Knee hip2011


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Knee, Hip, and Groin PPT to help study

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  • Make sure you know Greater Trochanter, Lesser Trochanter, Head and Neck of the Femur, Shaft, Medial Epicondyle, Medial Condyle, Lateral Condyle, Later Epicondyle, Patellar Surface, and Intercondlyar fossa.
  • Know the following muscles: Illiac Crest, Gluteus Medius, Tensor Fasciae Latae, Gluteus Maximus, Gracilis, Adductor muscles, IT band, Vastus Lateralis, Hamstring group, Quadricep group, Pectineus, Sartorius, Patella, Pattellar Ligament, Quadriceps femoris tendon.
  • Knee hip2011

    1. 1. Chapter 21: The Thigh, Hip,Groin, and Pelvis
    2. 2. Anatomy of the Thigh
    3. 5. Nerve and Blood Supply <ul><li>Tibial and common peroneal are given rise from the sacral plexus which form the largest nerve in the body the sciatic nerve complex </li></ul><ul><li>The main arteries of the thigh are the deep circumflex femoral, deep femoral, and femoral artery </li></ul><ul><li>The two main veins are the superficial great saphenous and the femoral vein </li></ul>
    4. 6. Fascia <ul><li>The fascia lata femoris is part of the deep fascia that invests the thigh musculature </li></ul><ul><li>Thick anteriorly, laterally and posteriorly but thin on the medial side </li></ul><ul><li>Iliotibial track (IT-band) is located laterally serving as the attachment for the tensor fascia lata and greater aspect of the gluteus maximum </li></ul>
    5. 7. Functional Anatomy of the Thigh <ul><li>Quadriceps insert in a common tendon to the proximal patella </li></ul><ul><li>Rectus femoris is the only quad muscle that crosses the hip </li></ul><ul><ul><li>Extends knee and flexes the hip </li></ul></ul><ul><li>Important to distinguish between hip flexors relative to injury for both treatment and rehab programs </li></ul>
    6. 8. <ul><li>Hamstrings cross the knee joint posteriorly and all except the short of head of the biceps crosses the hip </li></ul><ul><li>Bi-articulate muscles produce forces dependent upon position of both knee and hip joints </li></ul><ul><li>Position of the knee and hip during movement and method of injury (MOI) play important roles and provide information to utilize w/ rehab and prevention of hamstring injuries </li></ul>
    7. 9. Assessment of the Thigh <ul><li>History </li></ul><ul><ul><li>Onset (sudden or slow?) </li></ul></ul><ul><ul><li>Previous history? </li></ul></ul><ul><ul><li>Mechanism of injury? </li></ul></ul><ul><ul><li>Pain description, intensity, quality, duration, type and location? </li></ul></ul><ul><li>Observation </li></ul><ul><ul><li>Symmetry? </li></ul></ul><ul><ul><li>Size, deformity, swelling, discoloration? </li></ul></ul><ul><ul><li>Skin color and texture? </li></ul></ul><ul><ul><li>Is athlete in obvious pain? </li></ul></ul><ul><ul><li>Is the athlete willing to move the thigh? </li></ul></ul>
    8. 10. <ul><li>Palpation: Bony and Soft Tissue </li></ul><ul><li>Medial and lateral femoral condyles </li></ul><ul><li>Greater trochanter </li></ul><ul><li>Lesser trochanter </li></ul><ul><li>Anterior superior iliac spine (ASIS) </li></ul><ul><li>Sartorius </li></ul><ul><li>Rectus femoris </li></ul><ul><li>Vastus lateralis </li></ul><ul><li>Vastus medialis </li></ul><ul><li>Vastus intermedius </li></ul><ul><li>Semimembranosis </li></ul><ul><li>Semitendinosis </li></ul><ul><li>Biceps femoris </li></ul><ul><li>Adductor brevis, longus and magnus </li></ul><ul><li>Gracilis </li></ul><ul><li>Sartorius </li></ul>
    9. 11. <ul><li>Palpation: Soft Tissue (continued) </li></ul><ul><li>Pectineus </li></ul><ul><li>Iliotibial Band (IT-band) </li></ul><ul><li>Gluteus medius </li></ul><ul><li>Tensor fasciae latae </li></ul>
