertion site
    • Common sites
    • --Sartorius muscle and the ASIS
    • --Rectus Femoris muscle and the AIIS
    • --Hamstrings and the ischial tuberosity
  75. Avulsion Fracture--Signs of Injury
    • Sudden localized pain with limited movement
    • Swelling and Point tenderness
  76. Avulsion Fracture--Care
    • Rest
    • Limited Activity
    • Graduated Exercise