Hip and Thigh

Hips

 

Anatomy

  • Bones

    • Femur

    • Pelvis

      • Anterior Superior Iliac spine (ASIS)

      • Anterior Inferior Iliac Spine (AIIS)

      • Iliac crest

    • Ischium

    • Pubis

      • Ramus

      • Symphysis

 

  • Articulation

    • Head of femur with acetabulum

      • Lateral of pelvis

      • Depth of is allows it to encompass almost the entire head

      • Deepened by the peripheral labrum

    • Ball an Socket joint

    • Synovial joint

      • Capsule

  • Labrum

    • Ring of touch cartilage around the acetabulum

    • It distributes force and holds on to the head of the femur

    • Cushions joint

  • Foveal artery

    • Runs inside the ligament to the femoral head

    • Helps avoid avascular necroses,

  • Avascular necrosis

    • When the bone is not properly supplied with blood, that part will die and healing won't take place

    • Femoral head can loses its rounded shape and won't rotate smoothly within the acetabulum, it can lead to a form of arthritis

 

Movement

  • Circumduction

    • Flexion or extension

      • 120 degrees

    • Adduction and abduction

      • 50 degrees of abduction

    • Internal and external rotation

      • 45 external

      • 35 internal

 

Capsule, Ligament

  • Iliofemoral

    • anterior

  • Ischiofemoral

    • posterior

  • Pubofemoral

    • Anterior

  • Bursae

    • Iliopsoas

      • Between the iliopsoas muscle and anterior joint capsule

    • Trochanteric

      • Between the greater trochanter of femur and gluteus maximus muscle

 

Injuries

 

Sprain and Strains

Hx

  • Violent torsion or extension

  • Hip flexion against resistance

    • Iliopsoas strain

Ssx

  • Deep pain, worse with movement

  • Pain with AROM, no pain with Passive

Tx

  • Rest, NSAID, physiotherapy

 

Subluxation vs snapping hip

  • Sublux is seen in extreme ROM sports

    • Femoral heads comes out of acetabulum and pops back in

  • Snapping hip

    • Tendon slides over the trochanter

      • Iliotibial slides over the greater trochanter

      • Iliopsoas slides over lesser trochanter

    • Gymnastics, dancing martial arts

    • Narrow pelvis, abnormal increase in abduction ROM, lack of ROM in internal and external ROM

    • Cause by acetabulum labral tears and sublux of the joint itself

    • Relatively harmless

    • Often chronic

      • Could lead to osteoarthritis

  • Tx for sublux

    • Rest, ice, NSAIDs, stretching , change activities

 

Hip Dysplasia

  • Femur head id deformed and has a shallow hip socket

  • Allows for the hip joint to become partially or completely dislocation

  • Can be curable in childhood

  • Laeds to arthritis later in life

 

Bursitis

  • Hx

    • Overuse or direct blow

  • Ssx

    • Tenderness, pain on movement

  • Tx

    • POLICE

    • NSAID

    • Rest

    • Physio

 

Labral Tear

  • Hx

    • Shearing

    • Excessive forces at hip joint

      • Internal rotation

    • Hip labrum pulls away from acetabulum

  • 3 main causes

    • Trauma, motor vehicle accidents

    • Hip abnormalities

      • Hip dysplasia, FAI

    • Repetitive movements, most common

      • Twisting, hockey/golf

      • Extreme end range, ballet and gymnastics

      • Repetitive joint loading, marathoners

  • Ssx

    • Deep groin/buttock pain

    • Pain/stiffness moving hip in certain directions

    • Feeling clicking/locking when moving hip joint

  • Tx

    • Conservative

      • Rest, NSAIDS, injections, physiotherapy

    • Surgical

      • Arthroscopic labral debridement

      • Arthroscopic labral repair

      • Arthroscopic labral replacement

    • Labral tear predisposes athlete to articular cartilage degeneration or osteoarthritis

 

Fracture/Dislocation

  • Hx

    • Severe Trauma (MVA) or elderly person (Neck of femur)

  • Ssx

    • Extreme pain, markedly reduced ROM deformity, it may not be present

  • Tx

    • Recognize, stabilize and transport

    • NPO cause surgery

    • Avascular necrosis can be a complication

      • Fracture can damage blood vessels and reduce blood flow to bones

Thigh

 

Bones

  • Femur

    • Head

    • Neck

    • Greater and lesser trochanters

    • Shaft

    • Condyles

Artery

  • Femoral

  • Turns to popliteal

Nerves

  • Femoral

    • L2 to L4 nerve root

  • Sciatic

    • L4 to S3 Nerve root

Muscles

  • Anterior

    • Quadriceps femoris

  • Posterior

    • Hamstring

 

Hip Flexors

  • Iliopsoas

    • iliacus

  • Rectus femoris

Hip Extensors

  • Gluteus maximus

  •  hamstrings

Hip Adductors

  • Adductors

    • Magnus

    • Longus

    • Brevis

  • Gracilis

  • Pectineus

Hip Abductors

  • Gluteus medium, minimums, maximus

  • Tensor fascia latae and others

Hip External Rotators

  • Piriformis

  • Obturator externus and internus

  • Superior and inferior gemellus

  • Quadratus femoris

Hip Internal Rotatos

  • TFL, tensor fascia latae

  • Gluteus Medius

  • Adductors

  • pectineus

 

