Pelvis, Hip and Thigh Pathologies Competencies in Athletic

Pelvis, Hip and Thigh Pathologies Competencies in Athletic

Pelvis, Hip and Thigh Pathologies Competencies in Athletic Training SEATA Athletic Training Student Symposium Dr. Patricia M. Tripp, ATC, LAT, CSCS Clinical Associate Professor & Director, AT Program 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 What we will cover Clinical Anatomy - Review Biomechanical Factors Clinical Examination of the Pelvis, Hip and Thigh

Pathologies and Related Specialized Tools/Tests Clinical Anatomy Clinical Anatomy Labrum Deepens Acetabulum by 21% Clinical Anatomy

Spin = Same Direction as Motion Functional Anatomy Flexion/IR Spin (IR), Glide Posterior, Roll Anterior Extension/ ER

Spin (ER), Glide Anterior, Roll Posterior Abduction Glide Inferior, Roll Superior (Upward) Adduction Glide Superior, Roll Inferior (Downward)

Understanding the Mechanics Helps Identify the Pathology! Angle of Inclination Measured via Radiographs Forces on Femoral

Head Forces on Femoral Neck Observed as Valgus or Varus Femoral Angulation

Angle of Torsion Rotated anteriorly ~15 Rotation of Femoral Shaft Measured as Angle of Neck and Transcondylar

Position Structural vs. Compensatory Toe Out Gait Pattern Reduced IROT at Hip Structural Alignment between Femur and Acetabulum/Pelvis Greater than 1215 degree

Anterior Relationship [Anteversion] Decreased Anterior Femur Head/Neck Condyles Alignment Twisting of Femur compensates for Posterior Femoral Head

position Structural vs. Compensatory Toe In Gait Pattern Reduced EROT at Hip Structural Alignment between Femur and Acetabulum/Pelvis Increased Anterior Femur Head/Neck Condyles Alignment

Less than 12-15 degree Anterior Relationship [Retroversion] Twisting of Femur compensates for Anterior Femoral Head position

Pediatric Considerations Excessive IROT and Toe-In Gait Commonly Seen in Children Structural Retroversion Include Postural Assessment and Gait Observational Analysis

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) Synergistic Motion

Hip Flexion/Internal Rotation and Posterior Pelvic Tilting Hip Extension/External Rotation and Anterior Pelvic Tilting Walking Gait Muscle Mechanics

Stance Phase 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 Functional Anatomy Load Deformation = Injury

Muscular Anatomy Rectus Femoris or Iliopsoas Tightness May Cause Anterior Pelvic Tilting Muscular Function Lower Cross Syndrome Muscular Anatomy

Piriformis Quadratus Femoris Superior Gemellus Obturator Externus Obturator Internus

Inferior Gemellus Control FIR During Gait Muscular Anatomy Tight Hamstrings = Posterior Pelvic Tilt Engaging the Core (TA)

Fascial Connection Between Iliopsoas and Diaphragm Engaging the Transverse Yoga and Pilates Postures Primary Hip Bursae Friction Between

Gluteus Maximus and Bony Prominences Neurologic Anatomy Femoral Nerve (Hip Flexors, Knee Extensors) Obturator Nerve (Hip

Adductors, Obturator Externus) Vascular Anatomy CLINICAL EXAMINATION OF THE PELVIS, HIP AND THIGH History: Present Condition

Location of Symptoms Referred Pain from Lumbar Spine or SI Joint? Onset of Mechanism Symptoms of Injury? Acute, Chronic, Insidious Training Techniques Aggravating Banked Activities?

Surfaces/Hill Running Inspection Postural Assessment Gait Analysis Deformity or HP Defect

Height [Leg Swelling Length, Long-Sit Test] Ecchymosis Atrophy? Running Gait Analysis Functional

Movement Screening Palpation Modesty with palpation of origin points! Palpation

Crepitus Defects Spasms Trigger Points Active/Passive Hip ROM No Joint Play at Hip

Goniometric Assessment Axis of Rotation ASIS (Fixed Horizontal ASIS, Moving Femur) Axis of Rotation Greater Trochanter (Fixed Torso, Moving Femur)

Axis of Rotation Patella (Fixed , Moving , Moving Tibia) MMT (Eccentric) Hip Hip Flexion: Iliopsoas Knee Extended: Quadriceps + Iliopsoas

FABER: Sartorius MMT (Eccentric) Hip Extension Knee Extended: Gluteus and Hamstrings Knee Flexed: Gluteus MMT (Eccentric) Hip

Hip Abduction: Gluteus Medius and Minimus Hip Adduction: Adductors and Gracilis MMT (Eccentric) Hip Hip External Rotation:

Application of Force at Medial Ankle/Shank; Stabilize Femur Hip Internal Rotation: Application of Force at Lateral Ankle/Shank; Stabilize Femur Specialized Tests and Examination Techniques

Trendelenburg Test: Weak Gluteus Medius 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

Thomas Test Muscle Length Implications Hip Flexion Iliopsoas Tightness Knee Extension Rectus Femoris Tightness Hip Abduction IT Band Tightness Elys Test Muscle Length

Prone Passive Knee Flexion: (+) Test: Hip Flexion Implications: Tight/Shortened Rectus Femoris [Anterior Pelvic Tilting] Iliac Crest Contusion (Hip Pointer) Disproportionate

amount of pain Pain with trunk rotation and hip flexion Ice, Pad, Protect, Crutches? Signs and

