The HipThe Hip

Sports Med 2Sports Med 2

The HipThe Hip

A ball and socket jointA ball and socket joint Hip transmits the load Hip transmits the load

from the foot to the from the foot to the spine and vice versaspine and vice versa

Blood & Nerve SupplyBlood & Nerve Supply

Femoral arteryFemoral artery Common Iliac VeinCommon Iliac Vein Femoral NerveFemoral Nerve Sciatic NerveSciatic Nerve

Largest nerve in the bodyLargest nerve in the body Innervates thigh and lower legInnervates thigh and lower leg

BursaeBursae

Iliopsoas and deep trochanteric bursaeIliopsoas and deep trochanteric bursae Most important onesMost important ones

InjuryInjury

Trochanteric BursitisTrochanteric Bursitis MOI:MOI:

• Common at the greater trochanter, high in women w/ increased Q Common at the greater trochanter, high in women w/ increased Q angle, or leg length discrepancyangle, or leg length discrepancy

• Inflammation of bursa, or insertion of gluteus medius, or IT bandInflammation of bursa, or insertion of gluteus medius, or IT band S/S:S/S:

• c/o pain on lateral hipc/o pain on lateral hip• Radiating pain down to the kneeRadiating pain down to the knee• Tenderness over greater trochanterTenderness over greater trochanter

TX:TX:• PRICE, NSAIDS, ROM, PREs, no inclined runningPRICE, NSAIDS, ROM, PREs, no inclined running

Special Tests: Obers, Special Tests: Obers,

Ober’s TestOber’s Test-Athlete lays on unaffected Athlete lays on unaffected sideside-Knee flexed at 90 degreesKnee flexed at 90 degrees-Lift top leg into abduction, Lift top leg into abduction, slight hip extensionslight hip extension-Allow the affected leg to Allow the affected leg to drop into adductiondrop into adduction

-If leg does NOT drop = + If leg does NOT drop = + tight IT band tight IT band

BonesBones Sacrum, CoccyxSacrum, Coccyx

Innominate bones: Innominate bones: ossify and fuse early in ossify and fuse early in lifelife

PelvisPelvis Support the spine and Support the spine and

trunk trunk Transfer their weight Transfer their weight

to the lower limbsto the lower limbs Placement for bony Placement for bony

attachmentattachment Ilium, Ischium, PubisIlium, Ischium, Pubis

Make up pelvisMake up pelvis

InjuriesInjuries

Hip Pointer (contusion)Hip Pointer (contusion) MOIMOI

• blow to inadequately protected iliac crestblow to inadequately protected iliac crest• Most handicapping injury in sports, difficult to manageMost handicapping injury in sports, difficult to manage

S/SS/S• Immediate pain, spasms, transitory paralysis of soft Immediate pain, spasms, transitory paralysis of soft

structuresstructures• Unable to rotate the trunk or to flex the thigh with out pnUnable to rotate the trunk or to flex the thigh with out pn

TXTX• RICE, referral, x-ray, ice massage, ultrasound, injectionRICE, referral, x-ray, ice massage, ultrasound, injection• Doughnut pad for return to playDoughnut pad for return to play

Hip dislocationHip dislocation

InjuriesInjuries

Hip Dislocation pg 727 fig. 21-30Hip Dislocation pg 727 fig. 21-30 MOIMOI

• Rarely occur during sportsRarely occur during sports• Femur is adducted and flexedFemur is adducted and flexed

S/SS/S• Flexed, adducted, and internally rotated thighFlexed, adducted, and internally rotated thigh• Deformity, nerve damageDeformity, nerve damage

TXTX• Immobilization, ice, analgesicsImmobilization, ice, analgesics

InjuryInjury Avulsion FractureAvulsion Fracture

MOI:MOI:

• Most common: 1) ischial Most common: 1) ischial tuberosity (hamstrings), tuberosity (hamstrings), 2)AIIS(rectus femoris), ASIS 2)AIIS(rectus femoris), ASIS (sartorius)(sartorius)

• Sudden acceleration/decelerationSudden acceleration/deceleration S/S:S/S:

• Sudden local pain Sudden local pain

• Limited movementLimited movement TX:TX:

• X ray, PRICE, crutches, ROM, X ray, PRICE, crutches, ROM, PREsPREs

Special Tests: Hip MMTsSpecial Tests: Hip MMTs

InjuryInjury Osteitis PubisOsteitis Pubis

MOI:MOI:• Seen in running sports (XC, Seen in running sports (XC,

football, soccer, wrestlingfootball, soccer, wrestling• Repetitive stress on pubis Repetitive stress on pubis

symphysis by surrounding symphysis by surrounding musclesmuscles

S/S:S/S:• Groin pain while running, squats, Groin pain while running, squats,

sit upssit ups TX: rest, oral antiinflammatory TX: rest, oral antiinflammatory

agents, gradual return to playagents, gradual return to play Special Tests: running, sit up, squatsSpecial Tests: running, sit up, squats