Piriformis

  • Sciatic nerve is under

  • If it is tight it can pinch the sciatic nerve

 

Iliotibial Band

  • A lateral thickening of the fascia latae

  • Cord of connective tissue

  • Source of pain is from the richly innervated and vascularized layer of fat and connective tissue between the IT band and lateral epicondyle

 

Thigh Compartments

 

Anterior Compartment

  • Quad Muscle group

    • Primarily knee extensors

    • Rectus femoris

    • Vastus lateralis

    • Vastus intermedius

    • Vastus medialis

Posterior Compartment

  • Hamstring muscle group

  • Primarily knee flexors

  • Biceps femoris

    • Most lateral

  • Semitendinosus

    • Middle of hamstring group

  • Semimembranosus

    • Most medial

Medial Compartment

  • Adductor muscle groups

  • Adductor magnus, longus, brevis

  • Pectineus

  • Gracilis

 

Contusion

  • Hx

    • Direct blow

  • Ssx

    • Pain and bruising

    • Tenderness/firm on palpation

    • Localized swelling

    • Decreased ROM

    • Limp

  • Tx

    • POLICE

    • NO HEAT NO MASSAGE over the contusion

    • Padding

    • ROM exercise and physio

 

Myositis Ossification

  • Several contusions or mishandling or severe contusion

  • ROM not returning after contusion

  • Thigh firm on palpation weeks to months later

  • Send of imaging

  • Bone is being laid down within the injured muscle

  • Can be causes heating and massaging over the contusion

 

Strain

  • Hx

    • Resisting a force, torsion, hyperextension, abduction

    • Predisposed by decreased strength or flexibility, previous strains

  • Ssx

    • 1st degree

      • Pain (worse with resistance and AROM)

      • Tenderness

      • No limp, snap or pop

    • 2nd degree

      • Pain and tenderness, bruising

      • Snap or pop felt/heard

      • Limp

    • 3rd degree (rupture)

      • Pain and tenderness, bruising

      • Snap or pop felt/heard

      • Limp

      • Gap in the muscle

  • Tx

    • 1st degree

      • POLICE

      • ROM exercise, tape

    • 2nd degree

      • POLICE

      • Rest for 2-6 weeks

      • ROM exercise, tape

      • Physio and rheab

    • 3rd degree

      • NPO, stabilize

      • Transport to hospital for surgery

      • Rest, physio, rehab

Hamstring Strains

Cause

  • Inflexibility

  • Improper warm-up

  • Temperature

  • Fatigue

  • Violent contraction

Tx

  • POLICE, rest, stretching delayed, strengthening eccentric, gradual return to activities, hamstring tensor wrap and core shorts

 

 

Iliotibial Band Friction Syndrome

  • Clinical features

    • Subjective; ache on lateral aspect of the knee

    • Worse with cycling downhill running

  • Objective

    • Tenderness on palpation over lateral femoral epicondyle

    • Positive Ober's test

      • With or without burning sensation

    • Tightness of gluteus max and TFL

      • Over developed vastus lateralis

      • Overprotection can increase tibial rotation

      • Increase in femoral rotation/genu valgum

  • Treatment

    • Pathology is distal but need to treat proximal

    • Exercise therapy similar to patellafemoral pain syndrome

      • Strengthen hip abductors

      • Release glute max/TFL/ Vastus lateralis

      • Soft tissue release, massage, foam rolling, stretching

        • Dry needle

 

Fracture

  • Femoral fracture

  • Major trauma

  • Ssx

    • Severe pain, inability to weight bear

  • Tx

    • Stabilize NPO, get to hospital ASAP

  • Surgery with internal fixation with rod and plate

  • Rehab: gradual progression of ROM and strengthening/progressively weight bearing over 4-6 months

 

Review Pelvis and Genitalia anatomy in text

 

Scrotal contusion

  • Direct blow or trauma to the scrotum

  • Pain subsides over 5 minutes

  • Tx: hip flexion and gentle breathing

 

Traumatic hydrocoele

  • Delayed complications of contusion (days, weeks, months)

  • Appearance of cluster or swollen veins

  • Tx: surgical if warranted

 

Torsion of Spermatic Cord

  • Pain increase over time

  • Nausea, vomiting

  • Shock, rapid HR and RR; clammy skin

  • Swelling and extreme tenderness

  • Surgical emergency

  • NP and transport ASAP

 

Hip Pointer

  • Contusion of iliac crest

  • Ssx

    • Pain, tenderness, bruising

    • Localized swelling, limp

    • Difficulty with flexing thigh or rotating trunk

  • Tx

    • ICE, rest padding, physio

 

Coccygeal

  • Direct blow (fall, kick)

  • Ssx

    • Pain, bruising, tenderness

  • Tx

    • Hospital for X-ray

    • NSAID, warm baths

    • May need surgery

 

 

How the muscles that cross the pelvis (ie lats and glute max, external obliques and adductors) work together to squeeze and hold the pelvis stable is an example of: force closure