Symptoms Spasms, Loss of function Swelling, Discolor ation Muscle Strains Dynamic Eccentri

c Overloa d Excessiv e Tension Stress Concentri c Muscle Force

Abruptly Stopped Initial Management RICE, Crutches; Longer Healing Time vs. Sprain Skeletally Immature possible avulsion or apophysitis injury 2-Joint Muscle s

Rectus Femoris (Quadriceps) Strain Contraction/Dynamic Overload Pain with Activation and Stretching Palpable Defect, Ecchymosis, Swelling, Gait Changes depend on Grade I-III 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 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 Gluteus Maximus Strain Dynamic Overload | Eccentric or Isometric Contraction

Palpable Defect, Ecchymosis, Swelling, Gait Changes depend on Grade I-III Adductor Strain Overstretching, Dynamic Overload Adductor Longus (Most Common Occurs at MT Junction) Palpable Defect,

Ecchymosis, Swelling, Gait Changes depend on Grade I-III Thigh Contusion Direct Trauma (Acute) Signs and Symptoms Muscle Fiber Death Pain, Loss of Function,

Ecchymosis, Swelling, ROM Restrictions, Spasm Management RICE, Crutches 24hrs? 24hrs postinjury = critical Ice on Stretch (>120) = Faster RTP

Complication Myositis Ossificans Pediatric Considerations Legg-Calv-Perthes Disease (LCP) Slipped Capital Femoral Epiphysis (SCFE) Flattening of Femoral

Head; Hip IROT and Abduction (Avascular Necrosis; ages 3-12) Excessive Hip EROT and Restricted or Painful Hip IROT (, , ages 10-15) Legg-Calv-Perthes Disease Referred Pain: Medial

Thigh, Buttock, Suprapatellar Region Painless Antalgic Gait Pattern, Limited Hip IROT and Abduction Slipped Captial Femoral Epiphysis Common in Boys, Typically Unilateral (20% Bilateral) Anteversion of Hip, Toe-Out Gait

(EROT), IROT Clinical Management: Surgical Fixation SCFE vs. LCP Normal Femoral Head Slipped Femoral

Head (SCFE) Abnormal Shaped Femoral Head (LCP) Femoral Neck Stress Fx 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 Femoral Neck Stress Fx Superior Femoral Neck Stress Fractures Tension-Side Inferior Femoral Neck Stress

Fractures Compression Side FABER Test Intra-articular Pathology Anterior or Deep Hip/Groin Pain Reported Pincer FAI

Pain with EROT Degenerative Hip Changes Decreased Joint Space and Cartilage Degeneration Hip Scouring Test Downward Compression (Longitudinal) +

IROT and EROT (+) Test = Pain, Increased Symptoms Implications: OCD, Arthritis, Acetabular Labral Tear (if clicking) C-Sign and Log Roll Test

Groin Pain and (+) C Sign and Pain with Log Roll Test [Intra-articular Pathology] Acetabular Labral Tears Anterior Tears FABER Position Painful Posterior Tears IROT and Adduction Pain

Diagnosis MR Arthrogram and/or Lidocane Injection Management Surgical Intervention Labral Tears Sagittal T1 Weighted MR

Arthrogram Labral Separation from Acetabulum Right Hip Labral Clock FADDIR Impingement Test Femoral Acetabular Impingement

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 Groin Stress Biomechanics Cutting/ twisting at high speeds Shear forces transmitted to pubic symphysis

Common among Soccer, Hockey, Football Pubic-Related Groin Pain MRI Referral Edema Pubic Rami Pelvic Floor Reconstruction Surgery [6

Weeks RTP] Pubic-Related Groin Pain Repetitive stress on pubic symphysis leads to chronic inflammation Distance Running, Soccer, FB, Wrestling, Ice Skating T2 Weight MR Bone Marrow Edema Pubic-Related Groin Pain

Pain with Shear Stress at Pubic Symphysis Adductor Group Spasm and/or Weakness? Widening and Calcification of Pubic Symphysis Leg-Length Discrepancy

Predisposition? Diagnosis: X-ray | MRI Copenhagen Hip and Groin Outcome Score (HAGOS) 1. Pain 2. 3. 4. 5. 6.

Symptoms Physical function in ADLs Physical Sport and Recreation Function Participation in Physical Activities Hip and/or Groin-Related Quality of Life HAGOS Intraclass Correlation Coefficients (ICC) ranging from 0.820.91 for the six subscales Tight Piriformis Nerve Irritation (Piriformis Syndrome)

Pigeon Pose and Double Pigeon Pose for Piriformis Stretching Snapping Hip Syndrome (Coxa Saltans) External - IT Band/Gluteus Maximus Internal - Iliopsoas

Tendon (Lateral Shift with Flexion, Medial Shift with Extension) FABER with Extension/IR Moving from a FABER position into Extension and IROT Snapping Hip of Iliopsoas [Lesser Trochanter] Clinical Take Home Points Use

Systematic Approach with D/D to Rule In and Out Imaging warranted for majority of hip injuries Know your anatomy!

Understand the underlying root of the problem Connect gait analysis and posture with clinical exam

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