    10. 12. <ul><li>Special Tests </li></ul><ul><ul><li>If a fracture is suspected the following tests are not performed </li></ul></ul><ul><ul><li>Beginning in extension, the knee is passively flexed </li></ul></ul><ul><ul><ul><li>A normal muscle will elicit full range of motion pain free (one w/ swelling or spasm will have restricted motion) </li></ul></ul></ul><ul><ul><li>Active movement from flexion to extension </li></ul></ul><ul><ul><ul><li>Strong and painful may indicate muscle strain </li></ul></ul></ul><ul><ul><ul><li>Weak and pain free may indicate 3rd degree or partial rupture </li></ul></ul></ul><ul><ul><li>Muscle weakness against an isometric resistance may indicate nerve injury </li></ul></ul>
    11. 13. Prevention of Thigh Injuries <ul><li>Thigh must have maximum strength, endurance, and extensibility to withstand strain </li></ul><ul><li>In collision sports thigh guards are mandatory to prevent injuries </li></ul>
    12. 14. Recognition and Management of Thigh Injuries <ul><li>Quadriceps Contusions </li></ul><ul><ul><li>Etiology </li></ul></ul><ul><ul><ul><li>Constantly exposed to traumatic blunt blow </li></ul></ul></ul><ul><ul><ul><li>Contusions usually develop as a result of severe impact </li></ul></ul></ul><ul><ul><ul><li>Extent of force and degree of thigh relaxation determine depth and functional disruption that occurs </li></ul></ul></ul><ul><ul><li>Signs and Symptoms </li></ul></ul><ul><ul><ul><li>Pain, transitory loss of function, immediate effusion with palpable swollen area </li></ul></ul></ul><ul><ul><ul><li>Graded 1-4 = superficial to deep with increasing loss of function (decreased ROM, strength) </li></ul></ul></ul>
    13. 15. Quad Contusion
    14. 16. <ul><li>Management </li></ul><ul><ul><li>RICE, NSAID’s and analgesics </li></ul></ul><ul><ul><li>Crutches for more severe cases </li></ul></ul><ul><ul><li>Aspiration of hematoma is possible </li></ul></ul><ul><ul><li>Following exercise or re-injury, continued use of ice </li></ul></ul><ul><ul><li>Follow-up care consists of ROM, and PRE w/in pain free range </li></ul></ul><ul><ul><li>Heat, massage and ultrasound to prevent myositis ossificans </li></ul></ul>
    15. 17. <ul><ul><li>General rehab should be conservative </li></ul></ul><ul><ul><li>Ice w/ gentle stretching w/ a gradual transition to heat following acute stages </li></ul></ul><ul><ul><li>Elastic wrap should be used for support </li></ul></ul><ul><ul><li>Exercises should be graduated from stretching to swimming and then jogging and running </li></ul></ul><ul><ul><li>Restrict exercise if pain occurs </li></ul></ul><ul><ul><li>May require surgery of herniated muscle or aspiration </li></ul></ul><ul><ul><li>Once an athlete has sustained a severe contusion, great care must be taken to avoid another </li></ul></ul>
    16. 18. <ul><li>Myositis Ossificans Traumatica </li></ul><ul><ul><li>Etiology </li></ul></ul><ul><ul><ul><li>Formation of ectopic bone following repeated blunt trauma (disruption of muscle fibers, capillaries, fibrous connective tissue, and periosteum) </li></ul></ul></ul><ul><ul><ul><li>Gradual deposit of calcium and bone formation </li></ul></ul></ul><ul><ul><ul><li>May be the result of improper thigh contusion treatment (too aggressive) </li></ul></ul></ul><ul><ul><li>Signs and Symptoms </li></ul></ul><ul><ul><ul><li>X-ray shows calcium deposit 2-6 weeks following injury </li></ul></ul></ul><ul><ul><ul><li>Pain, weakness, swelling, decreased ROM </li></ul></ul></ul><ul><ul><ul><li>Tissue tension and point tenderness w/ </li></ul></ul></ul><ul><ul><li>Management </li></ul></ul><ul><ul><ul><li>Treatment must be conservative </li></ul></ul></ul><ul><ul><ul><li>May require surgical removal if too painful and restricts motion (after one year - remove too early and it may come back) </li></ul></ul></ul>
    17. 19. <ul><li>Quadriceps Muscle Strain </li></ul><ul><ul><li>Etiology </li></ul></ul><ul><ul><ul><li>Sudden stretch when athlete falls on bent knee or experiences sudden contraction </li></ul></ul></ul><ul><ul><ul><li>Associated with weakened or over constricted muscle </li></ul></ul></ul><ul><ul><li>Signs and Symptoms </li></ul></ul><ul><ul><ul><li>Peripheral tear causes fewer symptoms than deeper tear </li></ul></ul></ul><ul><ul><ul><li>Pain, point tenderness, spasm, loss of function and little discoloration </li></ul></ul></ul><ul><ul><ul><li>Complete tear may live athlete w/ little disability and discomfort but with some deformity </li></ul></ul></ul><ul><ul><li>Management </li></ul></ul><ul><ul><ul><li>RICE, NSAID’s and analgesics </li></ul></ul></ul><ul><ul><ul><li>Manage swelling, compression, crutches </li></ul></ul></ul><ul><ul><ul><li>Move into isometrics and stretching as healing progresses </li></ul></ul></ul><ul><ul><ul><li>Neoprene sleeve may provide some added support </li></ul></ul></ul>
