# Presentation: 400215

## Hip, Pelvis and Thigh Problems

- Scott W. Pyne, M.D.
- CDR, MC, USN
- Family Medicine/Sports Medicine
- United States Naval Academy

## Objectives for Hip, Pelvis and Thigh Problems

- Define relevant anatomy, physiology, and radiographic features
- Recognize the history, presenting signs and pertinent exam findings
- Demonstrate common rehabilitative exercises
- Demonstrate proper injection techniques, to include indications and contraindications

## Fitting Location 

## Practical Anatomy

- Practical vs. Surgical vs. Gross Anatomy
- Bones
- Cartilage
- Ligaments
- Nerves
- Blood Vessels
- Muscles

## Bones of the Hip and Pelvis

- Pelvis
- Ilium
- Anterior Superior Iliac Spine
- Anterior Inferior Iliac Spine
- Posterior Inferior Iliac Spine
- Ischium
- Ischial Spine
- Ischial Tuberosity
- Pubis
- Pubic Symphysis
- Inferior and Superior Rami
- Acetabulum

## Pelvis Details

## Femur

- Head
- Neck
- Greater Trochanter
- Lesser Trochanter
- Shaft

## Hip Cartilage

- Articular Cartilage
- Hyaline
- Caps Joints
- Labrum
- Fibrocartilage
- Stability and cushioning

## Ligaments of the Hip

- Joint Capsule
- Name two bones and connect them
- Pubofemoral
- Iliofemoral
- Ischiofemoral
- Ligamentum teres

## Nerves of Hip, Pelvis and Thigh

- Sciatic Nerve
- L4-S3
- Articular and Muscular
- Sensation
- External rotation and posterior thigh, foot
- Femoral Nerve
- L2-4
- Anterior thigh compartment
- Lateral Femoral Cutaneous
- L3-4
- Sensory

## Blood Supply

- Femoral Artery
- Profunda femoris
- Circumflex
- Artery of ligamentum teres
- Posterior division of the obturator artery
- Femoral head

## Hip, Pelvis and Thigh Muscles

## Easy, right?

## Planes of Motion

- Flexion/Extension
- Abduction/Adduction
- Internal/External Rotation

## Flexion /Extension

- Flexion
- Anterior Muscles
**Iliopsoas**, rectus femoris, sartorius, pectineus
- Extension
- 0-15 degrees
- Posterior muscles
**Gluteus maximus**
- Hamstrings, adductor magnus

## Abduction/Adduction

- Abduction
- 0-50 degrees
**Gluteus medius**, gluteus minimus, tensor fascia lata
- Adduction
- 0-30 degrees
**Adductor longus/brevis/magnus**
- Gracilis, pectineus, obturator externus

## Internal/External Rotation

- Internal Rotation
**Gluteus medius/minimus**, tensor fascia lata
- External Rotation
- Obturator externus/internus, superior/inferior gemelli, piriformis, quadratus femoris, gluteus maximus

## Hip Bursae

- Trochanteric
- Greater trochanter and Iliotibia band
- Ischial
- Ischial tuberosity and gluteus muscles
- Iliopsoas
- Iliopsoas tendon and lesser trochanter extending upward into the iliac fossa beneath the iliacus muscle

## Hip Special Tests

- FAbER

- Popliteal angle

- Ober’s Test

- Modified Thomas Test

## Hip Special Tests

- Leg Length
- ASIS to Medial Malleolus
- Labrum Test (FAdAxL)
- Hip Flexion, Adduction with Axial Loading (add some IR/ER) causes pain and/or click
- Obturator and Iliopsoas signs
- Pain with intra-abdominal pathology

## Hip Imaging

- X-rays
- AP
- Frog leg
- Bone Scan
- CT
- MRI
- Arthrogram

## Hip Pain Evaluation

## Is it the Hip?

- Low Back Pain
- Knee Pain
- Pelvic Pathology
- Intra-abdominal Pathology

## Case #1

- 32 yo female recreational runner
- Previous dancer
- Gradual increase in distance and abdominal workouts
- Pain and snapping in groin and anterior hip with hip flexion and crunches

## Iliopsoas Bursistis/Tendinosis

- Evaluation
- History and physical
- Consider X-ray or MRI to r/o other dx
- Treatment
- Relative rest, stretch, consider NSAIDs
- Physical therapy
- Injection?
- Surgical referral?

## Case #2

- 28 yo male skier
- Hip pain with deep click that persists 2 months after a fall
- Catching sensation
- Worse with deep flexion and raising from seated position
- Decreased ROM

## Acetabular Labrum Tear

- Evaluation
- History and Physical
- Pain with FAdAxL (hip flexion, adduction and axial loading)
- MRI arthrogram
- Treatment
- Physical Therapy to maximize ROM and strength
- Corticosteroid injection?
- Surgical referral?

