Hip and Thigh injuries in sports such as- Perthes Disease, Osteitis Pubis, Avascular Necrosis of The Femoral Head, Hip Pointer, Classic Groin Strain, ‘Pull’ Or Adductor Tendinopathy, Slipped Capital Femoral Epiphysis, Trochanteric Bursitis/Gluteus Medius Tendinopathy, Iliopsoas strain, Quadriceps strain, Irritable Hip etc.

1. Hip & Thigh Injuries
Dr. Usha (PT)
Assistant Professor

2. Contents
• Perthes Disease
• Osteitis Pubis
• Avascular Necrosis of The Femoral Head
• Hip Pointer
• Classic Groin Strain, ‘Pull’ Or Adductor Tendinopathy
• Slipped Capital Femoral Epiphysis
• Trochanteric Bursitis/Gluteus Medius Tendinopathy
• ‘Snapping’ Hip
• Quadriceps Contusion
• Irritable Hip
• Iliopsoas Strains

3. Perthes Disease
 Properly called Legg-Calve- Perthes disease.
 Perthes disease is a disturbance in the development of the hip,
with the head of the femur becoming misshapen. For some
reasons, the blood supply to the hip joint sometimes becomes
compromised in children.
 Perthes’ disease is an osteochondrosis affecting the femoral
head. It presents as a limp or low-grade ache in the thigh,
groin or knee. Perthes’ disease is usually unilateral but
sometimes it develops in both hips.

5.  Although it can affect children of nearly any age, but typically
affects children between the ages of 4 and 10 years, is more
common in males (boys), and may be associated with delayed
skeletal maturation.
 On examination there may be limited abduction and internal
rotation of the hip.
 Radiographs vary with the stage of the disease but may show
increased density and flattening of the femoral capital
epiphysis.

6. Radiographic appearance of Perthes’ disease

7.  Management consists of rest from aggravating activity and
range of motion exercises, particularly to maintain abduction
and internal rotation.
 The age of the child and the severity of the condition will
affect the intensity of the management. Rest, the use of a
brace, and even surgery may be required. Recently,
arthroscopic chondroplasty and loose body excision has
shown good short-term results

8.  There are many degrees of severity, and of significant
relevance to sport, some mild cases even remain undetected
until later in life particularly exacerbated by the more
intensive physical stress of sport.
 If diagnosed in childhood, sporting activities will have to be
modified to minimize the chance of exacerbating the
condition.
 In more severe cases, surgical intervention is indicated and
sporting activity has to be significantly managed.

9.  The condition usually resolves and return to sport is possible
when the athlete is symptom-free and radiographs show
some improvement.
 The main long-term concern is the development of
osteoarthritis due to irregularity of the joint surface.

10. Osteitis Pubis
 The symphysis pubis is a fibrous
joint between the two halves at the
front of the pelvis.
 The adductor muscles attach either
side and the abdominal muscles
attach along the top of the pubic
bones.

11.  Therefore the symphysis is subjected to significant shearing
forces, especially during alternate single leg weight bearing
with change of direction during activities like running and
kicking.
 The shearing forces can be increased by biomechanical
limitations, such as restriction of internal hip rotation

12.  Sometimes called Gracilis syndrome, this is a chronic
pathology affecting the bone or cartilage of the pubic
symphysis and relates to repetitive stress and resulting pain
and tenderness from activities like kicking, weightlifting,
running and jumping.
 Torsional or rotational movement stressing the pubic
symphysis seems to particularly aggravate, and postpartum
women are more susceptible, possibly due to the laxity of the
pelvic ligaments during and after pregnancy.

13.  Osteitis pubis causes pain in the pubic region, radiating into
the medial thigh of one or both sides. The pain may be
specifically in the thigh, but is often present in the lower
abdominal area.
 There may also be associated instability at the symphysis, and
the athlete may be aware of clicking in the region, often
noticed when turning in bed. Commonly pain will diminish
with warm up and be tolerable during activity.

