Hip & thigh injuries Flashcards
muscle strains - MOI
- explosive concentric contraction
- quick start/stop, change of direction
- eccentric contraction - lengthening; some muscles do two different actions simultaneously at two different joints
- overstretching
contributing factors: fatigue, pelvic asymmetry, strength imbalance, leg length discrepancy, muscle tightness
muscle strains can occur acutely or chronically, why?
-can become a chronic issue if there is no rest, during the repair process, scar tissue forms (creates a weak point in muscle)
muscle strains: S&S
- point tenderness with a palpable spasm
- possible palpable defect or divot
- bruising may or may not be present
- pain increases with AROM or IR testing
- PROM painful at end ROM when on stretch
- level of dysfunction or disability depends on severity of the injury
grade 1 muscle strain
minimal, few fibers torn, minor swelling
grade 2/3 muscle strain
complete rupture, more edema than grade 1
quadriceps muscle strain
- most common in rectus femoris
- possible avulsion fracture of AIIS
- vulnerable when hip extended and knee flexed
hamstrings muscle strain
- most commonly strained muscle in the body
- vulnerable with hip flexion and knee extension
- deceleration of leg swing
adductor muscle strains
- adductor longus most commonly injured
- adductor magnus presents similar to hamstring pain
hip flexor muscle strain
- sprinting or kicking MOI (unplanar movement)
- often tight due to seated posture
which special test is used to determine hip flexor muscle strains?
Thomas test (for hip flexors and quads) -looking to see where the quad is lying; someone with tight hip flexors will be above horizontal plane
initial management for muscle strain
- POLICE - tensor wrap/compression shorts, activity modification but early return to walk (want to engage muscle a bit; avoid intense activities)
- should not RTP until full ROM and strength - will feel a lot better before they actually have the strength needed to return
what types of therapy can be used to manage muscle strains after the initial treatment
- initially - gentle stretching, ROM and early contraction activation (isometric)
- address underlying causes (pelvis, muscle asymmetries)
- later - strengthening and functional exercises (eccentric and plyometric)
- testing in controlled environment before RTP
severe strain or rupture may require surgical intervention (grade 3)
quadriceps contusion MOI
direct blow to anterior or anterolateral thigh
-compression force between soft tissue and femur
S&S of quadriceps contusion
transitory loss of function/weakness and immediate bleeding; increased pain with AROM knee extension and hip flexion; PROM of knee flexion limited
which special test is used to diagnose quad contusion?
Ely’s test
-look at quad length; prone, bend person’s knee and see what happens at hip, if hip hikes up - tension in the quad; if hip is neutral, good length of quad
management of quad contusion
- POLICE - put the knee in max flexion and crutches - prevent stiffness, heal in length position
- therapy - gentle stretching and ROM (avoid soft tissue therapy - massage; RTP - pad and protect)
what is a secondary complication of a quadriceps contusion?
myositis ossificans
sciatica - def
any condition that causes irritation to the sciatic nerve including disk herniation in the low back, direct trauma (ex: hard fall), piriformis muscle compression
the sciatic nerve is a continuation of the _____ and travels through the _____
sacral plexus, greater sciatic notch
the sciatic nerve passes through the piriformis in ___% of the population
15
S&S of piriformis syndrome
- deep, dull ache in mid-buttock without pain
- numbness and tingling may extend down back of thigh and leg (further it travels down, the more severe it is considered)
- pain on palpation of sciatic notch/piriformis
- NEED to rule out disc herniation (straight leg raise test, coughing)
management of piriformis syndrome
- stretching, massage (trigger point or STRP - soft tissue release) (abduction, internal rotation)
- acupuncture has been known to provide relief from symptoms
hip dislocation MOI
- rare in sports
- traumatic force along the long axis of the femur when knee is flexed (MVA)
S&S of hip dislocation
-flexed, adducted, and internal rotated thigh
secondary complications of hip dislocation
capsular and ligamentous strains, fractures, sciatic nerve impingement, disruption of femoral head blood supply
management of hip dislocation
911 monitor vitals, treat shock and immobilize in position found
therapy for hip dislocation
immobilization (bed rest), crutches, progressive ROM exercises
labral tear MOI
- acute: hip dislocation
- chronic: increased joint stresses (deep squats) or repetitive movements cause degeneration
S&S of labral tear
- commonly asymptomatic
- catching, locking, or clicking in hip
- pain in hip/groin
- stiffness/limited ROM
what are the special tests to diagnose labral tears?
