Injuries to the Hip and Pelvis

Injuries to the Hip and PelvisWe will discuss a basic overview of the anatomy in the region of the hip and pelvisWe will have a brief description of movements by the joints and actions of the musculature in the areaWe will target more common hip and pelvis injuries incurred in sports and outlines emergency proceduresWe will also talk about injuries that arent common in sportsThe chapter reviews injuries to the male genitalia, including both testicular contusion and torsionIt also covers hernia and nerve problems and discusses proper referral http://www.youtube.com/watch?v=7VpS0T_kt2whttp://www.nbcolympics.com/video/gracie-gold-confident-after-outstanding-performance-team-event?ctx=olympic-journey

Anatomy ReviewThe hip and pelvis form a square in the way they are constructedThis area comprises the two large, irregularly shaped pelvic bones on the lateral sides, the sacrum and coccyx posteriorly, and the articulation of the pubic bones anteriorly

Anatomy ReviewThe pelvic bones are also known as the innominate bones and are made up three distinct parts:The iliumThe ischiumAnd pubis

Anatomy ReviewIn the adult, the three parts are fused and come together at a lateral point called the acetabulum, which is where the head of the femur articulates with the hip to form the hip joint

Anatomy ReviewThe bony pelvis has several functions in the body:The lower extremities attach hereMuscle attachments are prevalentIt provides substantial protection for the entire pelvic regionAnatomy ReviewThe major articulations of the bony pelvis include the hip joint, the sacroiliac joints, and the symphysis pubisThe hip joint is the articulation of the head of the femur and the acetabulum in the hip bone; it is a true ball-and-socket joint that is well supported by strong ligaments Anatomy ReviewThe sacroiliac joints are formed by the sacral bones and the iliac portion of the hip bonesThe symphysis pubis is formed by the two pubic bones meeting in anterior portion of the bony pelvisAll of these joints have strong ligamentous support that assist in joint stabilityAnatomy ReviewSeveral nerves and blood vessels course through the bony pelvisSome of the more important nerves that course down the lower extremity are subdivisions of the make up of the cauda equina

Anatomy ReviewThe spinal cord ends at L2 level, and the cauda equina exits the spinal cord beginning at L2 and proceeding inferiorly (Gray, 1974)Nerves exiting the spinal cord below the L1 level typically pass through the bony pelvis

Anatomy ReviewThese nerves include the formation of the lumbar plexus, the sacral plexus, the coccygeal plexus and other individual nervesProbably the most well known of these is the sciatic nerve, which is the largest in the body and is made up of nerve roots L4 S3

Anatomy ReviewThe sciatic nerve passes through the posterior portion of the bony pelvis and down the posterior aspect of the legThe blood vessels of the area include both arteries and veins that supply the pelvis and lower extremitiesThe more well known of these vessels include the iliac artery and vein

Anatomy ReviewMany of the muscles that attach to the bony pelvis are ones that move the lower extremitiesThe smaller muscles consist of the medial and lateral rotators of the femurSome of the medial rotators include the tensor fasciae latae and gluetus minimusThese muscles are quite active in many movements of the lower extremity

Anatomy ReviewThe lateral rotators of the hip are small muscles located deep within the hip area that are also quite active in many movements of the lower extremitySome of those muscles more commonly injured include the piriformisWhich attaches to the anterior surface of the sacrum and to the greater trochanter of the femur

Anatomy ReviewThe piriformis is a lateral rotator of the thigh; the sciatic nerve runs directly beneath the piriformis and can be irritated by the overuse of this muscle

Anatomy ReviewOther external rotators of the thigh include the gemelli (superior and inferior), which attach on the ischium and run to the greater trochanter of the femur

Anatomy ReviewAll of these muscles are small in comparison with the surrounding muscles, but they play an important part in the proper functioning of the hip and legMany muscles attach on the pelvis and provide musculature for the leg, back, and abdomenThese muscles responsible for many of the large movements at the hip joint include flexors, extensors, adductors, and abductorsAnatomy ReviewThe main hip flexors include the rectus femoris, the iliopsoas group, the tensor fasciae latae, and the sartoriusThe rectus femoris attaches at the ASIS and runs down the front of the leg to the common attachment of the quadriceps group at the patellar tendon

Anatomy ReviewThe iliopsoas group is a combination of the iliacus and psoas muscles, which attach on the anterior lumbar spine and iliac crest and come together as they run down to the lesser trochanter of the femur

Anatomy ReviewThe tensor fasciae latae and sartorius attach on the anterior iliac spineThe tensor fasciae latae runs to the lateraly condyle of the tibia, whereas the sartoris runs across the anterior thigh and attaches to the anterior medial aspect of the tibiaThe sartorius becomes one of the muscles of the pes anserinus group

