EDUCATIONAL OBJECTIVES

The learner should, at the completion of the chapter, be able to perform the following:

• Understand the anatomy of the hip and pelvis.
• Recognize the components of an injury evaluation format.
• Identify the common injuries associated with the hip and pelvis.
• Identify the protocol for a rehabilitation program to the hip and pelvis.
• Understand the preventive/supportive techniques and protective devices for the hip and pelvis.
• Review musculoskeletal conditions/disorders for the hip and pelvis.

The arrangement of bones, ligaments, muscles, and tendons make the hip the strongest joint in the body. The hip joint is a ball and socket joint. It is formed by the spherical head of the femur fitting into the deep socket of the hip. There are three parts of the hip: ilium, ischium and pubis. The hip and two sets of fused vertebrae (sacrum and coccyx) make up the pelvis. Attached to the pelvis are groin and torso muscles that are involved in supporting and moving the trunk, upper and lower extremities. These hip and pelvis bones are supported by these ligaments: ligamentum teres, transverse acetabular, iliofemoral, pubofemoral, and inguinal. The bones of the hip and pelvic region provide the structure to transfer weight between the torso and the lower extremities.

There are a number of important muscle groups that are located at the hip and pelvic region. The largest muscle group includes the gluteal muscles. The gluteus medius, gluteus minimus, and the gluteus maximus assist in hip extension, internal and external rotation, and abduction. Muscles that assist in hip flexion are the iliopsoas, sartorius, pectineus, and rectus femoris. Hip adduction is performed by the group of muscles known as the adductors. The hip adductor group is composed of the adductor longus, adductor brevis, and adductor magnus. The muscle groups that compose the bulk of the thigh (quadriceps and hamstrings) also assist in the movement of the hip. Those movements are hip flexion and hip extension, respectively.

This area of the body is innervated by a number of different nerves. The sensory distribution of a nerve root is called a dermatome, which produces feeling in a certain anatomical area. The motor distribution of a group of muscles innervated by a single nerve root is called a mytome and it produces movement of anatomical structures. Additional anatomical structures frequently injured are fat pads and bursi. Fat pads are specialized soft tissue structure for weight bearing and absorbing impact, whereas synovial sac generally located over bony prominences throughout the body are called bursi.

HIP AND PELVIS ANATOMY

Bones

1. Femur
2. Pelvis (Ilium, Ischium, Pubis)
3. Sacrum (5 fused vertebrae)
4. Coccyx (4 fused vertebrae)

1. Ligamentum teres
2. Transverse acetabular
3. Iliofemoral
4. Pubofemoral
5. Inguinal

Sagittal Plane: bisecting body into right and left halves
Frontal Plane: bisecting the body into front and back halves
Transverse Plane: bisecting body into upper and lower halves

Range of Motion - HIP

Adduction: moving leg toward midline in frontal plane
Abduction: moving leg away from midline of body in frontal plane
Flexion: decreasing angle between anterior thigh and abdomen through the sagittal plane
Extension: increasing angle between anterior thigh and abdomen through the sagittal plane
Internal Rotation: rotation of femur toward midline
External Rotation: rotation of femur away from midline

Range of Motion - TORSO

Flexion: moving the torso forward through the sagittal plane
Extension: moving the torso backward through the sagittal plane
Lateral Flexion: moving the torso laterally (side to side) in the frontal plane
Rotation: rotating the torso in the transverse plane

Muscles and Functions

1. Gluteus Maximus: extension and adduction of hip
2. Gluteus Medius: abduction and internal rotation of hip
3. Gluteus Minimus: abduction and internal rotation of hip
4. Tensor Fascia Latea: flexion and internal rotation of hip
5. Iliacus: flexion of hip
6. Psoas Major: flexes hip, flexes vertebral column
7. Sartorius: flexion and rotation of hip & knee
8. Pectineus: adduction and flexion of hip
9. Adductor Longus: adduction and flexion of hip
10. Adductor Brevis: adduction and flexion of hip
11. Adductor Magnus: adduction and flexion of hip
12. Gracilis: adduction of hip and flexion of knee
13. Piriformis: lateral rotator
14. Obturator Internus/Externus: lateral rotator
15. Gamellus Superior/Inferior: lateral rotator
16. Quadratus Femoris: lateral rotator
17. Biceps femoris: flexion of knee and lateral rotation of leg
18. Semimembranosus: flexion of the knee, medial rotation of leg
19. Semitendinosus: flexion of the knee, medial rotation of the leg
20. Rectus Femoris: extension of knee, flexion of hip
21. Vastus Medialis: extension of knee
22. Vastus Lateralis: extension of knee
23. Vastus Intermedius: extension of knee

