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![Key Points to Consider…
• Static and Dynamic Clinical Anatomy
• Angle of Inclination, Angle of Torsion and
Osteo/Arthrokinematics
• Postural Screening and Observational Gait
Analysis and Core Engagement
• Kinetic Chain Linking [Hip-Pelvis Motion
Patterns CKC]
• Specialized Assessment Techniques
• Lower Quarter Screen](https://image.slidesharecdn.com/pelvishipandthighpathologies-240121173114-534098eb/85/Pelvis-Hip-and-Thigh-Pathologies-pptx-2-320.jpg)
![Structural vs. Compensatory
• Toe Out Gait Pattern – Reduced IROT at Hip
Structural
Alignment between
Femur and
Acetabulum/Pelvis
• Greater than 12°-
15° degree
Anterior
Relationship
[Anteversion]
Decreased
Anterior Femur
Head/Neck -
Condyles Alignment
• “Twisting of
Femur”
compensates for
Posterior
Femoral Head
position](https://image.slidesharecdn.com/pelvishipandthighpathologies-240121173114-534098eb/85/Pelvis-Hip-and-Thigh-Pathologies-pptx-10-320.jpg)
![Structural vs. Compensatory
• Toe In Gait Pattern – Reduced EROT at Hip
Structural Alignment
between Femur and
Acetabulum/Pelvis
• Less than 12°-15°
degree Anterior
Relationship
[Retroversion]
Increased Anterior
Femur Head/Neck -
Condyles Alignment
• “Twisting of
Femur”
compensates for
Anterior Femoral
Head position](https://image.slidesharecdn.com/pelvishipandthighpathologies-240121173114-534098eb/85/Pelvis-Hip-and-Thigh-Pathologies-pptx-11-320.jpg)
![Inspection
Postural
Assessment
Gait Analysis
Running Gait
Analysis
Functional
Movement
Screening
Deformity or
Defect
HP
Height
[Leg
Length,
Long-Sit
Test]
Atrophy?
Ecchymosis
Swelling](https://image.slidesharecdn.com/pelvishipandthighpathologies-240121173114-534098eb/85/Pelvis-Hip-and-Thigh-Pathologies-pptx-29-320.jpg)
![Ely’s Test – Muscle Length
Prone Passive Knee
Flexion: (+) Test:
Hip Flexion
Implications:
Tight/Shortened
Rectus Femoris
[Anterior Pelvic
Tilting]](https://image.slidesharecdn.com/pelvishipandthighpathologies-240121173114-534098eb/85/Pelvis-Hip-and-Thigh-Pathologies-pptx-41-320.jpg)
![C-Sign and Log Roll Test
“Groin Pain” and (+) “C” Sign and Pain with
Log Roll Test [Intra-articular Pathology]](https://image.slidesharecdn.com/pelvishipandthighpathologies-240121173114-534098eb/85/Pelvis-Hip-and-Thigh-Pathologies-pptx-59-320.jpg)
![Pubic-Related Groin Pain
MRI Referral –
Edema Pubic
Rami
Pelvic Floor
Reconstruction
Surgery [6
Weeks RTP]](https://image.slidesharecdn.com/pelvishipandthighpathologies-240121173114-534098eb/85/Pelvis-Hip-and-Thigh-Pathologies-pptx-65-320.jpg)
![FABER with Extension/IR
Moving from a FABER position into Extension
and IROT – Snapping Hip of Iliopsoas
[Lesser Trochanter]](https://image.slidesharecdn.com/pelvishipandthighpathologies-240121173114-534098eb/85/Pelvis-Hip-and-Thigh-Pathologies-pptx-71-320.jpg)
Pelvis, Hip and Thigh Pathologies.pptx
- 1. Pelvis, Hip andThigh Pathologies Competencies in Athletic Training SEATA Athletic Training Student Symposium Dr. Patricia M. Tripp, ATC, LAT, CSCS Clinical Associate Professor & Director, AT Program
- 2. Key Points toConsider… • Static and Dynamic Clinical Anatomy • Angle of Inclination, Angle of Torsion and Osteo/Arthrokinematics • Postural Screening and Observational Gait Analysis and Core Engagement • Kinetic Chain Linking [Hip-Pelvis Motion Patterns CKC] • Specialized Assessment Techniques • Lower Quarter Screen
- 3. What we willcover… • Clinical Anatomy - Review • Biomechanical Factors • Clinical Examination of the Pelvis, Hip and Thigh • Pathologies and Related Specialized Tools/Tests
- 4.