14.  X-ray will sometimes demonstrate a mottled appearance at
the symphysis as a result of the inflammatory process taking
place in the joint.
 Standing antero-posterior and single-leg-stance pelvic
radiographs aid in the diagnosis of pelvic instability more
effectively than standard radiographs of the pelvis in supine
or a standing antero-posterior radiograph of the pelvis alone.
A bone scan usually shows increased uptake in the pubic bone
and MRI will often show oedema in the bone.

15. Avascular Necrosis of The Femoral Head
 This is an insidious condition that usually affects individuals
between the ages of 20–40. Disruption of the circulatory
supply to the femoral head either acutely or chronically
results in cell ischemia and necrosis, eventually damaging the
hip joint.
 Apart from well- documented systemic causes, factors for its
development include high loads and sudden or irregular
impact, as required in many sports. X-rays may not show the
condition for three months after the initial trauma. However,
MRI will usually specifically indicate an affected area.

16. Treatment and rehabilitation
 Caught early, rest and reduced weight bearing will help, but
there will usually be a longer term consequence requiring
careful guidance and management of everyday activity as
well as training in order to continue in sport.

17. Hip Pointer
 The hip pointer can arise from both
direct contusion causing impact and
indirect strain injuries of the hip,
primarily in contact sports.
 Forced extension of the hip, by for
example a tackle from behind in rugby,
may result in a sprain or avulsion of the
Sartorius muscle at its iliac crest
attachment.

18.  These injuries are severely painful and make leg movement
very painful, taking from one to several weeks to rehabilitate,
depending on severity.
 Pain may be felt when walking, laughing, coughing, or even
deep breathing. Direct contusions to the anterior superior
iliac crest may also involve the attachment of the Sartorius
muscle.

19.  Hip pointers are common in contact sports such as rugby and
judo and proper protective equipment is essential.
Additionally, developing appropriate skills and techniques
may help avoid a hip pointer.
 Ultimately, however, there is not much an athlete can do to
prepare for such an impact.

20. Treatment and rehabilitation
 Initial routine ice treatment and compression, and rule out
bony injury or more significant soft tissue damage by X-ray or
scan.
 Medication as required, including topical anti-inflammatory
when the injury is superficial.
 Immobilisation, with crutches if necessary during the acute
period, which may be days or weeks.

21.  Incremental progression to return to sport, including
proprioceptive, mobility and strengthening exercises, including
guidelines that can be applied to most groin injuries:
 Exercising within painful thresholds
 Isolating and reducing pelvic load sources
 Developing lumbo-pelvic stability
 Regional strengthening
 Progressing activity according to repeated assessment
 Static progressing to dynamic and finally sports specific.

22.  It is important that the sportsperson does not return too
quickly to activity.
 If they still have pain or tenderness, they are liable to
compensate by altering the movement pattern and technique
which may result in injury to another part of the body.

23. Classic Groin Strain, ‘Pull’ Or Adductor
Tendinopathy
 The most frequent acute strain of the groin may involve single
or multiple muscles, including the iliopsoas, adductors and
the gracilis, which attach to the femur or pubis and help to
stabilise the legs and flex the thigh.
 The muscle most commonly strained and injured in the groin
is the adductor longus. Other muscles that must be
considered include the rectus femoris, the rectus
abdominis and the sartorius.

24.  Falling, running, changing direction, kicking or doing the
splits may generate these injuries.
 Groin strains usually cause pain in the groin and radiate down
the inside of the thigh, more proximal than distal, with pain
on resisted adduction of the hip.
 There may be confusion on occasions as MRI and ultrasound
studies will often report changes at the adductor attachment,
when the patient is completely asymptomatic in that area.

25.  Occasionally there may be haematoma formation which can
prolong the healing time. The weakened area created by a
strain may continue to be susceptible to repeated injury for a
long time.
 In fact, in a review of ice hockey players, those with a previous
groin injury had twice the risk of repeat injuries as that of
athletes without a previous injury. Older, experienced hockey
players had an injury rate five times higher than that of novice
players.

26.  In another review in ice hockey, the statistics revealed that
adductor strains occurred 20 times more frequently during
training camps rather than during the playing season,
possibly related to the benefits of a strength-training
programme and to the fact that out- of- season lack of
maintenance conditioning may contribute to groin injuries.

