thigh, hip, groin, and pelvis anatomy

muscles of the thigh, hip, and groin: hip abduction

-gluteus medius -tensor fascia lata

muscles of the thigh, hip, and groin: hip adduction

-gracilis -pectineus -adductor magnus -adductor longus -adductor brevis

muscles of the thigh, hip, and groin: hip extension

-hamstrings -biceps femoris -semimenbranosis -semitendinosis -gluteus maximus

muscles of the thigh, hip, and groin: hip lateral rotation

-piriformis -superior gemellus -inferior gemellus -obturator internus -obturator externus -quadratus femoris

muscles of the thigh, hip, and groin: hip flexion

-rectus femoris -sartorius -illiacus -psoas

grade 1 (mild) contusion

A Grade 1 quadriceps contusion can be either a very superficial intramuscular bruise or a slightly deeper one. The very superficial contusion creates a mild hemorrhage, minimal pain, no swelling, and mild point tenderness with no restriction of the range of motion. In contrast, a deeper first-degree contusion produces pain, mild swelling, point tenderness, and knee flexion of no more than 90 degrees.

grade 2 (moderate) contusion

A Grade 2 quadriceps contusion is of moderate intensity, causing pain, swelling, and a range of knee flexion that is less than 90 degrees with an obvious limp present while walking.

grade 1 hamstring strain

A grade 1 hamstring strain is usually evidenced by muscle soreness on movement and is accompanied by point tenderness. These strains are often difficult to detect when they occur. Irritation and stiffness do not become apparent until the athlete has cooled down after activity. The soreness of the mild hamstring strain in most instances can be attributed to muscle guarding rather than to the tearing of tissue.

grade 2 hamstring strain

A grade 2 muscle strain represents partial tearing of muscle fibers and can be identified by a sudden snap or tear of the muscle accompanied by severe pain and a loss of function of knee flexion. It is possible to palpate a defect in the muscle with a grade 2 strain.

grade 3 hamstring strain

A grade 3 hamstring strain is the rupturing of tendinous or muscular tissue, involving major hemorrhage and disability and a palpable and sometimes visual defect.

grade 3 (severe) contusions

A severe, or grade 3, quadriceps contusion represents a major disability. The blow may have been so intense as to split the fasciae, allowing the muscle to protrude (muscle herniation). Characteristically, a deep intramuscular hematoma with an intramuscular spread is present. Pain is severe, and swelling may lead to the formation of a hematoma. Knee flexion is severely restricted, and motion is limited to 45-90 degrees. The athlete has a decided limp.

straight leg raises

A straight leg raise can be used to test tightness in the hip extensors. The athlete lies supine and one leg is lifted, flexing the hip. If the leg cannot be flexed to 90 degrees, there is tightness in the hip extensors. A positive straight leg test can also indicate a problem in the low back or sacroiliac joint. If there is an issue with a nerve, pain will radiate into the buttocks or maybe down the back of the leg

assessing thigh, hip, groin, and pelvis injuries: palpation

Bony palpation should include the iliac crest, hip joint, femur, sacrum, and coccyx, looking for point tenderness and discomfort. The soft tissues, including those on the anterior thigh, the posterior thigh, the groin, the buttocks, the lateral hip, and the anterior hip, should be palpated to identify areas of tenderness or pain on active movement.

avulsion

Fractures Cause of Injury An avulsion is the tearing away of a body part from its point of attachment. An avulsion fracture occurs when a tendon that attaches a muscle to a bone pulls part of the bone away after sudden, forceful contraction of that muscle. There are several muscles of the thigh that attach to various parts of the pelvis. Common sites for avulsion fractures in the pelvis include where the sartorius muscle attaches to the anterior superior iliac spine (ASIS), where the rectus femoris muscle attaches to the front anterior inferior iliac spine (AIIS), and where the hamstring muscle group attaches to the ischial tuberosity signs of injury The athlete complains of a sudden localized pain with limited movement. On inspection, swelling and a point tenderness can be observed. care Early conditions require rest, limited activity, and graduated exercise.