ArticulationsArticulations Sacroiliac JointSacroiliac Joint

Supported by ligamentsSupported by ligaments Connects sacrum to iliumConnects sacrum to ilium

Joint CapsuleJoint Capsule The acetabulum is The acetabulum is

cushioned by the labrumcushioned by the labrum

Hip JointHip Joint Made of femur head and Made of femur head and

acetabulumacetabulum Padded at the center by a Padded at the center by a

mass of fatty tissue, mass of fatty tissue, ligaments and capsuleligaments and capsule

LigamentsLigaments

IliofemoralIliofemoral Y ligament of BigelowY ligament of Bigelow Strongest ligament of Strongest ligament of

bodybody Prevents hyperextensionPrevents hyperextension

PubofemoralPubofemoral Prevents excessive Prevents excessive

abductionabduction

LigamentsLigaments

IschiofemoralIschiofemoral Prevents internal Prevents internal

rotation and adductionrotation and adduction On posterior aspectOn posterior aspect

Ligamentum TeresLigamentum Teres Ligament to the head Ligament to the head

of the femurof the femur A bridge to allow blood A bridge to allow blood

vessels and nerves to vessels and nerves to enter the head of the enter the head of the femurfemur

InjuriesInjuries Hip SprainHip Sprain

MOIMOI• Strong, therefore best protected, seldom injuredStrong, therefore best protected, seldom injured

• Violent twisting produced by opponent, foot firmly Violent twisting produced by opponent, foot firmly planted and trunk forced in opposing directionplanted and trunk forced in opposing direction

S/SS/S• Athlete is unable to circumduct the thighAthlete is unable to circumduct the thigh

• painpain TXTX

• X-rays to rule out fxX-rays to rule out fx

• RICE, analgesics, limit wt. bearing, pain free ROMRICE, analgesics, limit wt. bearing, pain free ROM Special Tests: active circumduction of thigh, IR, Special Tests: active circumduction of thigh, IR,

ERER

InjuriesInjuries Sacroiliac Joint Sprain (S.I. Joint)Sacroiliac Joint Sprain (S.I. Joint)

MOIMOI• Twists with both feet on the groundTwists with both feet on the ground

• Stumbles forward, falls backward, steps in holeStumbles forward, falls backward, steps in hole S/SS/S

• Pain over joint, muscle guarding, radiating pain down Pain over joint, muscle guarding, radiating pain down back of gluteus and hamstringback of gluteus and hamstring

• Asymmetrical ASIS/PSIS or leg length differenceAsymmetrical ASIS/PSIS or leg length difference TXTX

• Modalities, brace, stability exercisesModalities, brace, stability exercises Special Test: FABERS/PatricksSpecial Test: FABERS/Patricks

FABERs /Patrick TestFABERs /Patrick Test

Procedure: Place foot on Procedure: Place foot on the opposite extended knee the opposite extended knee of the painful SI jointof the painful SI joint

Apply pressure downward Apply pressure downward on the bent knee.on the bent knee.

Positive test: Pain felt in hip Positive test: Pain felt in hip or SI jt. = SI joint or SI jt. = SI joint dysfunctiondysfunction

MusclesMuscles AnteriorAnterior

IliacusIliacus• Triangular shaped, flexes the hipTriangular shaped, flexes the hip

Psoas (major and minor)Psoas (major and minor)• Flexes the hipFlexes the hip

SartoriusSartorius• Crosses medially across the Crosses medially across the anterior aspect of the thighanterior aspect of the thigh• Hip flexion, and external Hip flexion, and external rotationrotation

Rectus FemorisRectus Femoris• Hip flexion and knee extensionHip flexion and knee extension

MusclesMuscles LateralLateral

Tensor fascia lataeTensor fascia latae• Hip abductionHip abduction

PosteriorPosterior 3 gluteal muscles3 gluteal muscles

• Gluteus Maximus: extension, Gluteus Maximus: extension, adduction, helps us get up fromadduction, helps us get up froma sitting positiona sitting position• Gluteus Medius: abductionGluteus Medius: abduction• Gluteus Minimus: abductionGluteus Minimus: abduction

Hamstrings: hip extension, knee flexionHamstrings: hip extension, knee flexion• Biceps Femoris, Semitendinosis, SemimembranosusBiceps Femoris, Semitendinosis, Semimembranosus

MusclesMuscles Medial Medial

All act as adductors and All act as adductors and rotators of the hiprotators of the hip GracilisGracilis

• Adducts, flexes, external Adducts, flexes, external rotationrotation

PectineusPectineus• Adducts, flexes, external rotationAdducts, flexes, external rotation

Adductor longus, brevis and Adductor longus, brevis and magnusmagnus• Adducts, external rotationAdducts, external rotation

InjuriesInjuries Groin Strain (adductor/Hip flexor strain)Groin Strain (adductor/Hip flexor strain)

