Sports Related

Injuries In
Hip Region.
 Hip Region
• The hip joint is a ball and socket joint that is the point of
articulation between the head of the femur and the acetabulum
of the pelvis.
• Diarthrodial joint with its inherent stability dictated primarily
by its osseous articulations.
• Primary function of the hip joint is to provide dynamic support
the weight of the body/trunk while facilitating force and load
transmission from the axial skeleton to the lower extremities,
allowing mobility[
• Typically works in a closed kinematic chain
 Movements
• The hip joint connects the lower extremities with the axial skeleton. The hip joint
allows for movement in three major axes, all of which are perpendicular to one
another.
The location of the center of the entire axis is at the femoral head.
• The transverse axis permits flexion and extension movement.
• The longitudinal axis, or vertically along the thigh, allows for internal and external
rotation.
• The sagittal axis, or forward to backward, allows for abduction and adduction.
Acetabular labrum
which provides the following functions:
• Load transmission
• Negative pressure maintenance (i.e., the "vacuum seal") to enhance hip joint
stability
• Regulation of synovial fluid hydrodynamic properties
 Ligaments
In general, the hip joint capsule is tight in extension and more relaxed in flexion
The capsular ligaments include
• Iliofemoral ligament (also known as the Y ligament of Bigelow) is the
strongest ligament in the body; it lies on the anterior aspect of the hip joint - it
prevents hyperextension,
• Pubofemoral lies anteroinferiorly - it prevents excess abduction and extension
• Ischiofemoral ligaments - is the weakest of the three ligaments and consists of
a triangular band of fibres that form the posterior hip joint capsule. It attaches
to the ischium to behind the acetabulum and it attaches to the base of the
greater trochanter - it prevents excess extension
• The ligamentum teres (ligament of the head of the femur) Located
intracapsular and attaches the apex of the cotyloid notch to the fovea of the
femoral head. erves as a carrier for the foveal artery (posterior division of the
obturator artery).
 Joint Capsule
• The hip joint is extremely strong, due to its reinforcement by
strong ligaments and musculature, providing a relatively stable
joint. Unlike the weak articular capsule of the shoulder, the hip
joint capsule is a substantial contributor to joint stability [2]. The
capsule is thicker anterosuperiorly where the predominant
stresses of weight bearing occur, and is thinner
posteroinferiorly.
 Labrum

The labrum has three surfaces:

• Internal articular surface - adjacent to the joint (avascular)
• External articular surface - contacting the joint capsule (vascular)
• Basal surface - attached to the acetabular bone and ligaments
The functions of the acetabular labrum are:
• Joint stability
• Sensitive shock absorber
• Joint lubricator
• Pressure distributor
• Decreasing contact stress between the acetabular and the femoral
cartilage
 Nerve and blood supply
• The hip joint receives innervations from the femoral, obturator, superior gluteal
nerves.
• Most common variant results in blood supply coming from the medial
circumflex and lateral circumflex femoral arteries, each of which is a branch of
the profunda femoris (deep artery of the thigh).
• The profunda femoris is a branch of the femoral artery which travels
posteriorly.
• There is an additional contribution from the foveal artery (artery to the head of
the femur), a branch of the posterior division of the obturator artery, which
travels in the ligament of the head of the femur.
• The foveal artery helps avoid avascular necrosis with disruption of the medial
and lateral circumflex arteries.
• There are two significant anastomoses. The cruciate anastomosis supports the
upper thigh and the trochanteric anastomosis, which supports the head of the
femur
 Muscles
• Muscles of the hip joint can be grouped based upon their functions relative to the movements of the hip
Flexors:
Abductors:
• Psoas Major
• Gluteus Medius
• Psoas Minor
• Tensor Fascia Latae
• Iliacus Internal Rotators:
• Pectineus • Tensor Fascia Latae
• Rectus Femoris • Gluteus Minimus
Extensors: External Rotators:
• Gluteus Maximus Gluteus Maximus
• Semitendinosus Gemellus Superior
• Semimembranosus Gemellus Inferior
• Biceps Femoris (long head) Obturator Externus
Adductors: Obturator Internus
• Adductor Magnus Quadratus Femoris
• Adductor Longus
Piriformis
• Adductor Brevis
• Gracilis
 Sports related hip injuries
• Athletes have a greater chance of experiencing the following types of hip injuries:
• Labral Tears:
Affecting the tissue around the rim of the hip joint, these stem from a sharp twisting or pivoting
motion. Rather than direct pain, athletes may feel stiffness or locking in this area, or soreness
around the groin. Although physical therapy can help, the damaged tissue may need to be
surgically repaired.
• Hip Pointer:
This injury can result from falling directly on the hip and having the impact pass through the joint.
Afterwards, the athlete may feel a sharp sensation of pain if they do a jumping or twisting
motion.