Thomas test

The Thomas test indicates whether hip contractures are present. The patient lies supine on a table, arms across the chest, legs together and fully extended. The examiner places one hand under the athlete's lumbar curve; one thigh is brought to the chest, flattening the spine. In this position, the extended thigh should be flat on the table. If not, there is tightness of the hip flexors. When the patient fully extends the leg again, the curve in the low back returns.

ligaments

The hip joint is formed by articulation of the femur with the innominate. The head of the femur fits into a deep socket, the acetabulum, and is stabilized by strong iliofemoral ligaments and a joint capsule. The sacrum is joined to other parts of the pelvis by strong sacrotuberous and sacrospinous ligaments, forming the sacroiliac joint. A small backward-forward movement is present at the sacroiliac junction.

thigh muscles

The muscles located on the anterior thigh are the four quadriceps that function to extend the knee. One of the quadriceps, the rectus femoris muscle, also acts to flex the hip. The sartorius muscle is also on the anterior thigh and acts to flex the hip and outwardly rotate the thigh. The three hamstring muscles on the back of the thigh are flexors of the knee and act to extend the hip. The five medial muscles are known as the adductor group and collectively act as adductors of the hip. They include the gracilis, pectineus, and the adductor magnus, longus, and brevis

hip muscles

The muscles of the hip can be divided into anterior and posterior groups. The anterior group includes the iliacus and psoas muscles, which flex the thigh on the trunk. The posterior group includes the tensor fasciae latae and gluteus medius, which abduct the thigh; the gluteus maximus, which extends the thigh; the gluteus minimus, which internally rotates the thigh; and the six deep outward rotators-the piriformis, superior gemellus, inferior gemellus, obturator internus, obturator externus, and quadratus femoris

bones in the pelvis

The pelvis is a bony ring formed by two innominate bones, the sacrum, and the coccyx. The two innominate bones are each made up of an ilium, ischium, and pubis. The functions of the pelvis are to support the spine and trunk and to transfer their weight to the lower limbs. In addition to providing skeletal support, the pelvis serves as a place of attachment for the trunk and thigh muscles and protection for the pelvic organs. The hip and pelvis form the core for full body movement. The body's center of gravity is just in front of the upper part of the sacrum. Injuries to the hip or pelvis cause the athlete disability in the lower limb or trunk or both.

bones in the thigh

The thigh is generally considered that part of the leg between the hip and the knee. The femur is the longest and strongest bone in the body. It is designed for maximum support and mobility during weight-bearing activity. The proximal head of the femur articulates with the acetabulum of the pelvis to form the hip joint and the distal femoral condyles articulate with the tibia at the knee joint.

preventing injuries to the thigh, hip, groin, and pelvic region

To prevent or at least minimize the chance of injury, it becomes essential to maintain strength and flexibility of those muscles of the hip, thigh, and pelvis. Athletes should concentrate on a dynamic stretching program that focuses on quadriceps, hamstrings, and groin muscles. Muscle strains in any of these muscle groups can have long-term consequences for healing and can prove to be disabling for the athlete. Likewise muscles that are strong will be more resistant to injury, and thus a well-designed strengthening program can also help to minimize injuries. Strengthening exercises should routinely include squats, lunges, and leg presses as well as a variety of core strengthening exercises

slipped capital femoral epiphysis

cause of condition A slipped capital femoral epiphysis is an unusual disorder of the adolescent hip in which the epiphysis (growing end) of the femur slips from the femoral head in a backward direction. This is due to weakness of the growth plate. Most often, it develops during periods of accelerated growth, shortly after the onset of puberty. A slipped capital femoral epiphysis is found mostly in boys between the ages of 10 and 17 who are very tall and thin or are obese. Although the cause is unknown, the slipped capital femoral epiphysis may be related to the effects of a growth hormone. In one-quarter of the cases, both hips are affected. The femoral head or proximal femoral epiphysis slips posterior and inferior relative to the femoral neck or femoral metaphysis signs of condition Symptoms of this condition are similar to those for Legg-Perthes disease. The athlete has a pain in the groin that arises suddenly as a result of trauma or over weeks or months as a result of prolonged stress. In the early stages of this condition, signs may be minimal; however, in its most advanced stage there is hip and knee pain and major limitations on movement together with a limp. care In cases of minor displacement, rest and no weight bearing may prevent further slipping. Major displacement usually requires corrective surgery complications If the placement goes undetected or if surgery fails to restore normal hip mechanics, severe hip problems may occur in later life.

legg-perthes disease (coxa plana)

cause of condition Legg-Perthes disease, or coxa plana, is due to a loss of blood circulation to the articular head of the femur. It occurs in children ages 3 to 12 and in boys more often than in girls. The reason for this condition is not clearly understood. Because of a disruption of circulation to the head of the femur, the articular cartilage dies and becomes flattened. This condition is referred to as avascular necrosis. signs of condition The young athlete commonly complains of pain in the groin that sometimes is referred to the abdomen or knee. Limping is also typical. The condition can have a rapid onset, but more often it comes on slowly over a number of months. Examination may show limited hip movement and pain. care This condition can warrant complete bed rest to reduce the chances of a chronic hip condition. A special brace to avoid direct weight bearing on the hip may have to be worn. If treated in time, the head of the femur will revascularize and regain its original shape. complications If the condition is not treated early enough, the head of the femur will become ill shaped, producing osteoarthritis in later life.