Anatomy ReviewThe main muscles of hip extension are the gluteals and the hamstringsThe gluteus maximus is the main hip extensor of the glutealsAttaches on the posterior surface of the ilium and runs inferiorly to the femur

Anatomy ReviewThe hamstrings attach mainly on the ischial tuberosity; then, two of the muscles, the semitendinosus and semimembranosus, run more medially on the posterior leg and attach near the sartorius and on the posterior/medial condyle of the tibiaThe biceps femoris runs more laterally on the posterior leg and attaches to the lateral aspect of the tibia and head of the fibula

Anatomy ReviewThe muscles that adduct the hip are located on the medial portion of the leg are commonly called the groin areaMain muscles included in this group are the three adductors (brevis, longus, magnus) as well as the pectineus and gracilis

Anatomy ReviewThe adductors attach on the pubis and run to the femurThe pectineus also attaches at the pubis and runs to the femurThe gracilis attaches on the inferior portion of the pubis and runs medially down the leg to the anterior medial portion of the tibiaAnatomy ReviewThe sartoris, gracilis and the semitendinosus compose the pes anserinus groupSay grace before teaHow to remember them in orderhttp://www.youtube.com/watch?v=PHttidEwqz8

(MMG, 2008)

Common Sports InjuriesThe hip and pelvic regions are well designed anatomicallySports-related injuries to the skeletal structures of the hip and pelvis are not commonInjuries to the soft tissues in the region are more common and can be quite debilitating to the athleteInjuries commonly involve collision sports or forceful movements pursuant to an activity that requires power and speed of the lower extremitiesOveruse injuries may also be associated wit hthe hip and pelvisSkeletal InjuriesFX of the PelvisOne of the most devastating injuries to the pelvic region is the fracture of one of the pelvic bonesTypically, a great deal of force is necessary to cause a fracture of this typeThis is not a common injury related to sports participationStill, it can occur in sports such as hockey, pole-vaulting, or football in which there is the possibility of direct compression from another athlete, a fall from a height, or being twisted and hit by another player

Skeletal InjuriesFX of the PelvisSkeletal injuries to the pelvis in the adolescent population can be extremely serious, especially if the injury involves an open epiphysisAny suspected skeletal injury to this area should be referred to a physician as quickly as possible

Skeletal InjuriesFX of the PelvisS&S:Abdominal pain in the pelvic region after the injuryThere might be swelling at the site, with the rare occurrence of a visual or palpable deformity at the injuryPain is elicited when the iliac crests are pressed togetherAssociated injuries to internal organs such as the bladder are possible and should be ruled outTX:Treat for possible shock and internal bleedingMonitor the athletes vital signs regularlyTransport the athlete to the hospital on a long spine board with the foot of the board elevated to eliminate pooling of blood in the lower extremitiesSkeletal InjuriesFX of the pelvisA fracture of the pelvis is a serious injury and should be evaluated by a physician ASAPTreatment depends on the severity of the injury and should be complete before the athlete returns to practice or competitionUnder NO circumstances should an athlete with a suspected FX of the pelvis return to competition before seeing a physicianFemoral Neck Stress FractureThis injury occurs more commonly in the thin amenorrhea athlete involved in running or an endurance sportThe femoral neck stress fracture is a result of a loss in shock-absorbing capacity of the fatigued muscles in the hip area

Femoral Neck Stress FractureThis problem can also be a partial result of poor footwear, hard running surface, or hip deformities (Lacroix, 2000)Typically, athletes c/o severe anterior thigh or groin pain when they have a possible femoral neck stress fractureThe athlete will be able to walk but will experience pain during ambulationSeeing a physician is necessary to get radiographs

Slipped Capital Femoral EpiphysisThis problem occurs most commonly in 10 to 15 year old boysTypically, it occurs in boys who are tall and have recently experienced a rapid growth period, or in boys who are overweightThe boy exhibits a flexed hip, thigh or kneeAny child younger than the age of 12 who complains of knee pain should have a thorough hip evaluation by the physician to r/o any one of a number of hip pathologies that may exist in this populationHip PointerProbably the most common injury to the region is a contusion to the superior/anterior portion of the iliac crest, which is commonly referred to as a hip pointerTypically, with this injury the athlete receives a direct blow to the area from an opponents helmet or falls to the ground with great forceHip PointerThis can be an extremely painful and debilitating injury for the athlete, but it is not one that requires emergency attention or causes major complications if further activity is necessary