    18. 20. <ul><li>Hamstring Muscle Strains </li></ul><ul><ul><li>(second most common thigh injury) </li></ul></ul><ul><ul><li>Etiology </li></ul></ul><ul><ul><ul><li>Multiple theories of injury </li></ul></ul></ul><ul><ul><ul><ul><li>Hamstring and quad contract together </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Change in role from hip extender to knee flexor </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Fatigue, posture, leg length discrepancy, lack of flexibility, strength imbalances, </li></ul></ul></ul></ul><ul><ul><li>Signs and Symptoms </li></ul></ul><ul><ul><ul><li>Muscle belly or point of attachment pain </li></ul></ul></ul><ul><ul><ul><li>Capillary hemorrhage, pain, loss of function and possible discoloration </li></ul></ul></ul><ul><ul><ul><li>Grade 1 - soreness during movement and point tenderness (<20% of fibers torn( </li></ul></ul></ul><ul><ul><ul><li>Grade 2 - partial tear, identified by sharp snap or tear, severe pain, and loss of function (<70% of fiber torn) </li></ul></ul></ul>
    19. 21. <ul><ul><li>Signs and Symptoms (continued) </li></ul></ul><ul><ul><ul><li>Grade 3 - Rupturing of tendinous or muscular tissue, involving major hemorrhage and disability, edema, loss of function, ecchymosis, palpable mass or gap </li></ul></ul></ul><ul><ul><ul><li>>70% muscle fiber tearing </li></ul></ul></ul><ul><ul><li>Management </li></ul></ul><ul><ul><ul><li>RICE, NSAID’s and analgesics </li></ul></ul></ul><ul><ul><ul><li>Grade I - don’t resume full activity until complete function restored </li></ul></ul></ul><ul><ul><ul><li>Grade 2 and 3 should be treated conservatively w/ gradual return to stretching and strengthening in later stages of healing (modalities and isometrics) </li></ul></ul></ul><ul><ul><ul><li>When soreness is eliminated, isotonic leg curls can be introduced (focus on eccentrics) </li></ul></ul></ul><ul><ul><ul><li>Recovery may require months to a full year </li></ul></ul></ul><ul><ul><ul><li>Greater scaring = greater recurrence of injury </li></ul></ul></ul>
    20. 22. <ul><li>Acute Femoral Fractures </li></ul><ul><ul><li>Etiology </li></ul></ul><ul><ul><ul><li>Generally involving shaft and requiring great force </li></ul></ul></ul><ul><ul><ul><li>Occurs in middle third due to structure and point of contact </li></ul></ul></ul><ul><ul><li>Signs and Symptoms </li></ul></ul><ul><ul><ul><li>Pain, swelling, deformity </li></ul></ul></ul><ul><ul><li>Management </li></ul></ul><ul><ul><ul><li>Treat for shock, verify neurovascular status, splint before moving, reduce following X-ray </li></ul></ul></ul><ul><ul><ul><li>Analgesics and ice </li></ul></ul></ul><ul><ul><ul><li>Extensive soft tissue damage will also occur as bones will displace due to muscle force </li></ul></ul></ul>
    21. 23. <ul><li>Femoral Stress Fractures </li></ul><ul><ul><li>Etiology </li></ul></ul><ul><ul><ul><li>Overuse (10-25% of all stress fractures) </li></ul></ul></ul><ul><ul><ul><li>Excessive downhill running or jumping activities </li></ul></ul></ul><ul><ul><ul><li>Compression or distraction fracture generally occur </li></ul></ul></ul><ul><ul><li>Signs and Symptoms </li></ul></ul><ul><ul><ul><li>Persistent pain in thigh </li></ul></ul></ul><ul><ul><ul><li>X-ray or bone scan will reveal fracture </li></ul></ul></ul><ul><ul><ul><li>Commonly seen in femoral neck </li></ul></ul></ul><ul><ul><li>Management </li></ul></ul><ul><ul><ul><li>Analgesics, NSAID’s RICE </li></ul></ul></ul><ul><ul><ul><li>ROM and PRE exercises are carried out w/ pain free ROM </li></ul></ul></ul><ul><ul><ul><li>Rest, limited weight bearing </li></ul></ul></ul><ul><ul><ul><li>Complete stress fracture may require pins </li></ul></ul></ul>
