pelvis and thigh pathologies part 1

what muscles attach to the iliac crest?

• major trunk muscles

• major hip muscles

how do contusions to the iliac crest present?

seemingly disproportionate amount of pain, swelling, discoloration, and loss of function

what nerves are subject to compression due to the hematoma from the contusion?

superficial nerves (lateral femoral cutaneous)

what are intervention strategies for iliac crest contusion?

• pending the severity

• range from a pad with ACE wrap and retuning to play (after specific functional testing)

• severe contusions may require immediate removal from participation, applying ice, and placing patient on crutches to avoid WB stresses

• stretching should be done as tolerated

• referral for x-rays to rule out iliac fracture may be warranted

when do muscle strains/tears or avulsion fractures occur to a dynamic overload during eccentric contraction or overstretching of the muscle fibers?

muscle strains/tears or avulsion fracture occur secondary

what can happen to skeletally immature patients or those with osteoporosis that sustain dynamic overload?

can lead to avulsion or apophyseal injuries

where is pain located in skeletally immature patients or those with osteoporosis that sustain dynamic overload?

pain localized a muscle origin or insertion

what is needed to confirm diagnosis of avulsion or apophyseal injuries in skeletally patients or those with osteoporosis?

x-rays

when do muscle tears present with pain?

during activities that activate the affected muscle (concentrically or eccentrically)

how are muscle strains graded?

grades 1, 2, or 3 pending on severity

• mild, moderate, severe

what are the risk factors of hamstring strains?

• age

• prior history of hamstring injury

• hamstring weakness and fatigue

• imbalances between quadriceps and hamstrings

• decrease quadriceps flexibility

what is the MOI for hamstring strains?

explosive activities, especially those that involve simultaneous hip flexion and knee extension (dynamic overload - running)

what can patients report feeling after sustaining a hamstring strain?

a popping or tearing sensation

what can palpation reveal in hamstring strains?

a divot in the muscle, pending the severity of the tear

• swelling may mask the defect

how do we differentiate between the medial versus lateral hamstring muscle strains?

based on position of the tibia during resistive ROM

what motions may cause an antalgic gait for hamstring muscle strains?

knee flexion and hip extension

what is used to identify the extent of hamstring strain?

MRI or MSK US

where would avulsion fractures of the hamstrings be located?

located at or close to the ischial tuberosity

what are the intervention strategies for hamstring strain?

• if patient is unable to walk without limp, then partial WB use of crutches is indicated

• ice and gentle pain-free stretching should be performed

• once normal gait is restored, return to activity can be initiated with a very slow progression to the fast activities

what do quad contusions cause?

intramuscular hematoma formation

what happens if the intramuscular hematoma is not treated properly?

increases the risk of developing heterotrophic ossifications (HO)

what is heterotrophic ossification (HO)?

the presence of bone in soft tissue where it normally does not exist

what are the intervention strategies for quad contusions?

• remove from competition if functionally limiting and unable to actively flex knee

• ice should be applied in a flexed knee position to increase surface area to absorb hematoma

  • increase knee flexion once the ice numbs the area

• restrict WB until control of quad muscle is regained and patient can flex the knee to 09 degrees without pain

what is slipped capital femoral epiphysis (SCFE)?

the displacement of the femoral head relative to the femoral neck (femoral epiphyseal plate fracture)

what happens to the femoral head and neck during SCFE?

the femoral head stays in the acetabulum while the femoral neck displaces anteriorly causing proximal femur to retrovert in out toeing

what is SCFE most common in?

adolescents

what adolescents are most at risk for SCFE?

• children who are overweight and experiencing growth spurt are at increased risk

• can occur bilaterally

how can SCFE present?

stable or unstable depending on the ability to WB

what is the onset for SCFE?

acute-on-chronic

what are the pain characteristics for SCFE?

stable: pain referred to distal quadriceps (femoral n.), adductor area (obturator n.), and/or buttocks/hamstrings area (sciatic n.)

unstable: intense pain that prevents walking

what is the MOI for SCFE?

gradual onset or abrupt maneuver

how does functional assessment present for SCFE?

stable - antalgic gait

unstable - unable to WB

what can be found during inspection for SCFE?

leg length difference

what can be found during palpation for SCFE?

tenderness over femoral head and neck

how does function present for SCFE?

decrease AROM and PROM, decreased strength

what joint stability tests are performed for SCFE?

n/a

what selective tissue tests are performed for SCFE?

n/a

how does the neurological screening present for SCFE?

unexplained hip and knee pain in children. femoral, obturator, or sciatic nerve symptoms

how does vascular screening present in SCFE?

wnl

what other comments are important for SCFE?

long term consequences include chronic pain and osteoarthritis

what are SCFE intervention strategies?

• refer to physician immediately to prevent further displacement

• standard surgical repair for a stable SCFEs uses single-screw fixation following gradual return to activity

• unstable SCFEs are also managed operatively but outcomes are worse with a high risk of complications including avascular necrosis and chondrolysis

what is legg-calve-perthes disease?

ischemic lesions of the femoral head that develop during the first decade of life (ages 2-14)

what can result from permanent damage to the femoral head?

decreased ROM

can legg-calve-perthes disease present unilateral or bilateral?

can be bilaterally

what happens if legg-calve-perthes disease goes untreated?

may lead to hip arthritis

what is the cause of legg-calves-perthes disease?

the medial circumflex artery is constricted by something

where can pain refer in someone that has legg-calve-perthes disease?

pain may refer to the medial thigh (obturator n.), buttock (sciatic nerve.), or supra patellar region (femoral ne.)

what are the early stages of legg-calves-perthes disease?