piriformis syndrome

cause of condition The sciatic nerve, which is located either under the piriformis muscle or actually piercing the piriformis muscle itself, is compressed or irritated by tightness or spasm of this muscle. This particular syndrome can often mimic another condition known as sciatica, and is often misdiagnosed as sciatica. signs of condition Compression of the sciatic nerve by the piriformis causes pain, numbness, and tingling in the bum that can extend below the knee and into the foot. The pain may worsen as a result of sitting for a long period of time, climbing stairs, walking, or running. care Generally, treatment for the syndrome begins with stretching exercises and massage. Anti-inflammatory drugs may be prescribed. Cessation of running, bicycling, or similar activities may be advised. A corticosteroid injection near where the piriformis muscle and the sciatic nerve meet may provide temporary relief. In some cases, surgery is recommended.

myositis ossificans

cause of injury A severe blow or repeated blows to the thigh, usually the quadriceps muscle, can cause ectopic bone formation within the muscle, known as myositis ossificans traumatica. signs of injury Myositis ossificans commonly develops following bleeding into the quadriceps muscle. The contusion causes a disruption of muscle fibers, blood vessels, connective tissue, and the periosteum of the femur. Acute inflammation follows resolution of hemorrhage. The irritated tissue may produce tissue formations resembling cartilage or bone. In 2 to 4 weeks, formation of bone may be noted under X-ray examination. If the injury is to a muscle belly, complete absorption or a decrease in size of the formation may occur. This absorption is less likely if calcification is at a muscle origin or insertion. Some formations are completely free of the femur, whereas another may be stalklike and yet another broadly attached care Improper care of a thigh contusion can lead to ossification in muscle. Once myositis ossificans traumatica is apparent, treatment should be extremely conservative. If the condition is painful and restricts motion, the formation may be surgically removed after 1 year with much less likelihood of its return. Too early removal of the formation may cause it to return. Recurrent myositis ossificans may indicate a problem with blood clotting

groin strain

cause of injury Any one of the muscles in the groin region can be injured in sports activity and elicit a groin strain. In addition, overextension of the groin musculature may result in a strain. Running, jumping, and twisting with external rotation can produce such injuries. Groin injuries are very likely to occur in the early part of the season, particularly if an athlete has poor strength and flexibility in these muscles. signs of injury The strain can appear as a sudden twinge or feeling of tearing during a movement, or it may not be noticed until after termination of activity. As is characteristic of most tears, the groin strain also produces pain, weakness, and internal bleeding care If it is detected immediately after it occurs, the strain should be treated by intermittent ice, pressure, and rest for 48 to 72 hours. Rest has been found to be the best treatment for groin strains. Until normal flexibility and strength return, a protective spica bandage should be applied. A groin wrap using an elastic bandage can help support the area. Commercial restraints are also available to protect the injured groin. Note that a pelvic stress fracture may produce groin pain. Any athlete complaining of severe groin pain should be referred for medical attention.

stress fractures of the pelvis

cause of injury As with other stress fractures, pelvic stress fractures can be produced by repetitive abnormal overuse forces. Pelvic stress fractures tend to occur during intensive training or competitive racing. signs of injury Commonly, the athlete complains of groin pain along with an aching sensation in the thigh that increases with activity and decreases with rest. care The athlete complains of pelvic pain following intense exercise. Referral to a physician for a detailed examination with an X-ray is a must. Once this injury is verified, rest is the treatment of choice for 2 to 5 months.

dislocated hip joint

cause of injury Dislocation of the hip joint rarely occurs in sports. The dislocated hip is caused by traumatic force along the long axis of the femur or by the athlete falling on his or her side. Such dislocations are produced when the knee is bent. signs of injury The incomplete dislocation or subluxation presents a picture of a flexed, adducted, and internally rotated thigh. Palpation reveals that the head of the femur has moved to a position posterior to the acetabulum. A hip dislocation causes serious pathology by tearing capsular and ligamentous tissue. A fracture is often associated with this injury, accompanied by possible damage to the sciatic nerve and the nutrient artery, causing avascular necrosis. care Medical attention must be secured immediately after displacement, or muscle contractures may complicate the initial treatment. Immobilization usually consists of 2 weeks of bed rest and the use of a crutch for walking for a month or longer. complications Complication of a posterior hip dislocation is likely. Such complications include muscle paralysis as a result of nerve injury in the area and later development of degeneration of the femoral head.

