Nerve and Blood Supply Tibial and common peroneal are given rise from the
sacral plexus which form the largest nerve in the body the sciatic nerve complex
The main arteries of the thigh are the deep circumflex femoral, deep femoral, and femoral artery
The two main veins are the superficial great saphenous and the femoral vein
Assessment of the Thigh History
Onset (sudden or slow?) Previous history? Mechanism of injury? Pain description, intensity, quality, duration, type and
location?
Observation Symmetry? Size, deformity, swelling, discoloration? Skin color and texture? Is athlete in obvious pain? Is the athlete willing to move the thigh?
•Palpation: Bony and Soft Tissue
Medial and lateral femoral condyles
Greater trochanter
Lesser trochanter
Anterior superior iliac spine (ASIS)
Sartorius
Rectus femoris
Vastus lateralis
Vastus medialis
Vastus intermedius
Semimembranosis
Semitendinosis
Biceps femoris
Adductor brevis, longus and magnus
Gracilis
Sartorius
•Palpation: Soft Tissue (continued)
Pectineus
Iliotibial Band (IT-band)
Gluteus medius
Tensor fasciae latae
Special Tests
If a fracture is suspected the following tests are not performed
Beginning in extension, the knee is passively flexed
A normal muscle will elicit full range of motion pain free (one w/ swelling or spasm will have restricted motion)
Active movement from flexion to extension
Strong and painful may indicate muscle strain
Weak and pain free may indicate 3rd degree or partial rupture
Muscle weakness against an isometric resistance may indicate nerve injury
Recognition and Management of Thigh Injuries Quadriceps Contusions
Etiology Constantly exposed to traumatic blunt blow
Contusions usually develop as a result of severe impact
Extent of force and degree of thigh relaxation determine depth and functional disruption that occurs
Signs and Symptoms Pain, transitory loss of function, immediate effusion with
palpable swollen area
Graded 1-4 = superficial to deep with increasing loss of function (decreased ROM, strength)
Quad Contusion
Quad Contusion – Grade 1 Superficial
Intramuscular hematoma
Mild hemorrhage
Little Pain
No Swelling
Mild Point Tenderness
No restriction in Movement (FLEXION)
Quad Contusion – Grade 2 Signs and Symptoms
Deeper than grade 1
Mild pain
Mild swelling
Point tenderness
Flex NO MORE than 90 Degrees
Quad Contusion – Grade 3 Signs and Symptoms
Moderate Intensity
Swelling
Painful
ROM from 45 to 90 flexed
Obvious limp
Quad Contusion – Grade 4 Signs and Symptoms
MAJOR DISABILITY
Split the Fascia (Muscle Herniation)
Deep Intramuscular Hematoma
Severe Pain
Swelling
Hematoma
ROM is LESS than 45 Degreed flexed
LIMP
Quad Contusion -- Treatment Immediately placed into FLEXION with ice pack
applied to avoid muscle contracture (shortening)
RICE, NSAID’s & analgesics
Non-weight bearing (grade 2 and / or 3)
ROM exercises
PRE (Progressive Resistive Exercise)
Conservative
Gentle Stretching as able
Compression
Management RICE, NSAID’s and
analgesics Crutches for more severe
cases Aspiration of hematoma is
possible Following exercise or re-
injury, continued use of ice Follow-up care consists of
ROM, and PRE w/in pain free range
Heat, massage and ultrasound to prevent myositis ossificans
General rehab should be conservative
Ice w/ gentle stretching w/ a gradual transition to heat following acute stages
Elastic wrap should be used for support
Exercises should be graduated from stretching to swimming and then jogging and running
Restrict exercise if pain occurs
May require surgery of herniated muscle or aspiration
Once an athlete has sustained a severe contusion, great care must be taken to avoid another
Myositis Ossificans Traumatica Etiology
Formation of ectopic bone following repeated blunt trauma (disruption of muscle fibers, capillaries, fibrous connective tissue, and periosteum)
Gradual deposit of calcium and bone formation May be the result of improper thigh contusion treatment (too
aggressive)
Signs and Symptoms X-ray shows calcium deposit 2-6 weeks following injury Pain, weakness, swelling, decreased ROM Tissue tension and point tenderness w/
Management Treatment must be conservative May require surgical removal if too painful and restricts motion
(after one year - remove too early and it may come back)
Quadriceps Muscle Strain Etiology
Sudden stretch when athlete falls on bent knee or experiences sudden contraction
Associated with weakened or over constricted muscle Signs and Symptoms
Peripheral tear causes fewer symptoms than deeper tear Pain, point tenderness, spasm, loss of function and little
discoloration Complete tear may leave athlete w/ little disability and discomfort