MOIMOI• The groin is the area between the thigh and the abdominalsThe groin is the area between the thigh and the abdominals• Torn during twist or pull while running or jumpingTorn during twist or pull while running or jumping

S/SS/S• Felt as sudden twinge or feeling of tearing during an AROM, or Felt as sudden twinge or feeling of tearing during an AROM, or

may feel it the next daymay feel it the next day• Pain, weakness, internal bleedingPain, weakness, internal bleeding

TXTX• PRICE, analgesics, ROM and strengthening exercisesPRICE, analgesics, ROM and strengthening exercises• Rest has been the best treatment, protective spicaRest has been the best treatment, protective spica

Special Tests: MMTsSpecial Tests: MMTs

Thomas TestThomas Test

Procedure: Athletes lies supine Procedure: Athletes lies supine legs togetherlegs together

ATC places on hand under ATC places on hand under athletes lumbar curveathletes lumbar curve

One thigh is brought to the One thigh is brought to the chest flattening the spine.chest flattening the spine.

Return bent leg to extended Return bent leg to extended position, lumbar curve should position, lumbar curve should return. return.

Positive Test: Extended thigh Positive Test: Extended thigh should be flat on the table, if should be flat on the table, if not = tight hip flexornot = tight hip flexor

Kendall testKendall testProcedure: Athlete Procedure: Athlete lies supine with lies supine with knees off tableknees off table

Athlete brings one Athlete brings one leg to their chestleg to their chest

Positive Test: If Positive Test: If thigh comes off the thigh comes off the table = tight hip table = tight hip flexorflexor

InjuryInjury Quad ContusionQuad Contusion

MOIMOI• Direct blow to the thighDirect blow to the thigh

TX: flx w/ice pack ,PRICE,NSAIDS, crutchesTX: flx w/ice pack ,PRICE,NSAIDS, crutches

InjuryInjury

Myositis Ossificans TraumaticaMyositis Ossificans Traumatica MOI:MOI:

• Severe blow or repeated blows to thigh, usually the Severe blow or repeated blows to thigh, usually the quadricepsquadriceps

• Can lead to ectopic bone production (myosositis Can lead to ectopic bone production (myosositis ossificans)ossificans)

S/S:S/S:• Pain, swelling, decreased functionPain, swelling, decreased function

TX:TX:• Conservative, surgery one year laterConservative, surgery one year later

Special Tests:Special Tests:• AROM knee flexion/extAROM knee flexion/ext

InjuryInjury Hamstring StrainHamstring Strain

MOIMOI• Most common injury to thigh, exact cause is not Most common injury to thigh, exact cause is not

knownknown• Possible MOI: muscle fatigue, faulty posture, leg Possible MOI: muscle fatigue, faulty posture, leg

length discrepancy, tight hamstringslength discrepancy, tight hamstrings S/SS/S

• Hemorrhage, pain, loss of function. Hemorrhage, pain, loss of function. • 3 grades of strain3 grades of strain

TXTX• PRICE, NSAIDS, very conservative, PREsPRICE, NSAIDS, very conservative, PREs

Special test: MMTsSpecial test: MMTs

Hamstring MMTHamstring MMT

InjuryInjury Snapping Hip:Snapping Hip: Excessive repetitive movement in dancers, gymnasts, Excessive repetitive movement in dancers, gymnasts,

hurdlers, sprintershurdlers, sprinters MOI:MOI:

• Imbalance in muscleImbalance in muscle• IT band moves over the greater trochanterIT band moves over the greater trochanter

S/S:S/S:• c/o of snapping with painc/o of snapping with pain

TX:TX:• Ice, NSAIDS, ultrasound, then stretchingIce, NSAIDS, ultrasound, then stretching

Trendelenburg’s testTrendelenburg’s test

Procedure: Athlete stands, Procedure: Athlete stands, foot on the unaffected side foot on the unaffected side is liftedis lifted

Look at the iliac crest to Look at the iliac crest to see if it stays levelsee if it stays level

Positive test: if unaffected Positive test: if unaffected side is lowers side is lowers

OROR

If standing on leg and If standing on leg and affected hip moves into affected hip moves into abductionabduction

= Weak abductors= Weak abductors

Measuring for Leg lengthMeasuring for Leg length

2 main ways:2 main ways: Anatomical Anatomical

discrepancydiscrepancy Functional Functional

discrepancydiscrepancy

Anatomical Anatomical discrepancydiscrepancy(true method)(true method)

((actual bone is actual bone is shortened)shortened)

Athlete lies supine with Athlete lies supine with legs straightlegs straight

Measurement is taken Measurement is taken between the medial between the medial malleoli and ASIS malleoli and ASIS

Bilaterally compareBilaterally compare

Functional Functional discrepancydiscrepancy

Due to pelvic tilt or Due to pelvic tilt or deformitydeformity

Athlete lies supine, legs Athlete lies supine, legs straightstraight

Measurement is taken Measurement is taken from umbilicus to the from umbilicus to the medial malleoli medial malleoli

Bilaterally compareBilaterally compare