    22. 24. Anatomy of the Hip, Groin and Pelvic Region
    23. 31. Functional Anatomy <ul><li>Pelvis moves in three planes through muscle function </li></ul><ul><ul><li>Anterior tilting changes degree of lumbar lordosis, lateral tilting changes degree of hip abduction </li></ul></ul><ul><li>Hip is a true ball and socket joint w/ intrinsic stability </li></ul><ul><li>Hip also moves in all three planes, particularly during gait (body’s relative center of gravity) </li></ul><ul><li>Tremendous forces occur at the hip during varying degrees of locomotion </li></ul><ul><li>Muscles are most commonly injured in this region </li></ul><ul><li>Numerous injuries attach in this region and therefore injury to one can be very disabling and difficult to distinguish </li></ul>
    24. 32. Assessment of the Hip and Pelvis <ul><li>Body’s center of gravity is located just anterior to the sacrum </li></ul><ul><li>Injuries to the hip or pelvis cause major disability in the lower limbs, trunk or both </li></ul><ul><li>Low back may also become involved due to proximity </li></ul><ul><li>History </li></ul><ul><ul><li>Onset (sudden or slow?) </li></ul></ul><ul><ul><li>Previous history? </li></ul></ul><ul><ul><li>Mechanism of injury? </li></ul></ul><ul><ul><li>Pain description, intensity, quality, duration, type and location? </li></ul></ul>
    25. 33. <ul><li>Observation </li></ul><ul><ul><li>Symmetry- hips, pelvis tilt (anterior/posterior) </li></ul></ul><ul><ul><ul><li>Lordosis or flat back </li></ul></ul></ul><ul><ul><li>Lower limb alignment </li></ul></ul><ul><ul><ul><li>Knees, patella, feet </li></ul></ul></ul><ul><ul><li>Pelvic landmarks (ASIS, PSIS, iliac crest) </li></ul></ul><ul><ul><li>Standing on one leg </li></ul></ul><ul><ul><ul><li>Pubic symphysis pain or drop on one side </li></ul></ul></ul><ul><ul><li>Ambulation </li></ul></ul><ul><ul><ul><li>Walking, sitting - pain will result in movement distortion </li></ul></ul></ul>
    26. 34. <ul><li>Palpation: Bony </li></ul><ul><li>Iliac crest </li></ul><ul><li>Anterior superior iliac spine (ASIS) </li></ul><ul><li>Anterior inferior iliac spin (AIIS) </li></ul><ul><li>Posterior superior iliac spine (PSIS) </li></ul><ul><li>Pubic symphysis </li></ul><ul><li>Ischial tuberosity </li></ul><ul><li>Greater trochanter </li></ul><ul><li>Femoral neck </li></ul>
    27. 35. <ul><li>Palpation: Soft Tissue </li></ul><ul><li>Rectus femoris </li></ul><ul><li>Sartorius </li></ul><ul><li>Iliopsoas </li></ul><ul><li>Inguinal ligament </li></ul><ul><li>Gracilis </li></ul><ul><li>Adductor magnus, longus & brevis </li></ul><ul><li>Pectineus </li></ul><ul><li>Gluteus maximus, medius & minimus </li></ul><ul><li>Piriformis </li></ul><ul><li>Hamstrings </li></ul><ul><li>Tensor fasciae latae </li></ul><ul><li>Iliotibial Band </li></ul>- Major regions of concern are the groin, femoral triangle, sciatic nerve, lymph nodes
    28. 36. <ul><li>Special Tests </li></ul><ul><li>Functional Evaluation </li></ul><ul><ul><li>ROM, strength tests </li></ul></ul><ul><ul><li>Hip adduction, abduction, flexion, extension, internal and external rotation </li></ul></ul><ul><li>Tests for Hip Flexor Tightness </li></ul><ul><ul><li>Kendall test </li></ul></ul><ul><ul><ul><li>Test for rectus femoris tightness </li></ul></ul></ul><ul><ul><li>Thomas test </li></ul></ul><ul><ul><ul><li>Test for hip contractures </li></ul></ul></ul>
    29. 37. Kendall’s Test
    30. 38. Thomas Test
    31. 39. <ul><li>Test for Hip and Sacroiliac Joint </li></ul><ul><li>Patrick Test (FABER) </li></ul><ul><ul><li>Detects pathological conditions of the hip and SI joint </li></ul></ul><ul><ul><li>Pain may be felt in the hip or SI joint </li></ul></ul>
    32. 40. <ul><li>Gaenslen’s Test </li></ul><ul><ul><li>Test works to push SI joint into extension </li></ul></ul><ul><ul><li>Test is positive if hyperextension on affected side increases pain </li></ul></ul>
    33. 41. <ul><li>Testing the Tensor Fasciae Latae and Iliotibial Band </li></ul><ul><li>Renne’s test </li></ul><ul><ul><li>Athlete stands w/ knee bent at 30-40 degrees </li></ul></ul><ul><ul><li>Positive response of TFL tightness occurs when pain is felt at lateral femoral condyle </li></ul></ul>