- FABER (flexion, abduction, external rotation)
- flex-IR
- scouring
management for labral tears
- hip ROM, strengthening and stability exercises
- avoid painful movements/positions
- surgery to remove or repair
avascular necrosis - def
temporary or permanent loss of blood to proximal femur
causes of avascular necrosis
- hip dislocation
- lateral circumflex artery compromised
Legg-Calve-Perthes disease
- children 4-10 years
- boys more often than girls
- disruption to circulation to head of femur, articular cartilage necrotic and flattens
S&S of avascular necrosis
- gradual onset pain
- initially only with WB, progresses to even when at rest
- pain in groin, with referral to abdomen and knee (kinetic chain)
- limited ROM and antalgic gait (limp)
management of avascular necrosis
- NWB (bed rest or hip brace, if caught early)
- early treatment = femur vascularizes and re-ossifies
- complications = femur remains deformed, develop OA (later in life), and surgical repair
which type of bursitis is most common?
trochanteric
bursitis - MOI
-excessive friction or shear forces (repetitive stress) or direct blow (not a lot of muscle here)
bursitis - S&S
-burning or aching sensation over/posterior to greater trochanter which is aggravated by hip abduction (especially against resistance), hip flexion and extension while WB
which special test is used to diagnose bursitis?
Obler’s test
- TFL and ITB tightness
- bring hip back, then let leg hang off table - horizontal position indicates tension
management of bursitis
-POLICE and activity modification
therapy for bursitis
- stretching program and manual therapy (myofascial release) - IT band stretch
- later on strengthening exercises for the hip
- meds - NSAIDs or injections
- biomechanical analysis of training techniques, posture, and gait to identify contributory intrinsic factors (leg length discrepancy)
femoral fractures - MOI
- tremendous impact forces or direct compressive forces
- more common in middle aged or elderly
- can be very serious bc of potential damage to neurovascular structure (femoral artery, sciatic nerve)
S&S of femoral fracture
- extreme pain
- inability or unwillingness to move
- deformity or gross instability (crepitus)
- leg appears shortened and held in ER and ABD (neck); shortened and ER (shaft)
-monitor for S&S of shock
management of femoral fractures
- 911
- manually stabilize in position found; monitor vital signs (especially distal MSC)
- monitor and treat for shock
- EMS - traction splint applied, along with pain meds
how common are femoral stress fractures?
- femoral neck = uncommon
- more prevalent due to popularity of repetitive, sustained activities - ex: marathon runners
- more common in amenorrhoeic women
S&S of femoral stress fracture
- gradual onset of pain in groin or anterior thigh with activity
- eventually constant pain and antalgic gain
management of femoral stress fractures
- conservative (21 weeks)
- better success rate for medial side of femoral neck (compression)
- surgery after about 12 months
slipped capital femoral epiphysis is most common in who?
- tall boys 10-17 years (thin or obese)
- related to growth hormones
slipped capital femoral epiphysis - MOI
trauma or prolonged stress
S&S of slipped capital femoral epiphysis
initially minimal, progress to hip and knee pain with AROM and PROM; limited abduction, flexion, and medial rotation; limp
management of slipped capital femoral epiphysis
- minor slippage - NWB
- major slippage - surgery
- hip problems later in life if undetected or normal mechanics not restored
MCL sprain - MOI
- valgus force
- from outside of the knee
- lateral to medial
S&S of MCL sprain
-localized swelling and instability - NO big balloon swelling like cruciate ligaments
which special test is used to diagnose MCL sprains?
valgus stress test
- to see how lax the ligament is
- done at 0 and 30 deg flexion
LCL sprain - MOI
varus force
S&S of LCL sprain
localized swelling and instability
which special test is used to diagnose LCL sprains
varus stress test
which is more common? MCL sprain or LCL sprain?
MCL
how long is the recovery for MCL/LCL sprains?
weeks (for grade 1)
-heals relatively well
PCL sprain - MOI
- hyperflexion with ankle in plantar flexion
- dashboard injury
S&S of PCL sprain
- joint swelling and instability
- not as much swelling as ACL
which special test is used to diagnose PCL sprains?
- posterior drawer test - knee in flex position, push on tibia posteriorly
- posterior sag test - hips flexed, knees bent, see where tibial tubercle lies
why should we test for PCL sprain before ACL sprain?
to prevent false negative in ACL diagnosis
ACL sprain - MOI
- varus force
- also a rotary force - planting foot and twisting
- typically non-contact mechanism
S&S of ACL sprain
joint swelling and instability
-capsular swelling, sometimes not immediately
which special test is used to diagnose ACL sprains?
- anterior drawer test - test PCL first
- Lachman drawer test - hamstrings a bit looser (do similar actions to ACL, need to be relaxed for tests)
- pivot-shift test
what is the terrible triad of the knee? which structures make this up?
ligaments that are torn most often, together
-ACL, MCL, medial meniscus
why are females more susceptible to ACL injuries?
many risk factors:
- environmental
- anatomical - ex: Q-angle
- hormonal - ex: contraceptives
- neuromuscular (modifiable)
- biomechanical (modifiable)
what are the two types of ACL surgical reconstruction surgeries?