- 5.
- 6. Clinical Anatomy Spin =Same Direction as Motion
- 7. Functional Anatomy • Spin(IR), Glide Posterior, Roll Anterior Flexion/IR • Spin (ER), Glide Anterior, Roll Posterior Extension/ER • Glide Inferior, Roll Superior (Upward) Abduction • Glide Superior, Roll Inferior (Downward) Adduction Understanding the Mechanics Helps Identify the Pathology!
- 8. Angle of Inclination Measured via Radiographs Observedas Valgus or Varus Femoral Angulation ↑ Forces on Femoral Head ↑ Forces on Femoral Neck
- 9. Angle of Torsion Rotationof Femoral Shaft Measured as Angle of Neck and Transcondylar Position Rotated anteriorly ~15
- 10. Structural vs. Compensatory •Toe Out Gait Pattern – Reduced IROT at Hip Structural Alignment between Femur and Acetabulum/Pelvis • Greater than 12°- 15° degree Anterior Relationship [Anteversion] Decreased Anterior Femur Head/Neck - Condyles Alignment • “Twisting of Femur” compensates for Posterior Femoral Head position
- 11. Structural vs. Compensatory •Toe In Gait Pattern – Reduced EROT at Hip Structural Alignment between Femur and Acetabulum/Pelvis • Less than 12°-15° degree Anterior Relationship [Retroversion] Increased Anterior Femur Head/Neck - Condyles Alignment • “Twisting of Femur” compensates for Anterior Femoral Head position
- 12. Pediatric Considerations Excessive IROT andToe-In Gait Commonly Seen in Children Structural Retroversion
- 13. Include Postural Assessment andGait Observational Analysis
- 14. Muscle Activity –Gait 1. Flexibility – Necessary for Efficient Shock Absorption (Stance) 2. Stability – Necessary for Efficient Propulsion (Stance and Swing) 3. Full ROM – Necessary for Efficient Muscular Reponses (Stance and Swing) 4. Concentric and Eccentric Strength – Efficient Shock Absorption and Forward Movement (Stance and Swing)
- 15. Synergistic Motion Hip Flexion/Internal Rotationand Posterior Pelvic Tilting Hip Extension/External Rotation and Anterior Pelvic Tilting
- 16. Walking Gait Muscle Mechanics StancePhase of Gait - Eccentric Control of Pelvis and Shock Absorption (Thigh), Flexibility of Hip Flexors Required for Efficiency Swing Phase of Gait – Stability and Strength for Toe Clearance and Limb Advancement, Eccentric Hamstring Control Lower Leg
- 17. Functional Anatomy Load –Deformation = Injury
- 18. Muscular Anatomy Rectus Femorisor Iliopsoas Tightness May Cause Anterior Pelvic Tilting
- 19.
- 20.
- 21. Muscular Anatomy Tight Hamstrings= Posterior Pelvic Tilt
- 22. Engaging the Core(TA) Fascial Connection Between Iliopsoas and Diaphragm
- 23. Engaging the Transverse Yogaand Pilates® Postures
- 24. Primary Hip Bursae Friction Between Gluteus Maximus and Bony Prominences
- 25. Neurologic Anatomy Femoral Nerve (HipFlexors, Knee Extensors) Obturator Nerve (Hip Adductors, Obturator Externus)
- 26.
- 27. CLINICAL EXAMINATION OF THEPELVIS, HIP AND THIGH
- 28. History: Present Condition Locationof Symptoms - Referred Pain from Lumbar Spine or SI Joint? Onset of Symptoms - Acute, Chronic, Insidious Aggravating Activities? Training Techniques - Banked Surfaces/Hill Running Mechanism of Injury?
- 29. Inspection Postural Assessment Gait Analysis Running Gait Analysis Functional Movement Screening Deformityor Defect HP Height [Leg Length, Long-Sit Test] Atrophy? Ecchymosis Swelling
- 30. Palpation Modesty with palpationof origin points!