    34. 42. <ul><li>Nobel’s Test </li></ul><ul><ul><li>Lying supine the athlete’s knee is flexed to 90 degrees </li></ul></ul><ul><ul><li>Pressure is applied to lateral femoral condyle while knee is extended </li></ul></ul><ul><ul><li>Pain at 30 degrees at lateral femoral condyle indicates a positive test </li></ul></ul>
    35. 43. <ul><li>Ober’s Test </li></ul><ul><ul><li>Used to determine presence of contracted TFL or IT-band </li></ul></ul><ul><ul><li>Thigh will remain in abducted position, not falling into adduction </li></ul></ul>
    36. 44. <ul><li>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) </li></ul>
    37. 45. <ul><li>Piriformis Test </li></ul><ul><ul><li>Hip is internally rotated </li></ul></ul><ul><ul><li>Tightness or pain is indicative of piriformis tightness </li></ul></ul>
    38. 46. <ul><li>Ely’s Test </li></ul><ul><ul><li>Used to assess tightness of rectus femoris </li></ul></ul><ul><ul><li>Athlete is prone, w/ pelvis stabilized and knee on the affected side is flexed </li></ul></ul><ul><ul><li>If hip on that side extends as the knee is flexed, rectus femoris is tight </li></ul></ul><ul><li>Measuring Leg Length Discrepancy </li></ul><ul><ul><li>With inactive individual, difference of more that 1” may produce symptoms </li></ul></ul><ul><ul><li>Active individuals may experience problems w/ as little 3mm (1/8”) difference </li></ul></ul><ul><ul><li>Can cause cumulative stresses to lower limbs, hips, pelvis or low back </li></ul></ul>
    39. 47. <ul><ul><li>True or anatomical </li></ul></ul><ul><ul><ul><li>Shortening may be equal throughout limb or localized w/in femur or lower leg </li></ul></ul></ul><ul><ul><ul><li>Measurement taken from medial malleolus to ASIS </li></ul></ul></ul><ul><ul><li>Apparent or functional </li></ul></ul><ul><ul><ul><li>Result of lateral pelvic tilt or from a flexion or adduction deformity </li></ul></ul></ul><ul><ul><ul><li>Measurement is taken from umbilicus to medial malleolus </li></ul></ul></ul>
    40. 48. Leg Length Discrepancy Measures
    41. 49. Recognition and Management of Specific Hip, Groin, and Pelvic Injuries <ul><li>Groin Strain </li></ul><ul><ul><li>Etiology </li></ul></ul><ul><ul><ul><li>One of the more difficult problems to diagnose </li></ul></ul></ul><ul><ul><ul><li>Injury to one of the muscles in the regions (generally adductor longus) </li></ul></ul></ul><ul><ul><ul><li>Occurs from running , jumping, twisting w/ hip external rotation or severe stretch </li></ul></ul></ul><ul><ul><li>Signs and Symptoms </li></ul></ul><ul><ul><ul><li>Sudden twinge or tearing during active movement </li></ul></ul></ul><ul><ul><ul><li>Produce pain, weakness, and internal hemorrhaging </li></ul></ul></ul>
    42. 50. <ul><li>Groin Strain (continued) </li></ul><ul><ul><li>Management </li></ul></ul><ul><ul><ul><li>RICE, NSAID’s and analgesics for 48-72 hours </li></ul></ul></ul><ul><ul><ul><li>Determine exact muscle or muscles involved </li></ul></ul></ul><ul><ul><ul><li>Rest is critical; daily whirlpool and cryotherapy, moving into ultrasound </li></ul></ul></ul><ul><ul><ul><li>Delay exercise until pain free </li></ul></ul></ul><ul><ul><ul><li>Restore normal ROM and strength -- provide support w/ wrap </li></ul></ul></ul>
    43. 51. <ul><li>Trochanteric Bursitis </li></ul><ul><ul><li>Etiology </li></ul></ul><ul><ul><ul><li>Inflammation at the site where the gluteus medius ties into the IT-band </li></ul></ul></ul><ul><ul><li>Signs and Symptoms </li></ul></ul><ul><ul><ul><li>Complaint of lateral hip pain that may radiate down the leg </li></ul></ul></ul><ul><ul><ul><li>Palpation reveals tenderness over lateral aspect of greater trochanter </li></ul></ul></ul><ul><ul><ul><li>IT-band and TFL tests should be performed </li></ul></ul></ul><ul><ul><li>Management </li></ul></ul><ul><ul><ul><li>RICE, NSAID’s and analgesics </li></ul></ul></ul><ul><ul><ul><li>ROM and PRE directed toward hip abductors and external rotators </li></ul></ul></ul><ul><ul><ul><li>Phonophoresis if pain doesn’t respond in 3-4 days </li></ul></ul></ul><ul><ul><ul><li>Look at biomechanics and Q-angle </li></ul></ul></ul><ul><ul><ul><li>Avoid inclined surfaces; </li></ul></ul></ul>