acute femoral fracture

cause of injury Fractures of the femur most often occur in automobile accidents or in fall from a great height. Fractures are less common in sports because rarely are the forces great enough to actually cause a fracture. In sports, fractures of the femur occur most often in the shaft rather than at the bone ends. A fracture of the shaft most often takes place in the middle third of the bone because of the anatomical curve at this point and because the majority of direct blows are sustained in this area. signs of injury Shock generally accompanies a fracture of the femur as a result of the extreme amount of pathology and pain associated with this injury. Bone displacement is usually present as a result of the great strength of the quadriceps muscle, which causes overriding of the bone fragments. Direct impact produces extensive soft-tissue injury with muscle lacerations, major internal bleeding, and muscle spasms. An acute fractured femur is recognized by these classic signs: • Deformity, with the thigh rotated outward • A shortened thigh, caused by bone displacement • Loss of thigh function • Pain and point tenderness • Swelling of the soft tissues care Immediate emergency assistance and medical referral are necessary to prevent shock and a life threatening situation.

hip sprain

cause of injury Hip sprains may occur as the result of a violent twist, either produced through an impact force delivered by another participant or by forceful contact with another object, or sustained in a situation in which the foot is firmly planted and the trunk is forced in an opposing direction. This mechanism may also cause injury to the knee joint signs of injury A hip sprain displays all the signs of a major acute injury but is best revealed through the athlete's inability to circumduct the thigh. Symptoms are similar to a stress fracture. There is significant pain in the hip region. Hip rotation increases pain. care X-rays should be taken to rule out fracture; PRICE and analgesics are used as needed. Depending on the grade of sprain, weight bearing is restricted. Crutch walking is used for grade 2 and 3 sprains. Range-of-motion and progressive resistance exercises are delayed until the hip is pain free.

hamstring muscle sprains

cause of injury Of all the thigh muscles subject to strain, the hamstring group has the highest incidence of strain. A quick change of the hamstring muscle function from knee stabilization to extension of the hip when running may be a primary cause of this strain. What leads to this muscle failure and deficiency in the complementary action of opposing muscles is not clearly understood. Some possible reasons are muscle fatigue, sciatic nerve irritation, faulty posture, leg-length discrepancy, tight hamstrings, using improper form, and imbalance of strength between hamstring muscle groups. signs of injury Internal bleeding, pain, and immediate loss of function vary according to the degree of trauma. Discoloration may occur 1 or 2 days after injury. care Initially, an ice pack and compression by an elastic wrap should be employed. Activity should be restricted until soreness has been minimized. Ballistic stretching and explosive sprinting should be avoided initially. Strains are always a problem to the athlete; they tend to recur because they sometimes heal with inelastic fibrous scar tissue. The higher the incidence of strains at a particular muscle site, the greater the amount of scar tissue and the greater the likelihood of further injury.

osteitis pubis

cause of injury Since the popularity of distance running has increased, a condition known as osteitis pubis has become more prevalent. It also occurs in soccer, football, and wrestling. Repetitive stress on the pubic symphysis and adjacent bony structures by the pull of muscles in the area creates a chronic inflammatory condition. signs of injury The athlete has pain in the groin region and in the bony projection under the pubic hair called the symphysis pubis. There is point tenderness on the pubic tubercle and pain when movements such as running, sit-ups, and squats are performed. The pubic bones should be symmetrical from one side to the other. care Follow-up care usually consists of rest and an oral anti-inflammatory agent. A return to activity should be gradual

acute fracture of the pelvis

cause of injury The acute pelvic fracture usually occurs as the result of a direct trauma. signs of injury The athlete responds to this injury with severe pain, loss of function, and shock. care If a pelvic fracture is suspected, the athlete should be immediately treated for shock and referred to a physician. The seriousness of this injury depends on the extent of shock and the possibility of internal injury.