Hip PointerS&S:Swelling at the site of injuryDiscoloration at the site of injuryPain and discomfort at the site of injuryThe athlete may walk with a slight limp on the affected sideCoughing, sneezing, and laughing may also produce pain at the site of injuryTX:Immediately apply ice to the injured areaHave the athlete rest and avoid activity that involves the lower extremitiesIf the injury is severe, walking with crutches may be necessary for a few daysHip PointerLong-term care for this type of injury is rather simpleThe contusion has in most cases caused minimal damage to an area where several muscles attach directly to bone tissueThe muscular attachments in the abdominal region are the cause of pain when the athlete coughs, sneezes, or laughsThe player will usually be able to participate on a limited basis within 1 to 2 weeks, depending on the severityHip PointerIt is important to note that if an athlete wishes to continue participation in sports while recovering from a hip pointer, the area should be padded well so that further damage can not occur if a similar incident happens before recovery is completeOther Hip ProblemsAthletes who participate in excessive running as a part of their sport can experience what is known as snapping hip syndromeSnapping hip syndrome is a sensation that occurs when the athlete moves the hip in a specific directionUsually, there is little if any pain associated with snapping hipThis problem is attributed to one of the muscles in the lateral hip riding over the top of the greater trochanter of the femurOther Hip ProblemsThe structures that could be involved include the iliotibial band, tensor fascia lata, and the gluteus mediusThere could be subluxation of the hip or labral tears that induce extra movement of the femur during locomotionTypically, treatment consist of stretching tightened muscles that may contribute to the snapping sensation and correcting any biomechanical deviations of the areaAnti-inflammatory medications may helpOther Hip ProblemsTrochanteric bursitis is another rare problem experienced by some athletesIt is a problem seen most often in middle-aged people, but athletes, especially runners, are becoming more prone to trochanteric bursitisThis bursitis is usually a result of either acute trauma to the specific area or repeated microtrauma to the tendon attachments with secondary inflammation of the bursae in the areaOther Hip Problems..The iliotibial band can be a source of the problem if it is tight and the athlete continues to run when he/she is experiencing S&S of trochanteric bursitisWhen an athlete is experiencing the onset of trochanteric bursitis, he/she will initially c/o pain over the greater trochanter followed by pain radiating down the anterior/lateral thigh to the buttock regionOther Hip Problems..Most athletes benefit from stretching the iliotibial band and the low back area in the proximity of the sacroiliac joints, and taking an NSAIDFor some athletes, it may be necessary to pad the area if there is a chance of external trauma such as falling or being hit by another athlete in the hipOn rare occurrences, athletes do not respond to conservative treatment and benefit from surgical managementhttp://www.youtube.com/watch?v=ZDBLdEpsvvk

Osteitis PubisAnother type of skeletal injury to the pelvic area is osteitis pubis, a condition resulting from continued stress and possibly some degeneration in the symphsis pubis jointThis injury is commonly a result of overuse and chronic strain on the jointLong-distance runners, basketball and soccer players, and other athletes who experience repetitive pelvic movements in sports may c/o this conditionOsteitis PubisAthletes who produce repetitive shearing forces of the pelvis and have increased stresses on the lower abdominal structures during their sport participation are more susceptible to this problemOsteitis pubis is a difficult injury to diagnose because the many muscles and structures in the pelvic area, resulting in a delayed diagnosis or a non-diagnosed problemOsteitis PubisS&Sc/o an insidious onset of pain that worsens progressivelyMay indicate that the pain is in the groin areaTX:Should be referred to the appropriate doctor for complete evaluationBecause this is a chronic problem, first aid is typically not necessaryAthlete may benefit from RICESOsteitis PubisThe athlete typically responds well to therapy, with very few if any long-term side effectsAn athlete may take anywhere from 3 months to a year to return to preinjury functioning levels

Injury of the Sacroiliac JointThe sacroiliac (SI) joint, which is the articulation between the sacrum and pelvis, is a common site of pain in the posterior aspect of the pelvis Movement of this joint is limited because of the configuration of the bones and numerous ligaments