    44. 52. <ul><li>Sprains of the Hip Joint </li></ul><ul><ul><li>Etiology </li></ul></ul><ul><ul><ul><li>Due to substantial support, any unusual movement exceeding normal ROM may result in damage </li></ul></ul></ul><ul><ul><ul><li>Force from opponent/object or trunk forced over planted foot in opposite direction </li></ul></ul></ul><ul><ul><li>Signs and Symptoms </li></ul></ul><ul><ul><ul><li>Signs of acute injury and inability to circumduct hip </li></ul></ul></ul><ul><ul><ul><li>Similar S & S to stress fracture </li></ul></ul></ul><ul><ul><ul><li>Pain in hip region, w/ hip rotation increasing pain </li></ul></ul></ul><ul><ul><li>Management </li></ul></ul><ul><ul><ul><li>X-rays or MRI should be performed to rule out fx </li></ul></ul></ul><ul><ul><ul><li>RICE, NSAID’s and analgesics </li></ul></ul></ul><ul><ul><ul><li>Depending on severity, crutches may be required </li></ul></ul></ul><ul><ul><ul><li>ROM and PRE are delayed until hip is pain free </li></ul></ul></ul>
    45. 53. <ul><li>Dislocated Hip </li></ul><ul><ul><li>Etiology </li></ul></ul><ul><ul><ul><li>Rarely occurs in sport </li></ul></ul></ul><ul><ul><ul><li>Result of traumatic force directed along the long axis of the femur (posterior dislocation w/ hip flexed and adducted and knee flexed) </li></ul></ul></ul><ul><ul><li>Signs and Symptoms </li></ul></ul><ul><ul><ul><li>Flexed, adducted and internally rotated hip </li></ul></ul></ul><ul><ul><ul><li>Palpation reveals displaced femoral head, posteriorly </li></ul></ul></ul><ul><ul><ul><li>Serious pathology </li></ul></ul></ul><ul><ul><ul><ul><li>Soft tissue, neurological damage and possible fx </li></ul></ul></ul></ul><ul><ul><li>Management </li></ul></ul><ul><ul><ul><li>Immediate medical care (blood and nerve supply may be compromised) </li></ul></ul></ul><ul><ul><ul><li>Contractures may further complicate reduction </li></ul></ul></ul><ul><ul><ul><li>2 weeks immobilization and crutch use for at least one month </li></ul></ul></ul>
    46. 54. <ul><li>Avascular Necrosis </li></ul><ul><ul><li>Etiology </li></ul></ul><ul><ul><ul><li>Result of temporary or permanent loss of blood supply to proximal femur </li></ul></ul></ul><ul><ul><ul><li>Can be caused by traumatic conditions (hip dislocation), or non-traumatic circumstances (steroids, blood coagulation disorders, excessive alcohol use compromising blood vessels) </li></ul></ul></ul><ul><ul><li>Signs and Symptoms </li></ul></ul><ul><ul><ul><li>Early stages - possibly no S&S </li></ul></ul></ul><ul><ul><ul><li>Joint pain w/ weight bearing progressing to at times of rest </li></ul></ul></ul><ul><ul><ul><li>Pain gradually increases (mild to severe) particularly as bone collapse occurs </li></ul></ul></ul><ul><ul><ul><li>May limit ROM </li></ul></ul></ul><ul><ul><ul><li>Osteoarthritis may develop </li></ul></ul></ul><ul><ul><ul><li>Progression of S&S can develop over the course of months to a year </li></ul></ul></ul>
    47. 55. <ul><li>Avascular Necrosis (continued) </li></ul><ul><ul><li>Management </li></ul></ul><ul><ul><ul><li>Must be referred for X-ray, MRI or CT scan </li></ul></ul></ul><ul><ul><ul><li>Must work to improve use of joint, stop further damage and ensure survival of bone and joint </li></ul></ul></ul><ul><ul><ul><li>Most cases will ultimately require surgery to repair joint permanently </li></ul></ul></ul><ul><ul><ul><li>Conservative treatment involves ROM exercises to maintain ROM; electric stim for bone growth; non-weight bearing if caught early </li></ul></ul></ul><ul><ul><ul><li>Medication to treat pain, reduce fatty substances reacting w/ corticosteroids or limit blood clotting in the presence of clotting disorders may limit necrosis </li></ul></ul></ul>