- 31. Palpation • Crepitus • Defects •Spasms • Trigger Points
- 32. Active/Passive Hip ROM NoJoint Play at Hip
- 33. Goniometric Assessment Axis ofRotation – Greater Trochanter (Fixed – Torso, Moving – Femur) Axis of Rotation – ASIS (Fixed – Horizontal ASIS, Moving – Femur) Axis of Rotation – Patella (Fixed ┴, Moving – Tibia)
- 34. MMT (Eccentric) Hip HipFlexion: Iliopsoas Knee Extended: Quadriceps + Iliopsoas FABER: Sartorius
- 35. MMT (Eccentric) HipExtension Knee Extended: Gluteus and Hamstrings Knee Flexed: Gluteus
- 36. MMT (Eccentric) Hip HipAbduction: Gluteus Medius and Minimus Hip Adduction: Adductors and Gracilis
- 37. MMT (Eccentric) Hip HipExternal Rotation: Application of Force at Medial Ankle/Shank; Stabilize Femur Hip Internal Rotation: Application of Force at Lateral Ankle/Shank; Stabilize Femur
- 38. Specialized Tests and ExaminationTechniques
- 39. Trendelenburg Test: Weak GluteusMedius SLB – Stance Limb = Test Limb (+) Test: Dropped Hip Height on Contralateral Side Weak Gluteus Medius on Stance Limb Inability to Stabilize Pelvis During Stance Phase of Gait
- 40. Thomas Test –Muscle Length Implications •Hip Flexion – Iliopsoas Tightness •Knee Extension – Rectus Femoris Tightness •Hip Abduction – IT Band Tightness
- 41. Ely’s Test –Muscle Length Prone Passive Knee Flexion: (+) Test: Hip Flexion Implications: Tight/Shortened Rectus Femoris [Anterior Pelvic Tilting]
- 42. Iliac Crest Contusion (HipPointer) Signs and Symptoms Disproportionate amount of pain Swelling, Discolor ation Spasms, Loss of function Pain with trunk rotation and hip flexion Ice, Pad, Protect, Crutches?
- 43. Muscle Strains Dynamic Eccentric Overload Excessive Tension Stress Concentric Muscle Force Abruptly Stopped 2-Joint Muscles Initial ManagementRICE, Crutches; Longer Healing Time vs. Sprain Skeletally Immature – possible avulsion or apophysitis injury
- 44. Rectus Femoris (Quadriceps) Strain •Contraction/Dynamic Overload • Pain with Activation and Stretching Palpable Defect, Ecchymosis, Swelling, Gait Changes depend on Grade I-III
- 45. Iliopsoas (Hip Flexor)Strain • Hyperextension of Hip • Resisted Hip Flexion • Attachment on Lumbar Vertebrae – Back Pain? Palpable Defect, Ecchymosis, Swelling, Gait Changes depend on Grade I-III
- 46. Hamstring (Biceps Femoris) Strain •Dynamic Overload | Eccentric Stretching Palpable Defect, Ecchymosis, Swelling, Gait Changes depend on Grade I-III Eccentric Control of Lower leg During Terminal Swing
- 47. Gluteus Maximus Strain •Dynamic Overload | Eccentric or Isometric Contraction Palpable Defect, Ecchymosis, Swelling, Gait Changes depend on Grade I-III
- 48. Adductor Strain • Overstretching, DynamicOverload • Adductor Longus (Most Common – Occurs at MT Junction) Palpable Defect, Ecchymosis, Swelling, Gait Changes depend on Grade I-III
- 49. Thigh Contusion Direct Trauma(Acute) • Muscle Fiber Death Signs and Symptoms • Pain, Loss of Function, Ecchymosis, Swelling, ROM Restrictions, Spasm Management • RICE, Crutches 24hrs? Complication • Myositis Ossificans 24hrs post- injury = critical Ice on Stretch (>120°) = Faster RTP
- 50. Pediatric Considerations Legg-Calvé-Perthes Disease (LCP) •Flattening of Femoral Head; Hip IROT and Abduction (Avascular Necrosis; ages 3-12) Slipped Capital Femoral Epiphysis (SCFE) • Excessive Hip EROT and Restricted or Painful Hip IROT (♂, ages 10-15)
- 51. Legg-Calvé-Perthes Disease • ReferredPain: Medial Thigh, Buttock, Suprapatellar Region • Painless Antalgic Gait Pattern, Limited Hip IROT and Abduction