but with some deformity Management
RICE, NSAID’s and analgesics Manage swelling, compression, crutches Move into isometrics and stretching as healing progresses Neoprene sleeve may provide some added support
Hamstring Muscle Strains(second most common thigh injury) Etiology
Multiple theories of injury Hamstring and quad contract together Change in role from hip extender to knee flexor Fatigue, posture, leg length discrepancy, lack of flexibility, strength
imbalances,
Signs and Symptoms Muscle belly or point of attachment pain Capillary hemorrhage, pain, loss of function and possible
discoloration Grade 1 - soreness during movement and point tenderness (<20% of
fibers torn( Grade 2 - partial tear, identified by sharp snap or tear, severe pain,
and loss of function (<70% of fiber torn)
Signs and Symptoms (continued)
Grade 3 - Rupturing of tendinous or muscular tissue, involving major hemorrhage and disability, edema, loss of function, ecchymosis, palpable mass or gap
>70% muscle fiber tearing
Management
RICE, NSAID’s and analgesics
Grade I - don’t resume full activity until complete function restored
Grade 2 and 3 should be treated conservatively w/ gradual return to stretching and strengthening in later stages of healing (modalities and isometrics)
When soreness is eliminated, isotonic leg curls can be introduced (focus on eccentrics)
Recovery may require months to a full year
Greater scaring = greater recurrence of injury
Hamstring Strain
Acute Femoral Fractures Etiology
Generally involving shaft and requiring great force
Occurs in middle third due to structure and point of contact
Signs and Symptoms
Pain, swelling, deformity
Management
Treat for shock, verify neurovascular status, splint before moving, reduce following X-ray
Analgesics and ice
Extensive soft tissue damage will also occur as bones will displace due to muscle force
Femoral Stress Fractures Etiology
Overuse (10-25% of all stress fractures) Excessive downhill running or jumping activities Compression or distraction fracture generally occur
Signs and Symptoms Persistent pain in thigh X-ray or bone scan will reveal fracture Commonly seen in femoral neck
Management Analgesics, NSAID’s RICE ROM and PRE exercises are carried out w/ pain free ROM Rest, limited weight bearing Complete stress fracture may require pins
Anatomy of the Hip, Groin and Pelvic Region
Extra StructuresHip Capsule
Hip Labrum (like meniscus)
Assessment of the Hip and Pelvis Body’s center of gravity is located just anterior to the
sacrum Injuries to the hip or pelvis cause major disability in the
lower limbs, trunk or both Low back may also become involved due to proximity
History Onset (sudden or slow?) Previous history? Mechanism of injury? Pain description, intensity, quality, duration, type and
location?
Observation Symmetry- hips, pelvis tilt (anterior/posterior)
Lordosis or flat back
Lower limb alignment Knees, patella, feet
Pelvic landmarks (ASIS, PSIS, iliac crest)
Standing on one leg Pubic symphysis pain or drop on one side
Ambulation Walking, sitting - pain will result in movement distortion
•Palpation: Bony
Iliac crest
Anterior superior iliac spine (ASIS)
Anterior inferior iliac spin (AIIS)
Posterior superior iliac spine (PSIS)
Pubic symphysis
Ischial tuberosity
Greater trochanter
Femoral neck
•Palpation: Soft Tissue Rectus femoris
Sartorius
Iliopsoas
Inguinal ligament
Gracilis
Adductor magnus, longus & brevis
Pectineus
Gluteus maximus, medius & minimus
Piriformis
Hamstrings
Tensor fasciae latae
Iliotibial Band
- Major regions of concern are the groin, femoral triangle, sciatic nerve, lymph nodes
•Special Tests – more at end too…
Functional Evaluation
ROM, strength tests
Hip adduction, abduction, flexion, extension, internal and external rotation
Leg Length Difference
Leg Length Difference Anatomical – Leg is shorter
Functional – Leg is ok, appears shorter
Not Physically Active – over 1/2 inch may produce symptoms
Physically Active – 1/8 inch may produce symptoms
Cumulative stresses to lower limbs, hip, and pelvis or low back
Measure –
X-Ray best to determine due to soft tissue
Anatomical –lateral malleolus & ASIS
Functional – belly button & medial malleolus
Leg LengthApparent = Functional Difference – Measure from belly button to medial malleolus
True = Anatomical Difference – Measure from ASIS to medial malleolus
“Typically” – Anatomical = Functional, but Functional does NOT = Anatomical
Recognition and Management of Specific Hip, Groin, and Pelvic Injuries Groin Strain
Etiology
One of the more difficult problems to diagnose
Injury to one of the muscles in the regions (generally adductor longus)