    48. 56. Hip Problems in the Young Athlete <ul><li>Legg Calve’-Perthes Disease (Coxa Plana) </li></ul><ul><ul><li>Etiology </li></ul></ul><ul><ul><ul><li>Avascular necrosis of the femoral head in child ages 4-10 </li></ul></ul></ul><ul><ul><ul><li>Trauma accounts for 25% of cases </li></ul></ul></ul><ul><ul><ul><li>Articular cartilage becomes necrotic and flattens </li></ul></ul></ul><ul><ul><li>Signs and Symptoms </li></ul></ul><ul><ul><ul><li>Pain in groin that can be referred to the abdomen or knee </li></ul></ul></ul><ul><ul><ul><li>Limping is also typical </li></ul></ul></ul><ul><ul><ul><li>Varying onsets and may exhibit limited ROM </li></ul></ul></ul>
    49. 57. <ul><li>Legg-Calve’-Perthes Disease (continued) </li></ul><ul><li>Management </li></ul><ul><ul><li>Bed rest to alleviate synovitis </li></ul></ul><ul><ul><li>Brace to avoid direct weight bearing </li></ul></ul><ul><ul><li>Early treatment and head may reossify and revascularize </li></ul></ul><ul><li>Complication </li></ul><ul><ul><li>If not treated early, will result in ill-shaping and osteoarthritis in later life </li></ul></ul>
    50. 58. <ul><li>The Snapping Hip Phenomenon </li></ul><ul><ul><li>Etiology </li></ul></ul><ul><ul><ul><li>Common in young female dancers, gymnasts, hurdlers </li></ul></ul></ul><ul><ul><ul><li>Habitual movement predispose muscles around hip to become imbalanced (lateral rotation and flexion) </li></ul></ul></ul><ul><ul><ul><li>Related to structurally narrow pelvis, increased hip abduction and limited lateral rotation </li></ul></ul></ul><ul><ul><ul><li>Hip stability is compromised </li></ul></ul></ul><ul><ul><li>Signs and Symptoms </li></ul></ul><ul><ul><ul><li>Pain w/ balancing on one leg, possible inflammation </li></ul></ul></ul><ul><ul><li>Management </li></ul></ul><ul><ul><ul><li>Focus on cryotherapy and ultrasound to stretch musculature and strengthen weak musculature in hip region </li></ul></ul></ul>
    51. 59. Pelvic Conditions <ul><li>Athletes can suffer serious acute and chronic injuries to the pelvic region </li></ul><ul><li>Pelvis rotates along longitudinal axis when running, proportionate to the amount of arm swing </li></ul><ul><li>Also tilts as legs engage support and nonsupport </li></ul><ul><li>Combination of motion causes shearing and changes in lordosis throughout activity </li></ul>
    52. 60. <ul><li>Contusion (hip pointer) </li></ul><ul><ul><li>Etiology </li></ul></ul><ul><ul><ul><li>Contusion of iliac crest or abdominal musculature </li></ul></ul></ul><ul><ul><ul><li>Result of direct blow (same MOI for iliac crest fx and epiphyseal separation </li></ul></ul></ul><ul><ul><li>Signs and Symptoms </li></ul></ul><ul><ul><ul><li>Pain, spasm, and transitory paralysis of soft structures </li></ul></ul></ul><ul><ul><ul><li>Decreased rotation of trunk or thigh/hip flexion due to pain </li></ul></ul></ul><ul><ul><li>Management </li></ul></ul><ul><ul><ul><li>RICE for at least 48 hours, NSAID’s, </li></ul></ul></ul><ul><ul><ul><li>Bed rest 1-2 days </li></ul></ul></ul><ul><ul><ul><li>Referral must be made, X-ray </li></ul></ul></ul><ul><ul><ul><li>Ice massage, ultrasound, occasionally steroid injection Recovery lasts 1-3 weeks </li></ul></ul></ul>
    53. 61. <ul><li>Osteitis Pubis </li></ul><ul><ul><li>Etiology </li></ul></ul><ul><ul><ul><li>Seen in distance runners </li></ul></ul></ul><ul><ul><ul><li>Repetitive stress on pubic symphysis and adjacent muscles </li></ul></ul></ul><ul><ul><li>Signs and Symptoms </li></ul></ul><ul><ul><ul><li>Chronic pain and inflammation of groin </li></ul></ul></ul><ul><ul><ul><li>Point tenderness on pubic tubercle </li></ul></ul></ul><ul><ul><ul><li>Pain w/ running, sit-ups and squats </li></ul></ul></ul><ul><ul><ul><li>Acute case may be the result of bicycle seat </li></ul></ul></ul><ul><ul><li>Management </li></ul></ul><ul><ul><ul><li>Rest, NSAID’s and gradual return to activity </li></ul></ul></ul>