L1 - inguinal region
L2 - inguinal region: upper two thirds of anterior thigh (quadriceps) and lateral hamstring
L3 - upper two thirds of the anterior thigh (quadriceps) and medial hamstring
L4 - anteriomedial aspect of lower leg and rear 1/3 of foot
L5 - anteriolateral and posterior aspect of lower leg and dorsum of foot
S1 - phalanges and plantar aspect of foot
S2 - proximal 1/3 of posterior aspect of lower leg

Myotomes

L2 - Hip Flexion
L3 - Knee Extension
L4 - Dorsiflexion of ankle
L5 - Extensor Halluces Longus - toe extension
S1 - Plantar flexion of ankle or Hamstring Curl, foot eversion, hip extension
S2 - Dorsiflexion of foot

When determining strength of myotomes, provide resistive force.

EVALUATION FORMAT

The first purpose of an evaluation is to determine if a serious injury has occurred. The evaluation format of History, Observation, Palpation and Special Tests are thoroughly covered in Chapter 2 and Chapter 6. Listed below is an abbreviated version of this format.

History: Questions should include mechanism of injury, location of pain, sensations experienced, and previous injury.

Observation: Compare the uninjured to the injured hip, pelvis, and extremity and look for bleeding, deformity, swelling, discoloration, scars, and other signs of trauma.

Palpation: Using bilateral comparison, palpate neurological, circulatory, and anatomical structures, and assess for potential fractures.

Special Tests: Special tests assess disability to integrity of ligament, muscle, tendon, accessory anatomical structures, inflammatory conditions, range of motion, and pain or weakness in affected area.

ASSESSMENT TESTS

All injured joints should be properly evaluated. The purpose of a thorough evaluation is to enable the allied health professional to properly assess the severity of the injury and to make recommendations regarding treatment and possible return to participation. Listed below is a review of evaluation techniques for the hip and pelvis.

Tests for Bony Integrity

Compression Test - Anterior/Posterior force: assess fracture to pelvis
Compression Test - Lateral /Medial force: assess fracture to pelvis

Tests for Muscle Function

Knee Extension: test focusing on quadriceps muscles group with special emphasis on rectus femoris muscle
Hip Flexion: test focusing on rectus femoris and iliospsoas muscles
Hip Extension: test focusing on hamstrings and gluteus maximus muscles
Hip Adduction: test focusing on adductor muscles
Hip Abduction: test focusing on abductors muscles

Tests for Flexibility

Hip Flexor Stretch: determines the flexibility of the hip flexors
Quadricep Stretch: determines the flexibility of the quadriceps
Hamstring Stretch: determines the flexibility of the hamstrings muscle group
Low Back Flexion Stretches: determines the flexibility of the posterior muscles (extensors) of the spine
Low Back Extension Stretches: determines the flexibility of the anterior muscles (flexors) of the spine

CONDITIONS THAT INDICATE AN ATHLETE SHOULD BE REFERRED FOR PHYSICIAN EVALUATION

• Gross deformity
• Significant pain
• Increased swelling
• Circulation or neurological impairment
• Joint instability
• Suspected fracture or dislocation
• Persistent pain in hip and pelvis area
• Noticeable and palpable deficit in the muscle or tendon
• Abnormal sensations such as clicking, popping, grating, or weakness
• Any doubt regarding the severity or nature of the injury

Injury to the coccyx: The four fused vertebrae on the lower end of the spine are called the coccyx, or tail bone. Often, this area is bruised from falling on a hard surface. Most injuries to the coccyx will be contusions, although severe trauma could cause a dislocation or fracture. Contusions are treated with the basic treatment of protection, rest, ice, compression, elevation and support.

Hip Strains: Hip strains commonly occur when the joint has received violent twisting motions of the torso accompanied by the feet being fixed in a stationary position. When evaluating hip strains, have the athlete perform various range of movement (flexion, extension, adduction, adduction, circumduction) exercises. Application of basic treatment and use of compression girdles or elastics wrap will aid in support. If chronic pain exists referral to a physician is recommended.

Trochanteric Bursitis: Trochanteric bursitis occurs at the bursae sac at the gluteus medius/iliotibial band insertion at greater trochanter. Running technique should be examined as well as running on level and soft surfaces. If the condition is chronic, the application of heat to the area will help to reduce the chronic irritation.

