hip and thigh injuries

• Hip Anatomy: 

  Classification – Synovial. Ball and socket  

  
  

  Axes of movement – Sagittal, transverse and vertical  

  
  

  Articular surfaces: 

  Head of femur  

  2/3 of a sphere  

  Covered in Hyaline cartilage (apart from the fovea capitis)  

  
  

  Acetabulum  

  Hollow hemisphere  

  Orientated anteriorly, inferiorly and laterally

  Deficient inferiorly – acetabular notch & ligamentum teres 
• Hip Anatomy: 

  Joint capsule - Very strong, Fibrous, cylindrical sleeve closing the joint  

   

  Pelvis attachment – surrounds acetabulum  

  Femoral attachment – surrounds majority of NoF  

   

  3 extracapsular ligaments – Key ligaments forming thickening of the capsule  

  Iliofemoral (Anterior)  

  Pubofemoral (Anterior)  

  Ischiofemoral (Posterior to anterior) 
• Hip and thigh pathologies: 

  Traumatic 

  Atraumatic 

   

  Structures affected: 

  Muscle  

  Tendons  

  Ligaments  

  Bursa  

  Bone  

  Neurovascular 
• Red flags can include: 

  • A history of cancer: Metastases or cancer present in the prostate, breast or hip and groin region  
  • Infection: High fever, STI/UTI’s can cause hip and groin pain  
  • Neurological: CES, Saddle anaesthesia, sexual dysfunction  
  • Fractures: Trauma or overuse 

   

  Triage – pathologies to consider: 

  Stress and insufficiency fractures  

  Neck of Femur fracture  

  Avascular necrosis of the femoral head 
•  

  Insufficiency fractures vs. stress fractures: 

   

  Atraumatic fracture / gradual onset  

  Stress: Overload in sports athletes  

  Insufficiency: Fracture in response to normal daily loading 

   

  Prevalent in:  

  women >50 years with Osteoporosis: Lack of vit D, calcium and bone turnover  

  Young – overload in training, Runners, Base of 5th metatarsal 20%  

  • Pelvic ring stress # common in women 

   

  Common sites: Pubic rami, Sacrum 
• Atraumatic fracture / gradual onset :

  Contributing factors:  

  Mechanically weak bone (low bone density)  

  Diet and eating disorders (Calcium and Vit D) 

  Females: Relative Energy Deficiency in sport (RED-S)  

  Training errors / load 

   

   

  Symptoms:  

  Pain with exercise, that stops at rest. à increased pain at earlier stage of exercises and takes longer to wean as # progresses  

  - Localised tenderness  

  Xray / MRI if suspicious of # 

   

  Treatment:  

  Rest/unload stress area  

  Ideally 4-12 weeks away from sport  

  • Exercise readjustment  

  - Orthopaedic referral 
• Intracapsular causes of hip pain: 

  OA 

   

  Incidence:  

  Older population >50 years / post intra-articular injury  

  Obesity  

  Insidious onset  

   

  Pain: 

  Groin / anterior thigh and knee  

  Worse on weight bearing tasks  

  Diurnal pattern: Mornings and evenings  

   

  Loss of range: 

  -Most ranges: Flexion, extension, rotation, Hard end feel  

  Difficult to put on shoes and socks  

  Pain on FABER, FADIR  

   

  Crepitus:  

  Grating sensation, noisy and painful on movement  

  • Articular surface debris, osteophytes 

   
• Muscle atrophy:  

  - Gluteals: Trendelenburg gait  

  Antalgic gait  

   

  Treatment:  

  Education  

  - Pain control  

  Weight management  

  Maintain ROM  

  Strength  

  Injections  

  • Surgery 
• Patterns causing hip and thigh pain: 

  Impingement Pattern 

  Instability pattern  

  Labral pathology can tend to be secondary to either of these patterns. It is our job to determine which pattern is causing the issue 
• Acetabular labral tear: 

  Damage to the rim of the acetabulum – The Labrum. Can occur with hip instability OR impingement, therefore thorough subjective and objective findings are useful for treatment. 

   

  MOI:  

  High trauma (Traumatic tear)  

  Repetitive overuse (Atraumatic degenerative tear)  

  Repeated hip rotation / flexion  

  Running with internal rotation of the hip  

   

  Population: 

  Young athletes  

  • Older generation from progressive OA  

   
• Acetabular labral tear: 

  Subjective: 

  Unilateral anterior hip/groin pain  

  Dull pain worse with activity  

  Mechanical clicking/clunking/giving way  

  +/- Osteochondral lesions 

   

  Objective: 

  Hip quadrant testing i.e. Kemp test = pain  

  FADIR = pain  

   

  Treatment: 

  Analgesia  

  Manual therapy for joint mobilisation  

  Graded return to sport  

  Hip/Glute strengthening  

  Balance/Proprioception training  

   

  Further treatment: 

  • Surgery: Labral repair RTS approximately 3 months after hip testing e.g. 30 SL squats pain free and of good stability 

   

  Imaging:  

  MR Arthrography 

   
•  

  FAI – Femoro-acetabular impingement syndrome: 

  Motion-related clinical disorder of the hip with a triad of symptoms, clinical findings and imaging. Premature contact of the acetabulum and proximal femur. 