• Pulled or Torn Hamstring:
Athletes who don’t correctly warm up have a higher chance of experiencing a pulled or torn
hamstring, resulting in sharp pain during activity. A mild resistance can provoke pain and
sympotoms or streching can reinduce the symptomatic things ( hyperflexion test, muscle
belly palpation test, hamstring stretch test).
• Sprains and Strains:
As with all joints in the body, the ligament and muscles surrounding the hip can experience a
sprain or strain, often as a result of overuse.
• Tendonitis:
The tendons surrounding the hip experience inflammation, which can result in pain and stiffness.
Cont..
• Tendinosis:
Also affecting the tendon, this non-inflammatory condition causes the ligament to degrade,
decreasing strength and changing its structure.
• Bursitis:
The hip’s bursae sacs experience inflammation, often as a result of overuse. Designed to
support and cushion the muscles and ligaments, these sacs occur on the inside and outside of
the hip. In turn, pain may extend from the hip to the groin area.
• Osteoarthritis:
Athletes have a risk of developing osteoarthritis through activities that involve repetitive
motion or a large amount of strain placed on the joint.
• Sacroiliitis:
The sacroiliac joint becomes irritated or inflamed, through overuse or in relation to arthritis.
• Piriformis Syndrome:
Involving the smaller muscles located on the rear of the hip, this condition can feel like a back
injury, as it may also aggravate the sciatic nerve. You may experience a sharp pain on your
backside that radiates down your leg.
 Hip Pain
• Hip pain is a common cause of discomfort in athletes and can
be a frustrating problem to treat. In the past, just about any hip
pain symptom was attributed to a "muscle strain"-type injury.
While this can be a very common cause of hip pain in athletes,
there are many other conditions that can sideline a player as
well.
 Groin strain.
Etiology
The groin is the region that lies on the medial and anterior aspect of the upper
thigh. The musculature of this area includes the iliopsoas, the rectus femoris,
and the adductor group (gracilis, pectineus, adductor brevis, adductor longus,
and adductor magnus). Groin pain is one of the more difficult problems to
diagnose, especially if it is chronic. Any one of the muscles in the region of the
groin can be injured during sports activity and elicit what is commonly
considered a groin strain. The adductor longus muscle is most often strained.
Running, jumping, or twisting with external rotation can produce such injuries.
Pathology
The groin is one of the most difficult injuries to care for in sports. The strain
can be felt in a sudden twinge or feeling of tearing during an active movement,
or the athlete may not notice it until after the termination of the activity. Like
most tears, the groin strain produces pain, weakness, and internal hemorrhage.
 Treatment
If it is detected immediately after it occurs, the strain should be treated by PRICE,
NSAIDs, and analgesics as needed for 48 – 72 hours.
• Passive, active, and resistive muscle tests should be given to determine the exact
muscle or muscles involved.
• The ATC frequently encounters difficulty when attempting to care for a groin
strain.
• Rest has been the best treatment.
• Daily whirlpool therapy or cryotherapy are palliative ((of a treatment or medicine)
relieving pain or alleviating a problem without dealing with the underlying
cause.);
• ultrasound offers a more definite approach.
• Exercise should be delayed until the groin is pain free.
• Exercise rehabilitation should emphasize gradual stretching and restoration of the
normal ROM. Until normal flexibility and strength are developed,
• a protective spice bandage or commercial brace should be applied.
Piriformis syndrome
• Etiology
Piriformis syndrome is an uncommon neuromuscular disorder that is caused when the piriformis
muscle compresses the sciatic nerve. This muscle is important in lower body movement because it
stabilizes the hip joint and lifts and rotates the thigh away from the body. This enables us to walk,
shift our weight from one foot to another, and maintain balance. It is also used in sports that
involve lifting and rotating the thighs -- in short, in almost every motion of the hips and legs.
Nerve compression can be caused by spasm of the piriformis muscle.
• Pathology
Piriformis syndrome usually starts with pain, tingling, or numbness in the buttocks. Pain can be
severe and extend down the length of the sciatic nerve (called sciatica). The pain is due to the
piriformis muscle compressing the sciatic nerve, such as while sitting on a car seat or running.
Pain may also be triggered while climbing stairs, applying firm pressure directly over the
piriformis muscle, or sitting for long periods of time. Most cases of sciatica, however, are not due
to piriformis syndrome. There is no definitive test for piriformis syndrome. In many cases, there is
a history of trauma to the area, repetitive, vigorous activity such as long-distance running, or
prolonged sitting.
 Treatment
• If pain is caused by sitting or certain activities, try to avoid positions that trigger pain.
Rest, ice, and heat may help relieve symptoms.
• A doctor or physical therapist can suggest a program of exercises and stretches to help
reduce sciatic nerve compression.
• Some health care providers may recommend anti-inflammatory medications, muscle
relaxants, or injections with a corticosteroid or anesthetic.