27.  Sometimes in explosive sports, the adductor tendon may fully
rupture, and even pull away from its osseous attachment,
taking a piece of the bone with it. These are called avulsion
fractures and if they cause severe displacement, surgical
repair may be indicated.
 Most groin strains are mild, however, and eventually respond
to conservative treatment. Unfortunately, adductor tendon
pathology often coexists with other dysfunction around the
pelvic region.

28. Treatment and rehabilitation
 Adductor tendon strains may be treated specifically if the
symptoms are very localised and imaging is consistent with
the clinical observations.
 Soft-tissue release techniques to reduce tightness can be
combined with progressive strengthening of the adductor
muscles.
 However, it is very important that treatment should be
accompanied by attention to any other strength or flexibility
deficiencies in the pelvic area.

29.  The adductors work with gluteus medius after propulsion in
running; and with the hip abductors to maintain pelvic stability
during the stance phase, therefore it is considered that pelvic
stability prevents excessive eccentric loading of the adductors.
 Strain of the adductor longus should be managed depending on
the location of the injury. Physical examination should reveal
whether the injury lies within the muscle belly or within the teno-
periosteal attachment.

30.  Injuries to the muscle belly are best managed with
strengthening, gentle stretching and progressive return to
activity.
 However, avulsion injury to the teno-periosteal attachment
requires more conservative management with rest until the
patient is pain free, then strengthening and very careful
stretching over a significantly longer period of weeks; then
running and sprinting; and, lastly, running and sprinting
combined with rapid changes in direction if the sport
demands it.

31.  Injection of corticosteroid around the adductor origin may be
beneficial in stubborn cases, as long as the athlete has, and
continues to, conform to the guidance given.
 Proximal thigh strapping during activity will often be
successful in dissipating stress away from the weakened area.
 When all conservative measures have failed, surgical release
of the tendon from the bone called an adductor tenotomy
may be indicated. Although adductor tenotomy has been
shown to leave a strength deficit in some studies, this does not
appear to significantly be associated with adverse
performance.

32. Slipped Capital Femoral Epiphysis
 A slipped capital femoral epiphysis may occur in older
children, particularly between 12 and 15 years. This is similar
to a Salter–Harris type I fracture. It occurs typically in
overweight boys who tend to be late maturers.
 The slip may occur suddenly or, more commonly, as a gradual
process. There is sometimes associated pain, frequently in the
knee, but the most common presenting symptom is a limp.

33. Slipped Capital Femoral
Epiphysis
Normal

34.  Examination reveals shortening and
external rotation of the affected leg.
Hip abduction and internal rotation
are reduced.
 During flexion the hip moves into
abduction and external rotation.
Radiographs show widening of the
growth plate and a line continued
from the superior surface of the neck
of the femur does not intersect the
growth plate.
Radiographic appearance of slipped
capital femoral epiphysis

35.  Bilateral involvement is common. Slips are a matter of
considerable concern because they may compromise the
vascular supply to the femoral head and lead to avascular
necrosis.
 These require orthopedic assessment. A gradually
progressing slip is an indication for surgery. An acute severe
slip occurs occasionally. This is a surgical emergency.

36. Iliopsoas Strains
 The iliopsoas muscle is the strongest flexor
of the hip joint. It arises from the five
lumbar vertebrae and the ilium and inserts
into the lesser trochanter of the femur.
 It is occasionally injured acutely but
frequently becomes tight with neural
restriction.
 Iliopsoas problems may occur as an
overuse injury resulting from excessive hip
flexion, such as kicking.

37.  They present as a poorly localized ache that patients usually
describe as being a deep ache in one side of the groin. They
are also a common injury in sprinters. Direct palpation of the
iliopsoas muscle is difficult in its proximal portion as it lies
deep within the pelvis.
 The skilled examiner may detect tenderness in thin athletes
by palpating carefully with the muscle positioned
appropriately in passive hip flexion. Pain on iliopsoas stretch
that is exacerbated on resisted hip flexion in the stretch
position suggests the iliopsoas as the source of the pain.