## Hip MRI

## Case #3

- 52 yo woman with left lateral hip pain after a vacation at the beach
- Gradual onset
- No trauma or previous hx
- Painful laying on left side

## What is your leading diagnosis?

- Femoral neck stress fracture
- Acetabular labrum injury
- Trochanteric bursitis
- Meralgia paresthetica

**Q**

## Trochanteric Bursitis

- Evaluation
- History and Physical
- Point tender over lateral thigh
- Deconditioned
- Value of X-ray?
- Treatment
- Ice, stretch, strengthen
- Evaluate biomechanics – leg length and gait
- Corticosteroid injection

## Trochanteric Bursa Injection

## Case #4

- Retired Navy CPO with progressive right hip and groin pain
- Associated decreased ROM
- Bowling game suffering
- No trauma, no other joint complaints

## Osteoarthritis of the Hip

- Evaluation
- History and Physical
- X-rays
- Treatment
- Physical therapy, relative rest, NSAIDs
- Viscosupplementation
- Corticosteroid injections
- Surgical referral

## Case #5

- 13 yo female gymnast with increasing groin pain over the past 2 months
- Pain to jump, run, stretch, and land
- Increased pain with increased activity
- No acute trauma

## What else is important?

- Menstrual history
- Exercise and activity history
- Dietary history
- All of the above

**Q**

## Pubic Ramus Stress Fracture

- Evaluation
- Point Tender left superior pubic ramus
- Non-tender adductors
- Normal hip exam
- Imaging
- X-ray, bone scan, MRI
- Treatment
- Relative rest, slow increase
- Address other factors

## Stress Fractures of Hip, Pelvis and Thigh

- High index of activity based suspicion
- Protect pending imaging
- X-ray
- Bone Scan
- MRI
- Gradual protected return to activity
- Address causation
- Diet, activity level, maturity

## Mid-Thigh Pain

## Case #6

- 25 yo male soccer player with chronic right groin pain for the past several weeks
- Increased training in the past month
- Worse with right footed kicking and resisted adduction

## Adductor Tendinopathy

- Evaluation
- Pain and stiffness gradually loosen up
- Pain with resisted adduction
- TTP at tendon insertion
- Treatment
- Rest, ice, isometric and eccentric strengthening, physical therapy

## Case #7

- 22 yo college hockey player with left groin pain
- Progressive sx over past month
- Worse with skating and hip motion
- No specific trauma

## Case #7 Differential Diagnosis

- Adductor Injury
- Osteitis Pubis
- Pelvis stress fracture
- Nerve injury
- Ilioinguinal
- Obturator
- Hernia

## Athletic Pubalgia/Sports Hernia

- Evaluation
- Pain in hernia region without palpable hernia
- Possible dilated superficial ring
- Etiology
- Injury to conjoined tendon, internal oblique, external oblique, transversalis fascia, inguinal ligament, etc.
- Surgical referral

## Case #8

- 19 yo female rugby player struck in the right thigh with a knee
- Pain, swelling, bruising and decreased ROM
- Otherwise healthy

## What is your leading diagnosis?

- Thigh contusion
- Femur fracture
- Vastis medialis strain
- Thigh splint

**Q**

## Thigh Contusion

- Evaluation and grading
- Palpate for muscle defect
- Test strength
- Role of Imaging?
- Treatment
- Splint in flexion
- Ice, rest, protect
- Gradual stretch and return to activities
- NSAIDS?

## Muscle Strains and Contusions

- Patients generally recall injury
- Palpate for muscle defect although rare
- Swelling, ecchymosis, decreased ROM
- Consider image with X-ray or MRI if suspect avulsion or complete tear
- Protect, Rest, Ice, Compression, Medications
- Gradual protected return to activity

## Case #9

- 41 yo female with left buttocks pain
- Retired professional soccer player
- Insidious onset
- Pain to sit
- Increase after run
- Annoying!

## What would be most worrisome?

- Pain radiating to lateral knee
- Mother of three
- Fever
- Uncomfortable during prolonged sitting

**Q**

## Questions to ask?

- Back history
- Trauma
- Recent
- Remote
- Red flag signs
- Fever, weight loss, h/o cancer, saddle anesthesia, loss of bowel or bladder control, IV drug use, HIV

## Case #9 History and Physical

- History
- Previous back aches
- No specific trauma
- Points to left lower back and buttocks
- Some radiation of pain to hamstrings
- No numbness
- No red flags

- Physical
- Normal gait and appearance
- TTP left buttocks
- Decreased left piriformis and SI motion
- Normal sensory and strength

## Piriformis Syndrome

- Variable muscle and nerve relationship
- Exam
- Local tenderness
- Pain w/ stretch (Add, IR)
- Pain w/ resisted ER
- Treatment
- Rule out other things
- Stretch/strengthen
- Core program
- NSAIDs
- Don’t forget the feet

## Questions?

- What’s this?
- Post-concussion
- Haka
- Silly college kids
- “Dancing with the
- Stars” audition

**Q**