1) autographs
- patellar tendon bone
- hamstrings (SM and gracilis)
2) allographs
- from donor tissue bank (achilles or quad tendon)
ACL prevention and rehabilitation strategies
- strength
- flexibility
- balance/proprioception - movement correction
- core stability
- plyometrics
- agility
- jump landing
FIFA 11+ is one of the manu rehab programs available
osteochondral fracture
- fracture of articular cartilage and underlying bone
- very impactful injury
- WB surfaces (femur, tibia, posterior patella)
- joint effusion, crepitus, and pain WB
patellar fracture
- forcible quadriceps contraction or direct impact
- general swelling
patellar/quad tendon rupture MOI
- sudden, powerful contraction of the quads
- usually secondary to tendon degeneration (tendinosis) - repetitive overuse
S&S of patellar/quad tendon rupture
- patella moves up thigh
- significant pain and swelling
management of patellar/quad tendon rupture
- surgical repair
- cannot treat only with exercise
patellar subluxation/dislocation MOI
- deceleration combined with cutting motion (valgus position)
- quadriceps pulls straight, as a result pulls patella laterally
- sometimes it shifts out and comes back in
- lateral because valgus knee position
- commonly associated with alignment issues
S&S of patellar subluxation/dislocation
- pain, swelling, and complete loss of function
- patella displaced laterally
which special test is used to diagnose patellar subluxation/dislocation
aprehension test
management of patellar subluxation/dialocation
- splint and ice - do not attempt to reduce
- refer to physician - requires X-ray; associated with osteochondral fracture
- immobilization (4 weeks)
- therapy: strengthen quads/stretch lateral retinaculum and ITB
- add strength and stability to medial structures so it doesn’t go lateral again
- brace for RTP
quad/patellar tendinopathy “jumper’s knee”
- repetitive or eccentric knee extension activities
- involving changing direction or jumping
quad tendinitis - def
chronic inflammation at superior patellar pole
patellar tendinitis
- distal pole of patella
- more common in younger population - bones grow and tendons have to catch up
when it results in tendon degeneration - tendinosis (no inflammation)
quad/patellar tendinopathy management
Acute inflammatory phase - POLICE, ice and activity modification
Chronic inflammatory phase
- correct any biomechanical issues
- quad stretching and friction massage
- eccentric quad strengthening - more forceful and function and sport specific
bracing or taping: chopat
Apophysitis: osgood schlatter disease
-inflammation of the patellar ligament at the tibial tuberosity
apophysitis: larsen johanson disease
juvenile osteochondrosis and traction epiphysitis affecting the extensor mechanism of the knee which disturbs the patella tendon attachment to the inferior pole of the patella
in who is apophysitis common?
adolescents
- pain and inflammation resolve at skeletal maturity
- deformity remains
what is a secondary complication of apophysitis?
avulsion fractures
management of apophysitis
- POLICE
- rest for a period of time and avoidance of aggravated activities
- can take a long time to resolve
- stretch and strengthen quads and hams
ITB friction syndrome - MOI
- excessive compression against lateral femoral epicondyle
- genu varum and pronated feet
S&S of ITB friction syndrome
achy pain in lateral knee aggravated by running or cycling; worsens with activity
which special test is used to diagnose ITB friction syndrome?
Obler’s test
-lying on side, leg into abduction and extension and let leg hang
management of ITB friction syndrome
- cryotherapy and electrotherapy modalities
- physician - NSAIDs or corticosteroid injections
- therapy - stretching (gluts/TFL) and manual (massage, STR, MFR, and foam rolling); strengthening ER’s, ABD’s of the hip
- correct pelvic or foot malalignments
bursitis in the knee - MOI
-direct blow, overuse (friction caused by tight structures and repetitive movements or repetitive blows), infections, RA, tumours
what are the most common forms of bursitis in the knee?
-pre-patellar (kneeling) and pes anserine (sartorius, gracilis, and semitendinosus; medial repetitive flexion/extension)
S&S of bursitis in the knee
localized swelling, depends on where the bursal sad is located
-ask for MOI to distinguish from ACL injury, palpation, look at rectus femoris (Eli’s test), ROM
management of bursitis in the knee
- POLICE
- physician - NSAIDs, pain relievers, may drain the bursal sac; surgery (bursectomy)
- activity modification and protective knee pad
- avoidance of kneeling or uneven running surfaces
- therapy - ROM and flexibility
- correct faulty mechanics