38. Passive movement— Psoas stretch (Thomas position). Pain in the hip
being stretched suggests psoas abnormality. Pain in the hip being
compressed can be significant for anterior impingement of the hip joint

39.  It is important to examine the lumbar spine as there is
frequently an association between iliopsoas tightness and
hypomobility of the upper lumbar spine from which the
muscle originates.
 Treatment consists of avoiding aggravating activity, stretching
of the psoas muscle and strengthening involving resisted hip
flexion exercises.
 Often, mobilization of the lumbar intervertebral joints at the
origin of the iliopsoas muscles will result in an increase in
muscle length.

40. Trochanteric Bursitis/Gluteus Medius
Tendinopathy
 Long-distance runners can present with
fairly acute onset of pain in the lateral hip
region about the greater trochanter that
may radiate down the lateral aspect of the
thigh.
 This can be due to bursitis in one of
several bursae around the hip and it is
aggravated by activities involving hip
movements, such as climbing stairs and
getting out of a car.

41.  There are two bursae around the greater trochanter.
 The gluteus medius bursa lies beneath the tendon of the
gluteus medius and medial to the greater trochanter.
 The trochanteric bursa is lateral to the greater trochanter.
 Gluteus medius tendinopathy/enthesopathy and bursitis
often exist together.

42.  The site of tenderness in these
conditions is typically immediately
above the greater trochanter and pain
can be reproduced on stretching the
gluteus medius.
 Treatment for these conditions
involves initial rest from aggravating
activities, stretching and strengthening
of the gluteus medius.
Gluteus medius stretch

43.  Corticosteroid injection may be required and should be placed
into the area of maximal tenderness above and behind the
greater trochanter.
 As the conditions are often associated with biomechanical
abnormality, muscle tightness or excessive lateral tilt of the
pelvis, pelvic stability exercises may play an important role
in treatment

44. ‘Snapping’ Hip
 ‘Snapping’ hip, a condition seen in ballet dancers, refers to a
snapping noise in the hip region. There are two forms of
snapping hip.
 Lateral (or external) snapping hip is localized at the lateral
aspect of the hip and is produced by the tensor fascia lata or
the abducting fibers of gluteus maximus sliding over the
greater trochanter and producing a characteristic sound. It is
usually not painful.

45.  The young dancer (and usually the parent) requires
reassurance that this does not signify any bony abnormality.
 Although the condition may resolve with rest, attention to
ballet technique, sustained myofascial tension to excessively
tight soft tissue structures, pelvic stability exercises and
stretching of the involved tissues may hasten recovery.

46.  A second form of snapping hip (internal
snapping hip) is caused by the
iliopsoas tendon as it flips over the
iliopectineal eminence.
 The patient complains of pain with hip
flexion.
 Treatment consists of iliopsoas
stretches and soft tissue therapy to the
iliopsoas muscle. Occasionally surgical
release may be required.
Internal snapping hip refers to
the iliopsoas tendon flipping
over the iliopectineal eminence

47. Quadriceps Contusion
 If the patient suffered a direct blow to
the anterior thigh and examination
confirms an area of tenderness and
swelling with worsening pain on
active contraction and passive stretch,
thigh contusion with resultant
hematoma is the most likely
diagnosis.
 In severe cases with extensive
swelling, pain may be severe enough
to interfere with sleep.

48.  Quadriceps contusion is an extremely common injury and is
known colloquially as a ‘charley horse’ or ‘cork thigh’. It is
common in contact sports such as football and basketball. In
sports such as hockey, lacrosse and cricket, a ball traveling
at high speed may cause a contusion.
 Trauma to the muscle will cause primary damage to
myofibrils, fascia and blood vessels.
 Localized bleeding may increase tissue pressure and cause
relative regional anoxia that can result in secondary tissue
damage.

49.  The contusion may be either intramuscular or
intermuscular.
 In the intermuscular hematoma, the blood escapes through
the fascia and is distributed between the compartments of the
thigh.
 The intramuscular hematoma is confined to the muscle
compartment which fills up with blood. The intramuscular
hematoma is more painful and restrictive of range of motion.
Usually only a single quadriceps muscle will be affected.