ROM is limited secondary to muscle spasms and synovitis

how does legg-calve-perthes disease progress?

ROM is limited by bony degeneration

what test would be positive for someone that has legg-calve-perthes disease?

trendelenburg test is often positive

what is needed to confirm LCPD?

x-rays

what is the treatment plan for LCPD?

immobilization to maintain femoral head in acetabulum so femoral head can ossify in a rounded shape

what pathology is most prevalent in endurance athletes, especially women with infrequent or absent menstruation?

femoral stress fractures

what are the types of femoral stress fractures?

• displaced

• compression

• tension

what predisposes athletes to develop fatigue stress fractures?

insufficient recovery periods

what are insufficiency stress fractures associated with?

bone lacking expected bone density

what is the onset for femoral stress fracture?

insidious

what are the pain characteristics for femoral stress fractures?

localized pain on femur that is relieved with rest. throbbing or burning pain may be reported

what is the MOI for femoral stress fractures?

repetitive stress/overuse, rapid increase in frequency, intensity, and duration of activity

how does the functional assessment present with femoral stress fractures?

antalgic gait

what can be found during inspection of femoral stress fractures?

pain increases hopping on one leg, pain prohibits activity

what can be found during palpation of femoral stress fractures?

tenderness over fracture site

how does function present with femoral stress fractures?

ROM: limited in extreme ranges

what joint stability tests are performed for femoral stress fractures?

n/a

what selective tissue tests are performed for femoral stress fractures?

axial loading on femoral head may cause pain (as with hip scouring); fulcrum test

how does neurological screening present for femoral stress fractures?

rule out referred pain from lumbar or sacral plexus

how does vascular screening present for femoral stress fractures?

WNL

what are other important comments for femoral stress fractures?

• MRI is the best modality to diagnose a stress fracture

• treatment is pending the location

  • compression side - treat conservatively

  • tension side - closely monitor for displacement which would require surgery

  • progression return to activity following resolution of symptoms is important

what’s another test that can be used that replicated the heel strike in running and a positive test indicates groin pain?

heel strike test

what is considered an intra-articular pathology?

femoral acetabular impingement

who is FAI more common in?

young and middle-aged individuals

how does FAI result in labral tears, chondral degeneration, and ultimately osteoarthritis (OA)?

FAI creates abnormal stress on surrounding soft tissue and bone

what are the 2 types of FAI deformities?

• cam lesion

• pincer lesion

what is a cam lesion?

located on femoral head and result from abnormally shaped femoral head repeatedly contacting the acetabulum and surrounding labrum

what is a pincer lesion?

acetabulum overly covers the femoral head, resulting in compression between the acetabular rim and femoral neck-head function, especially during hip flexion

what is the onset for FAI?

gradual

what are the pain characteristics for FAI?

groin pain; initially sporadic and progresses to constant

what is the MOI for FAI?

repetitive compressive forces from either Cam or Pincer lesion or both

how does the functional assessment present for FAI?

reproduction of symptoms in deep hip flexion; antalgic gait; poor hip control with squatting due to pain

what can be found during inspection for FAI?

unremarkable

what can be found during palpation for FAI?

deep pain in anterior hip region

how does function present for FAI?

ROM: limited AROM, weak MMT, decreased PROM

what joint stability tests are used for FAI?

n/a

what selective tissue tests are used for FAI?

FADDIR test, anterior impingement test

how doe the neurological assessment present for FAI?

WNL

how does the vascular assessment present for FAI?

WNL

what are other comments that are important for FAI?

• diagnosis is made with x-ray and MRI

• MRI may also discover chondral or labral damage

what are intervention strategies for FAI?

• initially conservative - avoid aggravating activities

• surgery may be needed

what causes labral tears?

• hip dislocations

• slipped capital epiphysis

• acetabular dysplasia

• repeated athletic trauma

what is the MOI for hip subluxations?

fall onto flexed knee with hip adducted or jump-stop pivot

what is the onset of labral tears?

acute or degenerative (insidious)

what are the pain characteristics for labral tears?

pain mostly in anterior or medial hip

what is the MOI for labral tears?

acute: hip dislocation or subluxation

insidious: repeated subtle subluxations that impinges anterior capsule; repeated weight-bearing rotation; hyper mobility

how does the functional assessment present for labral tears?

reproduction of symptoms with activities that require hip flexion; limp or shortened stance may be noted

what can be found during inspection for labral tears?

limb length discrepancy

what can be found during palpation of labral tears?

often unremarkable, clicking or popping may be noted during motion

how does function present for labral tears?

AROM: limited secondary to pain at end ranges

MMT: may cause discomfort pending on the position

PROM: pain and/or catching pending on the location of the tear

what joint stability tests are used for labral tears?

n/a

what selective tissue tests are used for labral tears?

hip scouring test, anterior impingement test, Thomas test may be positive, trendelenburg may be positive