Occurs from running , jumping, twisting w/ hip external rotation or severe stretch
Signs and Symptoms
Sudden twinge or tearing during active movement
Produce pain, weakness, and internal hemorrhaging
Groin Strain (continued) Management
RICE, NSAID’s and analgesics for 48-72 hours
Determine exact muscle or muscles involved
Rest is critical; daily whirlpool and cryotherapy, moving into ultrasound
Delay exercise until pain free
Restore normal ROM and strength -- provide support w/ wrap
Hip flexor vs Groin strain…
Pull up to assist hip flexor strain, pull
down to assist groin strain
Contusion (hip pointer) Etiology
Contusion of iliac crest or abdominal musculature
Result of direct blow (same MOI for iliac crest fx and epiphyseal separation
Signs and Symptoms Pain, spasm, and transitory paralysis of soft structures
Decreased rotation of trunk or thigh/hip flexion due to pain
Management RICE for at least 48 hours, NSAID’s,
Bed rest 1-2 days
Referral must be made, X-ray
Ice massage, ultrasound, occasionally steroid injectionRecovery lasts 1-3 weeks
Trochanteric Bursitis Etiology
Inflammation at the site where the gluteus medius ties into the IT-band
Signs and Symptoms Complaint of lateral hip pain that may radiate down the
leg
Palpation reveals tenderness over lateral aspect of greater trochanter
IT-band and TFL tests should be performed
Management RICE, NSAID’s and analgesics
ROM and PRE directed toward hip abductors and external rotators
Phonophoresis if pain doesn’t respond in 3-4 days
Look at biomechanics and Q-angle
Avoid inclined surfaces;
Dislocated Hip Etiology
Rarely occurs in sport
Result of traumatic force directed along the long axis of the femur (posterior dislocation w/ hip flexed and adducted and knee flexed)
Signs and Symptoms Flexed, adducted and internally rotated hip
Palpation reveals displaced femoral head, posteriorly
Serious pathology
Soft tissue, neurological damage and possible fx
Management Immediate medical care (blood and nerve supply may be
compromised)
Contractures may further complicate reduction
2 weeks immobilization and crutch use for at least one month
Avascular Necrosis Etiology
Result of temporary or permanent loss of blood supply to proximal femur
Can be caused by traumatic conditions (hip dislocation), or non-traumatic circumstances (steroids, blood coagulation disorders, excessive alcohol use compromising blood vessels)
Signs and Symptoms Early stages - possibly no S&S
Joint pain w/ weight bearing progressing to at times of rest
Pain gradually increases (mild to severe) particularly as bone collapse occurs
May limit ROM
Osteoarthritis may develop
Progression of S&S can develop over the course of months to a year
Avascular Necrosis (continued) Management
Must be referred for X-ray, MRI or CT scan
Must work to improve use of joint, stop further damage and ensure survival of bone and joint
Most cases will ultimately require surgery to repair joint permanently
Conservative treatment involves ROM exercises to maintain ROM; electric stim for bone growth; non-weight bearing if caught early
Medication to treat pain, reduce fatty substances reacting w/ corticosteroids or limit blood clotting in the presence of clotting disorders may limit necrosis
Sprains of the Hip Joint Etiology
Due to substantial support, any unusual movement exceeding normal ROM may result in damage
Force from opponent/object or trunk forced over planted foot in opposite direction
Signs and Symptoms
Signs of acute injury and inability to circumduct hip
Similar S & S to stress fracture
Pain in hip region, w/ hip rotation increasing pain
Management
X-rays or MRI should be performed to rule out fx
RICE, NSAID’s and analgesics
Depending on severity, crutches may be required
ROM and PRE are delayed until hip is pain free
Osteitis Pubis
Etiology
Seen in distance runners
Repetitive stress on pubic symphysis and adjacent muscles
Signs and Symptoms
Chronic pain and inflammation of groin
Point tenderness on pubic tubercle
Pain w/ running, sit-ups and squats
Acute case may be the result of bicycle seat
Management
Rest, NSAID’s and gradual return to activity
•Special Tests
Functional Evaluation
ROM, strength tests
Hip adduction, abduction, flexion, extension, internal and external rotation
Tests for Hip Flexor Tightness
Kendall test
Test for rectus femoris tightness
Thomas test
Test for hip contractures
Kendall’s Test
Thomas Test
•Femoral Anteversion (A) and Retroversion (B) Relationship
between neck and shaft of femur
Normal angle is 15 degrees anterior to the long axis of the femur and condyles
Internal rotation in excess of 35 degrees is indicative of anteversion, 45 degrees of external rotation is an indicator of retroversion