iliac crest contusion (hip pointer)

cause of injury The hip pointer results from a blow to the inadequately protected iliac crest. The hip pointer is one of the most handicapping injuries in sports. A direct impact to the unprotected iliac crest causes a severe pinching action to the soft tissue of that region. signs of injury The hip pointer produces immediate pain, muscle guarding, and transitory paralysis of the soft structures. As a result, the athlete is unable to rotate the trunk or to flex the thigh without pain. care Cold and pressure should be applied immediately after injury and should be maintained intermittently for at least 48 hours. In severe cases, bed rest for 1 to 2 days will speed recovery. Referral to a physician must be made and an X-ray examination given. When the athlete returns to play, a protective pad should be used to minimize the chances of additional injury. Protection is the key to recovery.

quadriceps contusions

cause of injury The quadriceps group is continually exposed to traumatic blows in a variety of sports. Contusions of the quadriceps display all the classic symptoms of most muscle bruises. signs of injury Quadriceps contusions usually develop as the result of a severe impact on the relaxed thigh, compressing the muscle against the hard surface of the femur. At the instant of trauma, pain, a temporary loss of function, and the immediate bleeding of the affected muscles usually occur. The extent of the force and the degree of thigh relaxation determine the depth of the injury and the amount of structural and functional disruption that take place. care Immediate action includes compression by elastic bandage with the knee flexed to 120 degrees to minimize the loss in range of motion for the first 12 hours. This places the quadriceps in a stretched position and also helps to compress the injured area. The application of a cold medium can help control superficial hemorrhage. The thigh contusion should be handled conservatively, with PRICE followed by a very gentle static stretch and crutch walking when a limp is present.

quadriceps muscle sprain

cause of injury The rectus femoris muscle of the quadriceps muscle group occasionally becomes strained by a sudden stretch (e.g., falling on a bent knee) or a sudden contraction (e.g., jumping in volleyball or kicking in soccer). Usually, this muscle strain is associated with a muscle that is weakened or overly constricted. A tear in the region of the rectus femoris may cause partial or complete disruption of muscle fibers. The incomplete tear may be located centrally within the muscle or more peripherally to the muscle. signs of injury A peripheral quadriceps rectus femoris tear causes fewer symptoms than the deeper tear. In general, there is less point tenderness and little bleeding. A more centered partial muscle tear causes more pain and discomfort than does the peripheral tear. The deep tear causes a great deal of pain, point tenderness, spasm, and loss of function, but little discoloration from internal bleeding. In contrast, complete muscle tear of the rectus femoris may leave the athlete with little disability and discomfort but with some deformity of the anterior thigh. care On-site care of the quadriceps strain includes rest, cold application, and pressure to control internal bleeding. The extent of the year should be ascertained as soon as possible before swelling masks the extent of injury. To stabilize the muscle, consider having the athlete wear a neoprene sleeve as healing occurs

hip labral tear

cause of injury The socket of the hip joint (acetabulum) is lined by articular cartilage called the labrum. This cartilage provides stability and cushioning for the hip joint, permitting the head of the femur to move smoothly and painlessly in the acetabulum. A hip labral tear most often results from repetitive movements such as running or pivoting of the hip that cause degeneration and breakdown of the labrum. It may also be caused by an acute injury such as a dislocation. signs of injury Most commonly a hip labral tear can be asymptomatic. Occasionally, however, a hip labral tear may cause a catching, locking or clicking sensation in the hip joint; pain in the hip or groin; and a feeling of stiffness or limited motion. care Treatment for a hip labral tear may consist of exercises to maximize hip range of motion, hip strengthening and stability exercises, and avoiding movements that place stress on the hip joint. Pain medications may also help, and a physician may choose to inject a corticosteroid. If pain persists more than 4 weeks, surgery may be indicated to either remove a piece of the torn labrum or to repair the tear using sutures.

muscles of the thigh, hip, and groin: hip medial rotation

gluteus minimus

assessing thigh, hip, groin, and pelvis injuries: observations

• The athlete should be observed for postural asymmetry while standing on one leg and during ambulation. • From the front view, do the hips look even? • From the side view, is the pelvis abnormally tilted anteriorly or posteriorly? • The patella should also be noted for relative position and alignment. • Does standing on one leg produce pain in the hip? • The athlete should be observed during walking, bending, and sitting. Pain in the hip and pelvic region is normally reflected in movement distortions.

assessing thigh, hip, groin, and pelvis injuries: history

• What mechanism do you think caused this injury to occur? • When did you first notice this pain? • Did the pain begin immediately, or did it occur gradually over a period of time? • Have you ever had a problem in the area before? • Has training intensity changed or increased recently? • Where is the pain located? • Describe the type of pain you have (e.g., sharp, dull, burning, aching). • Does the pain radiate down the back or front of the legs or buttocks? • When is the pain the worst (e.g., during activity, at rest, at night)?