50.  It is important to assess the severity of the contusion to determine
prognosis (this can vary from several days to a number of weeks
off sport) and plan appropriate treatment.
 The degree of passive knee flexion after 24 hours is an indicator of
the severity of the hematoma. For optimal treatment and accurate
monitoring of progress, it is important to identify the exact muscle
involved.
 MRI will show significant edema throughout the involved muscle.
 Blood from contusions of the lower third of the thigh may track
down to the knee joint and irritate the patellofemoral joint.

51. Treatment- The treatment of a thigh contusion can be divided
into four stages:
 Stage 1—control of hemorrhage;
 Stage 2—restoration of pain-free range of motion;
 Stage 3—functional rehabilitation;
 Stage 4—graduated return to activity.
 Progression within each stage, and from one stage to the next,
depends on the severity of the contusion and the rate of
recovery.

54. RICE treatment of an acute thigh
contusion in a position of
maximal pain-free stretch
Quadriceps stretching exercises
(a) Standard quadriceps stretch while standing. It
is important to have good pelvic control and not to
lean forward while performing the stretch

55. Passive stretch. The tension of the
stretch can be altered by adding hip
extension
Quadriceps strengthening exercises
(a) Active quadriceps exercises. Initially inner range
quadriceps strengthening is performed with a rolled
towel under the knee as shown. The range is slowly
increased, depending on symptoms, until through range
quadriceps contraction can be performed pain-free

56. (b) Resisted quadriceps. Concentric and eccentric
exercises are performed against gradually
increased resistance. Knee extension involves
concentric contraction of the quadriceps muscle,
while lowering the foot from extension involves
eccentric quadriceps contraction
(c) Functional exercises. A variety of functional
exercises can be performed in the late stage of
rehabilitation: squats, wall squats, step-downs
(illustrated), shuttle. Most of these involve both
eccentric and concentric contraction of the
quadriceps

57.  The most important period in the treatment of a thigh
contusion is in the first 24 hours following the injury. Upon
suffering a thigh contusion, the player should be removed
from the field of play and the RICE regimen instituted
immediately.
 The importance of rest and elevation of the affected leg must
be emphasized. The use of crutches ensures adequate rest if
full weight-bearing is painful and encourages the athlete to
recognize the serious nature of the condition.

58.  In the acute management of a thigh contusion, ice should be
applied in a position of maximal pain-free quadriceps stretch.
 The patient must be careful not to aggravate the bleeding by
excessive activity, alcohol ingestion or the application of heat.
 Loss of range of motion is the most significant finding after
thigh contusion and range of movement must be regained in a
gradual, pain-free progression.

59.  After a moderate-to-severe contusion there is a considerable
risk of re-bleed in the first seven to 10 days.
 Therefore, care must be taken with stretching, electrotherapy,
heat and massage. The patient must be careful not to
overstretch. Stretching should be pain-free.

60.  Soft tissue therapy is contraindicated for 48 hours following
contusion. Subsequently, soft tissue therapy may be used but
great care must be taken not to aggravate the condition.
 Treatment must be light and it must produce absolutely no
pain. The aim of soft tissue therapy in the first few days after a
thigh contusion is to promote lymphatic drainage.

61.  Quadriceps contusion is a condition that can be prevented.
Patients who are recovering from a previous contusion may
benefit from thigh protection. Athletes in high-risk sports
should consider wearing thigh protection routinely.
 Players such as ruckmen in Australian football, forwards in
basketball and running backs in American football may
sustain a series of minor contusions during the course of a
game. These appear to have a cumulative effect and may
impair performance later in the game. Protective padding
helps to minimize this effect.

62. Irritable Hip
 ‘Irritable hip’ is common in children but should be a diagnosis
of exclusion. The child presents with a limp and pain that may
not be well localized.
 Examination reveals painful restriction of motion of the hip
joint, particularly in extension and/or abduction in flexion.
 In the majority of cases, a specific cause is never identified
and the pain settles after a period of bed rest and observation.
Radiographs, bone scanning and blood tests are usually
normal, and the child is treated with rest.

63. Thank You