Trauma to the genitalia: Injuries to the male genitalia are common, resulting from a direct blow or testicular torsion, which causes excruciating pain and temporary disability. A contusion to the testes will produce the same physiological tissue reaction as contusions to other body parts. There is hemorrhaging, fluid effusion, and muscle spasm. Although less common, female athletes can suffer trauma to the reproductive system. One method to relieve this spasm is to have the athlete lie on the ground and to flex their thighs to their chest. Additionally, have the athlete loosen the clothing area. First aid treatment should include reducing the spasm, applying a cold pack to the affected area and referrel to a physician for medical evaluation.

Hip Pointer: Some of the muscles that control trunk movement attach to the iliac crest.

Due to limited natural protection, injuries to the illiac crest result from direct blow, (contusion) and can disable an athlete. If the force is severe, the muscles that attach at the crest of the ilium are bruised and the injury is called a hip pointer. With all hip pointers, there is immediate pain and swelling may or may not be present. Any movement requiring involvement of the trunk and extremities will result in more pain and discomfort. Extreme caution should be taken when treating this injury. Basic treatment of protection, bed rest, ice, compression, elevation, support, and medical re-evaluation should be incorporated.

Hip Dislocation: A hip dislocation is a dangerous condition that should only be handled by emergency medical personnel. In most cases, the athlete will be lying on his or her back with the injured extremity flexed and externally rotated. These injuries are usually caused by abnormal stress and the joint will be dislocated either anteriorly or posteriorly. Never attempt to reduce such a dislocation. Nerves and blood vessels could become permanently damaged by the head of the femur. An athlete who has suffered this suspected injury must be handled and transported by qualified medical personnel.

REHABILITATION

Sending an athlete back to competition before healing is complete leaves the player susceptible to further injury. The best way to determine when healing is complete is by the absence of pain during stressful activity and by the return of pain free full range of motion and strength. Before returning to competition, the following rehabilitation guidelines must be met:

• Full range of motion
• Strength, power and endurance are proportional to the athlete's size and sport
• No pain during running, jumping, or cutting

Range of Motion Exercises

Hip        Adduction
              Abduction
              Flexion
              Extension
              Internal Rotation
              External Rotation
              Circumduction

Torso    Flexion
              Extension
              Lateral Flexion
              Rotation

Resistance/Strengthening Exercises: Hip and Pelvis

• Range-of-Motion Exercises
• Resistance Exercises
• Cardiovascular/Fitness Activities (walking, stair climbing, running, swimming, cycling, etc)
• Sport Specific Activities (jumping, figure of eights, cutting, jumping rope, etc.)

An outline of basic taping and wrapping techniques utilized to support the hip and opelvic is listed below.

Wrapping Techniques for Support

Hamstrings
Quadriceps
Hip Flexor
Hip Adductor

Hip Pointer
Low Back
Rib/Torso

An outline of potential protectives devices that can be utilized to protect the hip and pelvis is listed below. The use of protective devices is beneficial. Consultation with an equipment specialist and certified athletic trainer is highly encouraged.

• Sport Specific Pads (football, hockey, etc.)
• Athletic Supporter with Cup
• Sports Compression Girdle

Listed below are musculoskeletal conditions/disorders that affect the hip and pelvis. A valuable learning experience would be to define and review these conditions using a medical dictionary.

• Contusion of the Thigh

• Fracture (pelvis or femur)

• Iliotibial Band Syndrome

• Osteitis Pubis

• Piriformis Syndrome

• Sprain

• Tendinitis

Anderson M. and Hall S. (1995) Sports Injury Management Baltimore: Williams and Wilkins.

Booher, J. & Thibodeau, G. (1994). Athletic Injury Assessment. St. Louis: Times Mirror/Mosby College.

Cailliet, R. (1997) Soft Tissue Pain and Disability. Philadelphia: F.A. Davis.

Donnelly, J. (1990) Living Anatomy Champaign, Human Kinetics

Gallaspy J. and May D. (1995) Signs and Symptoms of Athletic Injuries St. Louis: Mosby.

Gould, J. (1990) Orthopaedic and Sports Physical Therapy. St. Louis: Mosby

Hoppenfield, S. (1976) Physical Examination of the Spine and Extremities New York: Appleton, Century, and Crofts.