    54. 62. <ul><li>Stress Fractures </li></ul><ul><ul><li>Etiology </li></ul></ul><ul><ul><ul><li>Seen in distance runners - repetitive cyclical forces from ground reaction force </li></ul></ul></ul><ul><ul><ul><li>More common in women than men </li></ul></ul></ul><ul><ul><ul><li>Common site include inferior pubic ramus, femoral neck and subtrochanteric area of femur </li></ul></ul></ul><ul><ul><li>Signs and Symptoms </li></ul></ul><ul><ul><ul><li>Groin pain, w/ aching sensation in thigh that increases w/ activity and decreases w/ rest </li></ul></ul></ul><ul><ul><ul><li>Standing on one leg may be impossible </li></ul></ul></ul><ul><ul><ul><li>Deep palpation results in point tenderness </li></ul></ul></ul><ul><ul><ul><li>Intense interval or competitive racing may cause </li></ul></ul></ul>
    55. 63. <ul><li>Stress Fractures (continued) </li></ul><ul><ul><li>Management </li></ul></ul><ul><ul><ul><li>Rest for 2-5 months </li></ul></ul></ul><ul><ul><ul><li>Crutch walking for ischium and pubis fractures </li></ul></ul></ul><ul><ul><ul><li>X-ray normal 6-10 weeks and bone scan will be required </li></ul></ul></ul><ul><ul><ul><li>Swimming can be used -- breast stroke avoided </li></ul></ul></ul>
    56. 64. <ul><li>Avulsion Fractures and Apophysitis </li></ul><ul><ul><li>Etiology </li></ul></ul><ul><ul><ul><li>Traction epiphysis (bone outgrowth) </li></ul></ul></ul><ul><ul><ul><li>Common sites include ischial tuberosity, AIIS, and ASIS </li></ul></ul></ul><ul><ul><ul><li>Avulsions seen in sports w/ sudden accelerations and decelerations </li></ul></ul></ul><ul><ul><li>Signs and Symptoms </li></ul></ul><ul><ul><ul><li>Sudden localized pain w/ limited movement </li></ul></ul></ul><ul><ul><ul><li>Pain, swelling, point tenderness </li></ul></ul></ul><ul><ul><ul><li>Muscle testing increases pain </li></ul></ul></ul>
    57. 65. <ul><li>Avulsion Fractures and Apophysitis </li></ul><ul><ul><li>Management </li></ul></ul><ul><ul><ul><li>X-ray </li></ul></ul></ul><ul><ul><ul><li>If uncomplicated, RICE, NSAID’s, crutch toe-touch walking </li></ul></ul></ul><ul><ul><ul><li>After control pain and inflammation, 2-3 weeks of gradual stretching </li></ul></ul></ul><ul><ul><ul><li>When 80 degrees of ROM have been regained, athlete can return to competition </li></ul></ul></ul>
    58. 66. Thigh and Hip Rehabilitation Techniques <ul><li>General Body Conditioning </li></ul><ul><ul><li>Must maintain cardiovascular fitness, muscle endurance and strength of total body </li></ul></ul><ul><ul><li>Avoid weight bearing activities if painful </li></ul></ul><ul><li>Flexibility </li></ul><ul><ul><li>Regaining pain free ROM is a primary concern </li></ul></ul><ul><ul><li>Progress from passive to PNF stretching </li></ul></ul>
    59. 68. Mobilization <ul><li>Will be necessary if injury and subsequent limitation is caused by tightness of ligaments and capsule surrounding the joint </li></ul><ul><li>Use to re-establish appropriate arthrokinematics </li></ul><ul><li>Series of glides (anterior and posterior) and rotations can be used to restore motion </li></ul>
    60. 70. Strength <ul><li>Progression should move from isometric exercises until muscle can be fully contracted to isotonic strengthening PRE’s into isokinetics </li></ul><ul><li>PNF strengthening should then be incorporated to enhance functional activity </li></ul><ul><li>Active exercise should occur in pain free ranges -- in an effort not to aggravate condition </li></ul><ul><li>Exercises for the core must also be included </li></ul><ul><ul><li>Develop optimal levels of functional strength and dynamic stabilization </li></ul></ul>
    61. 73. Neuromuscular Control <ul><li>Establish through combination of appropriate postural alignment and stability strength </li></ul><ul><li>As neuromuscular control is enhanced, the ability of the kinetic chain to maintain appropriate forces and dynamic stabilization increases </li></ul><ul><li>Focus on balance and closed kinetic chain activities </li></ul>
    62. 74. Balance Shoe for Neuromuscular Control
    63. 75. Functional Progression and Return to Activity <ul><li>Begin in pool, non-weight bearing </li></ul><ul><li>Depending on activity, progression of walking, to jogging, to running and more difficult agility tasks can occur </li></ul><ul><li>Before returning to play, athlete should demonstrate pain free function, full ROM, strength, balance and agility </li></ul>