• Other therapies such as iontophoresis, which uses a mild electric current, and injection
with botulinum toxin (botox) may be used. Surgery may be recommended as a last
resort. Since piriformis syndrome is usually caused by sports or movement that
repeatedly stresses the piriformis muscle, such as running or lunging, prevention is
often related to good form.
• Avoid running or exercising on hills or uneven surfaces. Warm up properly before
activity and increase intensity gradually.
• Use good posture while running, walking, or exercising.
• If pain occurs, stop the activity and rest until pain subsides. See a health care provider
as needed.
 Hip pointer
• Etiology
Iliac crest contusion and contusion of the abdominal musculature,
commonly known as a hip pointer, occurs most often in contact and
collision sports. The hip pointer results from a blow to an inadequately
protected iliac crest. The hip pointer is considered one of the most
handicapping injuries in sports and one that is difficult to manage. A
direct force to the unprotected iliac crest causes severe pinching action
to the soft tissue of that region.
• Pathology
A hip pointer produces immediate pain, spasms, 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.
Palpation along the greater trochanter reproduce symptoms
 Treatment
• PRICE should be applied immediately after the injury occurs and
should be maintained for at least 48 hours. In severe cases, bed rest
for one to two days will speed recovery. The mechanism for the hip
pointer injury is either a direct blow or fall on the iliac crest. The
athlete must be referred to a physician, and an X-ray must be
performed to rule out an iliac crest fracture or epiphyseal
separation. A variety of treatment procedures can be used for this
injury. Ice massage and ultrasound have been found to be
beneficial. Initially the injury may be injected with a steroid to
reduce inflammation. Later, an oral anti-inflammatory agent may be
used. When returning to participation the body part should be
padded properly to prevent re-injury and offer more protection.
Recovery time usually ranges from one to three weeks.
 Trochanteric bursitis
• Etiology
Trochanteric bursitis is a relatively common condition of the
greater trochanter of the femur. Although commonly called
bursitis, the condition also could be an inflammation at the site
where the gluteus medius muscle inserts or the iliotibial band
passes over the trochanter.
• Pathology
The athlete complains of pain in the lateral hip. Pain may radiate
down to the knee, causing a limp. Palpation reveals tenderness
over the lateral aspect of the great trochanter. The ATC should
perform tests for tensor fascia latae and iliotibial band tightness.
Palpation along the greater trochanter reproduce symptoms
 Treatment
• Therapy includes PRICE, NSAIDs, and analgesics as needed. ROM
exercises and progressive resistance exercises (PREs) directed toward the
hip adductors and external rotators should follow.
• Phonophoresis (is the use of ultrasound to enhance the delivery of
topically applied drugs. Phonophoresis has been used in an effort to
enhance the absorption of topically applied analgesics and anti-
inflammatory agents through the therapeutic application of ultrasound)
may be added if the athlete does not respond in three to four days.
• The athlete’s return to running should be cautious; the athlete should
avoid running on inclined surfaces.
• Faulty running form, leg-length discrepancy, and faulty foot biomechanics
must be taken into consideration.
• The condition is most common among women runners who have
increased Q-angle or a leg-length discrepancy.
 Osteitis Pubis
• Etiology
The popularity of distance running has increased, a condition known as
osteitis pubis has become more prevalent. It is also caused by the sports of
soccer, football, and wrestling. Repetitive stress on the pubic symphysis and
adjacent bony structures caused by the pull of muscles in the area creates a
chronic inflammatory condition.
• Pathology
The athlete has pain in the groin region and in the area of the symphysis
pubis. There is point tenderness on the pubic tubercle, and the athlete
experiences pain while running, doing sit-ups, and doing squats. Acute
osteitis pubis may occur as a result of pressure from a bicycle seat.
• Treatment
Follow-up care consists of rest, an oral anti-inflammatory agent, and a
gradual return to activity.
 Hip dislocation/ subluxation
• Etiology
Dislocation of the hip joint rarely occurs in sports and then usually only as the
end result of traumatic force directed along the axis of the femur. Such
dislocations are produced when the knee is bent. The most common displacement
is one posterior to the acetabulum, with the femoral shaft adducted and flexed.
• Pathology
The injury presents a picture of a flexed, adducted, and internally rotated thigh
(posterior displacement). Palpation will reveal 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.
If the injury presents with a abducted, flexed and externally rotated thigh the you
should suspect an anterior displacement, but this is much less common than the
posterior displacement.
 Treatment
• Splint/stabilize the body part in the position they are found in.
May need to use rolled towels or pillows to provide support for
the athlete’s injured leg.
• Should be backboarded and immediately transported to the ER
for medical attention. Muscle contractures may complicate the
reduction of the joint.
• Immobilization usually consists of two weeks of bed rest and
the use of crutches for walking a month or longer.