- 52. Slipped Captial Femoral Epiphysis Commonin Boys, Typically Unilateral (20% Bilateral) Anteversion of Hip, Toe-Out Gait (EROT), IROT Clinical Management: Surgical Fixation
- 53. SCFE vs. LCP Normal FemoralHead Slipped Femoral Head (SCFE) Abnormal Shaped Femoral Head (LCP)
- 54. Femoral Neck StressFx Deep aching pain that with activity Referred pain to groin and/or knee, night pain ROM is limited and painful near end ranges Crutches and REFER for CT or Bone Scan vs. X-Rays
- 55. Femoral Neck StressFx Superior Femoral Neck Stress Fractures “Tension-Side” Inferior Femoral Neck Stress Fractures “Compression – Side”
- 56. FABER Test • Intra-articular Pathology •Anterior or Deep Hip/Groin Pain Reported • Pincer FAI – Pain with EROT
- 57. Degenerative Hip Changes DecreasedJoint Space and Cartilage Degeneration
- 58. Hip Scouring Test Downward Compression (Longitudinal)+ IROT and EROT (+) Test = Pain, Increased Symptoms Implications: OCD, Arthritis, Acetabular Labral Tear (if clicking)
- 59. C-Sign and LogRoll Test “Groin Pain” and (+) “C” Sign and Pain with Log Roll Test [Intra-articular Pathology]
- 60. Acetabular Labral Tears •FABER Position Painful Anterior Tears • IROT and Adduction Pain Posterior Tears • MR Arthrogram and/or Lidocane Injection Diagnosis • Surgical Intervention Management
- 61. Labral Tears Right Hip Labral“Clock” Sagittal T1 Weighted MR Arthrogram – Labral Separation from Acetabulum
- 62. FADDIR – ImpingementTest Femoral Acetabular Impingement
- 63. Groin Pain –New Consensus and Classification 1. Adductor-related, Iliopsoas-related, Inguinal-related and Pubic-related groin pain 2. Hip-related groin pain 3. Other causes of groin pain in athletes Atheltic Pubalgia and Osteitis Pubis – fall under “Pubic-Related Groin Pain
- 64. Groin Stress Biomechanics Cutting/twisting at high speeds Shear forces transmitted to pubic symphysis Common among Soccer, Hockey, Football
- 65. Pubic-Related Groin Pain MRIReferral – Edema Pubic Rami Pelvic Floor Reconstruction Surgery [6 Weeks RTP]
- 66. Pubic-Related Groin Pain Repetitivestress on pubic symphysis leads to chronic inflammation Distance Running, Soccer, FB, Wrestling, Ice Skating T2 Weight MR – Bone Marrow Edema
- 67. Pubic-Related Groin Pain Painwith “Shear” Stress at Pubic Symphysis Adductor Group Spasm and/or Weakness? Leg-Length Discrepancy – Predisposition? Diagnosis: X-ray | MRI Widening and Calcification of Pubic Symphysis
- 68. Copenhagen Hip andGroin Outcome Score (HAGOS) 1. Pain 2. Symptoms 3. Physical function in ADLs 4. Physical Sport and Recreation Function 5. Participation in Physical Activities 6. Hip and/or Groin-Related Quality of Life HAGOS Intraclass Correlation Coefficients (ICC) ranging from 0.82-0.91 for the six subscales
- 69. Tight Piriformis –Nerve Irritation (Piriformis Syndrome) “Pigeon Pose” and “Double Pigeon Pose” for Piriformis Stretching
- 70. Snapping Hip Syndrome (CoxaSaltans) External - IT Band/Gluteus Maximus Internal - Iliopsoas Tendon (Lateral Shift with Flexion, Medial Shift with Extension)
- 71. FABER with Extension/IR Movingfrom a FABER position into Extension and IROT – Snapping Hip of Iliopsoas [Lesser Trochanter]
- 72. Clinical Take HomePoints Know your anatomy! Understand the underlying root of the problem Connect gait analysis and posture with clinical exam Imaging warranted for majority of hip injuries Use Systematic Approach with D/D to Rule In and Out