Injury of the Sacroiliac JointThis joint can present problems for the athlete if it becomes completely immobile or if it becomes inflamed from an injury or other problemInjuries resulting in an immobile SI joint require specific movement techniques by a trained professional to restore the normal motion in the jointProblems with inflammation in the SI joint can be treated by a certified athletic trainer or physical therapist under the direction of a physicianHip DislocationInfinitely more serious is a hip dislocationThis injury is actually quite rare in athletic events; however, it may occur to an athlete participating in contact sportsIf a violent collision occurs between two players or between a player and another object (for example, the boards surrounding a hockey rink), this type of injury can happenTypically, when the injury occurs the hip joint is in flexion, and the force is applied through the femurMost often the hip dislocates posteriorly, and the athlete experiences extreme pain and loss of movement in the affected extremityHip DislocationS&S:Abnormal pain at the site of injurySwelling at the site of injury, with a palpable defectKnee of the involved extremity is angled toward the opposite legThis injury is typically quite visible to the observerTX:Treat for possible shockImmobilize the athlete and transport to the nearest medical centerCare should be given to monitor blood flow to the leg at all timesSoft-tissue InjuriesBecause of the size and functions of the musculature in the hip and pelvic region, soft-tissue injures are not very common in sportThe ligamentous support of the hip, sacrum, and other structures in the area is very strong; as a result, sprains rarely occur herehowever, several muscles attach in the area of the pelvis, including the musculature on both the anterior and posterior aspects of the thigh, and these are subject to avulsionAvulsion FracturesThe possibility of muscle avulsions during forceful activity always existsSkeletally immature athletes are more prone to avulsion fractures around the hip because their tendons are stronger than their cartilaginous growth centersThe MOI is a sudden near maximal muscle contractionThis results in the tendon pulling off a piece of bone at the attachment siteAvulsion FractureIn a skeletally mature adult, this action usually results in a torn muscle or tendon because the bone is stronger than the tendonIn the adolescent, the tendon is stronger than the bone, so the result is an avulsion fracture

Avulsion FractureAvulsion fractures occur more commonly in adolescents who participate in sports requiring short bursts of maximal muscle contraction, such as soccer, tennis, sprinting, or jumpingThe injured athlete will c/o severe localized pain and ecchymosis at the site of injury

Avulsion FractureCommon sites of injury in adolescents are ASIS where the rectus femoris attaches, and the ischial tuberosity where the hamstrings attachAvulsion FractureS&S:Pain and swelling at the site of injuryInability to produce specific movement that is usually accomplished easilyPoint tenderness over the affected areaMovement of the muscle closer to its opposite attachment when contractedMay have felt or heard a snap or pop at the time of injuryTX:Immediately apply ice and require the athlete to restLimit motion as much as possibleHave the athlete evaluated by a physician ASAP to determine the extent of the injuryAvulsion Fracture..Are debilitating and should be treated conservatively to reduce the amount of scar tissueWithout proper treatment and rehabilitation, this type of injury can be a problem in an athletes future careerHerniasA hernia is the protrusion of abdominal viscera through the abdominal wall; this typically occurs in the groin areaIn males, inguinal hernias are more commonFemoral hernias are more prevalent among female athletes (Crowley, 2010)Most hernias are detected during a preparticipation physical evaluationHerniasHowever, an athlete who is suffering from a hernia most likely has an abnormal protrusion in the groin area and experiences pain in the groin and/or testiclesThe area should seek proper medical advice promptly to discern how soon the hernia will have to be repaired

HerniaAthletes can experience sports hernias in which the posterior inguinal wall is weakened w/o any protrusion of abdominal contents through the abdominal wallIn this situation, no palpable hernia is discovered during a routine physical examination, yet the athlete c/o continuing pain in the groin and lower abdominal regionsHerniaThe sports hernia is difficult to diagnose for the physician and usually exhibits diffuse, deep groin that does not have a specific onset and gradually gets worse as the days passThe athlete may c/o pain along the inguinal ligament and into the rectus musclesIt has been suggested that sports hernias may be a common cause of chronic groin pain in athletes

HerniasIn any case, groin pain must be addressed with proper treatment and the course of action taken needs to follow a predetermined timelineConservative treatment of rest, ice, stretching, and a change in kicking biomechanics may be all that is needed to relieve groin pain in a soccer playerIf the symptoms do not resolve over a 2-week period, it is time to see the team physicianAthletes need to understand that many different techniques for surgical repair exist and new ideas are being reportedNerve ProblemsA common complaint among many athletes is a burning or tingling sensation radiating from the hip and buttocks area and going down the back of the legThese symptoms are often the result if irritation of the sciatic nerveTypically, if an athlete continues to pursue the activity that has caused the irritation, the pain will radiate farther down the leg to the foot and become more debilitating over timeStrengthening and stretching exercises will help depending on the situationPreventionMany of these injuries can be prevented by the use of proper conditioning and strengthening of the associated musculatureRest is important for the body to repair micro damages incurred by stresses of trainingThe use of proper shoes for each activity can be helpful in preventing slipping or sliding by the athlete that might result in overstretch or tearing of muscles

PreventionSoccer players or similar types of athletes slipping on a wet field can sustain severe groin injuryEven though injuries to the hip and pelvis are relatively uncommon as a result of sports participation, it is important to realize that injuries to this area do occur and that they can be debilitating to the athlete