•Test for Hip and Sacroiliac Joint
Patrick Test (FABER)
Detects pathological conditions of the hip and SI joint
Pain may be felt in the hip or SI joint
Gaenslen’s Test
Test works to push SI joint into extension
Test is positive if hyperextension on affected side increases pain
•Testing the Tensor Fasciae Latae and Iliotibial Band
Renne’s test
Athlete stands w/ knee bent at 30-40 degrees
Positive response of TFL tightness occurs when pain is felt at lateral femoral condyle
Nobel’s Test
Lying supine the athlete’s knee is flexed to 90 degrees
Pressure is applied to lateral femoral condyle while knee is extended
Pain at 30 degrees at lateral femoral condyle indicates a positive test
Ober’s Test
Used to determine presence of contracted TFL or IT-band
Thigh will remain in abducted position, not falling into adduction
•Trendelenburg’s Test- Iliac crest on unaffected side should be higher when standing on one leg- Test is positive when affected side is higher indicating weak abductors (glut medius)
Piriformis Test
Hip is internally rotated
Tightness or pain is indicative of piriformis tightness
`
Ely’s Test
Used to assess tightness of rectus femoris
Athlete is prone, w/ pelvis stabilized and knee on the affected side is flexed
If hip on that side extends as the knee is flexed, rectus femoris is tight
Measuring Leg Length Discrepancy
With inactive individual, difference of more that 1” may produce symptoms
Active individuals may experience problems w/ as little 3mm (1/8”) difference
Can cause cumulative stresses to lower limbs, hips, pelvis or low back
True or anatomical
Shortening may be equal throughout limb or localized w/in femur or lower leg
Measurement taken from medial malleolus to ASIS
Apparent or functional
Result of lateral pelvic tilt or from a flexion or adduction deformity
Measurement is taken from umbilicus to medial malleolus
Hip Problems in the Young Athlete Legg Calve’-Perthes Disease (Coxa Plana)
Etiology
Avascular necrosis of the femoral head in child ages 4-10
Trauma accounts for 25% of cases
Articular cartilage becomes necrotic and flattens
Signs and Symptoms
Pain in groin that can be referred to the abdomen or knee
Limping is also typical
Varying onsets and may exhibit limited ROM
•Legg-Calve’-Perthes Disease (continued)
Management
Bed rest to alleviate synovitis
Brace to avoid direct weight bearing
Early treatment and head may reossify and revascularize
Complication
If not treated early, will result in ill-shaping and osteoarthritis in later life
Slipped Capital Femoral Epiphysis
Etiology Found mostly in boys ages 10-17 who are characteristically tall
and thin or obese
May be growth hormone related
25% of cases are seen in both hips, trauma accounts for 25%
Head slippage on X-ray appears posterior and inferior
Signs and Symptoms Pain in groin that comes on over weeks or months
Hip and knee pain during passive and active motion; limitations of abduction, flexion, medial rotation and a limp
Management W/ minor slippage, rest and non-weight bearing may prevent
further slippage
Major displacement requires surgery
If undetected or surgery fails severe problems will result
The Snapping Hip Phenomenon Etiology
Common in young female dancers, gymnasts, hurdlers
Habitual movement predispose muscles around hip to become imbalanced (lateral rotation and flexion)
Related to structurally narrow pelvis, increased hip abduction and limited lateral rotation
Hip stability is compromised
Signs and Symptoms
Pain w/ balancing on one leg, possible inflammation
Management
Focus on cryotherapy and ultrasound to stretch musculature and strengthen weak musculature in hip region
Stress Fractures
Etiology Seen in distance runners - repetitive cyclical forces from
ground reaction force
More common in women than men
Common site include inferior pubic ramus, femoral neck and subtrochanteric area of femur
Signs and Symptoms Groin pain, w/ aching sensation in thigh that increases w/
activity and decreases w/ rest
Standing on one leg may be impossible
Deep palpation results in point tenderness
Intense interval or competitive racing may cause
Stress Fractures (continued)
Management Rest for 2-5 months
Crutch walking for ischium and pubis fractures
X-ray normal 6-10 weeks and bone scan will be required
Swimming can be used -- breast stroke avoided
Avulsion Fractures and Apophysitis
Etiology Traction epiphysis (bone outgrowth)
Common sites include ischial tuberosity, AIIS, and ASIS
Avulsions seen in sports w/ sudden accelerations and decelerations
Signs and Symptoms Sudden localized pain w/ limited movement
Pain, swelling, point tenderness
Muscle testing increases pain