Mellion, M., Walsh, W. & Shelton, G. (1992) The Team Physician's Handbook. Philadelphia: Hanley & Belfus.

Miller, R. & Dunn, R. (1979) Athletic Training Techniques. Bowling Green, KY: WKU Press.

Prentice, W. (1994) Rehabiliation Techniques in Sports Medicine. St. Louis: Mosby.

Stone R. & Stone J. (1997) Atlas of Skeletal Muscles (2^nd ed.) Dubuque: McGraw Hill.

Williams, P. & Warwick, R. (1980) Gray's Anatomy (36^th ed.) Philadelphia: W.B. Saunders.

Wright K. & Whitehill W. (1996) The Comprehensive Manual of Taping and Wrapping Techniques Gardner: Cramer Products

Wright K. & Whitehill W. (1997) Sports Medicine Taping Series: Wrapping Techniques for Support and Compression Dubuque, : McGraw Hill.

Completion:

1. When conducting compression tests to the hip joint, apply these forces: __________/__________ and __________/__________.

2. The hip joint is formed by the spherical head of the __________ fitting into the deep __________ of the hip.

3. The __________ joint is the strongest in the body.

Short Answer:

1. What type of joint is the hip?

2. What are the signs of a fracture?

3. Why should you never attempt to reduce a dislocation of the hip?

4. What is the best way to determine when healing is complete?

5. What are the exercises used in prevention/rehabilitation of a hip injury?

6. What are the forms of preventive/supportive wrapping techniques for the hip and pelvis?

7. Explain why the hip joint is the strongest in the body.

8. What muscles are most often injured in a groin strain?

9. What rehabilitation exercises may be done to return an athlete who has suffered a thigh or hip injury back to full sports participation?

Textbook Source: Wright K. & Whitehill W. (1996) The Comprehensive Manual of Taping and Wrapping Techniques Gardner: Cramer Products

HIP FLEXOR WRAP

Purpose: To provide support to the hip flexor.

General Condition Procedure Used for: Strain to the hip flexors.

Anatomical Structure: Hip and thigh.

Anatomical Position: Ask the athlete to stand with the affected extremity placed in hip flexion and the foot in slight, internal rotation. A continuous strip of elastic wrap is applied in a hip spica method, abducting the thigh.

Supplies Needed: 6" extra long elastic wrap, and 1 1/2" adhesive tape

Pre-Wrapping Procedure: Instruct the athlete to contract the muscles around the hip joint.

Wrapping Procedures:

1. Begin the wrap at the proximal end of the thigh. From the anterior surface, angle diagonally to the distal lateral aspect of the quadriceps. Above the knee, begin an upward spiral supportive procedure with the wrap. Overlap each layer by one-half its width.

2. At the proximal end of the thigh, continue the wrap around the waist, pulling to the lateral and posterior aspect.

3. Once the waist has been encircled, continue the wrap around the thigh two to three times.

4. At this point, continue the wrap around the waist. This upward and outward pull should assist in hip flexion and limit hip extension. End the wrap on the thigh. Secure the wrap in place by applying an anchor strip of 1-1/2" adhesive tape.

HIP ADDUCTOR WRAP

Purpose: To provide support to the hip adductors.

General Condition Procedure Used For: Strain to the hip adductors.

Anatomical Structure: Hip and thigh.

Anatomical Position: The athlete should stand with the affected extremity placed in hip flexion and the foot in slight internal rotation. A continuous strip of elastic wrap is applied in a hip spica method, adducting the thigh.

Supplies Needed: 6" extra long elastic wrap, and 1 1/2" adhesive tape

Pre-Wrapping Procedure: Instruct the athlete to contract the muscles around the hip joint.

Wrapping Procedures:

1. Begin the wrap at the proximal end of the thigh. From the anterior surface, angle diagonally to the distal medial aspect of the quadriceps. Above the knee, begin an upward spiral supportive procedure with the wrap. Overlap each layer by one-half its width.

2. At the proximal end of the thigh, continue the wrap around the waist, pull across the abdomen, to the lateral aspect, and then to the posterior aspect. This upward and anterior pull should assist in hip adduction and limit hip abduction.

3. Once the waist has been encircled, continue the wrap downward and around the quadriceps muscle group two to three times.

4. At this point, pull the wrap around the waist, crossing the abdomen, lateral, and posterior aspects. End the wrap on the thigh. Secure the wrap in place by applying an anchor strip of 1-1/2" adhesive tape.