   

  Symptoms: 

  Can be asymptomatic  

  Inner hip / groin pain after walking or prolonged sitting e.g. driving  

  Clicking, locking, catching sensation at hip with movement  

  Pain with hip flexion involvement e.g: Uphill walking, donning shoes and socks  

  • Pain can refer to SIJ and posterior hip  
• FAI – Femoro-acetabular impingement syndrome: 

  Who is at risk?

  - High level athletes

  - CAM: Young male athletes ~20 years old

  - Pincer: Athletic women in 30’s-40’s - Sports involving hip flexion: Martial arts, ballet, cycling, rowing, football, power lifting

  
  

  Objective findings:

  - Pain on FADIR (Flexion – Adduction – Internal rotation)* sensitive but not specific

  - Reduced hip ROM, particularly internal rotation (Active / passive)

  - Quadrant testing pain

  - MR Arthrography to identify CAM or Pincer Sensitive, but not specific
• FAI – Femoro-acetabular impingement syndrome: 

  Aim of physio: 

  Symptom control / pain management  

  Global hip strengthening of adjacent muscle groups: Abductors, adductors, extensors  

  Sport modification to allow pain free hip squatting, lunging  

  Improve neuromuscular control and stability  

  Improve functional patterns / training  

  • Set pain limits 
• FAI Management: 

  Surgery:  

  Can be done to improve hip morphology if severe  

  Reduced outcomes for ages <40 with no OA or soft tissue damage  

  No evidence for prophylactic surgery  

  
  

  Prognosis: 

  Patients can improve and return to full activity with treatment 

  FAI likely to worsen with no treatment  
• Instability Pattern: 

  Generally defined as extra-physiological hip motion, causing pain with or without hip joint stability. Contributes to increased movement of the femoral head with the acetabulum, which eventually damages the labrum, cartilage and capsule  

  
  

  Common conditions:  

  Developmental hip dysplasia  

  Connective tissue disorders: Ehlos Danlos, hypermobility, Marfans, Downs Syndrome  

  Females <40 years - Gymnasts, dancers 

  Pain with hip extension based activities, standing, running, wearing heels  
• Instability Pattern: 

  Symptoms:

  - Unilateral anterior hip or groin pain

  - Dull ache worsening with activity

  - Mechanical clicking, clunking, giving way

  
  

  Objective findings:

  Pain when tested:

  - Quadrant testing

  - FADIR testing

  - Anterior pelvic tilt

  - Traction to the limb = apprehension

  
  

  Aim of physio:

  - Pain reduction and symptom control

  - Activity modification

  - Sagittal and frontal plane hip ROM exercises

  - Global hip strengthening

  - Improve functional sport specific training, pain limited
• Perthes Disease: 

  Idiopathic (no exact cause) avascular necrosis of the femoral head in young patients due to temporary blood loss at the femoral head 

   

  Potential causes:  

  Linked to smoking during pregnancy  

  Repeated or single episode of ischemia  

  Repetitive microtrauma  

   

  Who is at risk?  

  Children aged 4-9 years old  

  Boys > girls 4:1 

   

  Symptoms: 

  Dull ache in hip/groin region  

  Usually unilateral pain  

  Pain typically worse during physical activity

  Diurnal pattern: Worse later in the day and night  

   
• Perthes Disease: 

  Objective findings: 

  Altered gait: Trendelenburg  

  Restricted hip ROM and FABERS test  

  Adduction tightness  

  Glute and abductor atrophy 

   

  Prognosis: 

  The 4 stages can be self limiting and may require surgery  

  Recovery approximately 3-5+ years  

  Better outcome for ages <6, due to better remodelling chances  

  80% hips have a good outcome into early 40’s

  Over 50% most likely to develop severe OA and require a hip replacement  

   
• Perthes Disease: 

  Imaging: 

  X-ray can determine the prognosis via identifying the stages  

   

  Management aims: 

  - Pain free ROM  

  Global hip strengthening (abductors, extensors) 

  Gait retraining  

  Balance retraining  

  • Orthosis to maintain hip congruency 
• Extracapsular causes of hip pain: 

   

  Nerve Entrapment:  

  Repetitive low injury OR high force trauma to soft tissue surrounding nerves. This can create scar tissue, which reduces smooth excursion of the nerve 

   

  Nerve irritation can be caused by:  

  Pelvic masses e.g. tumour  

  Weightlifting belts 

  Pregnancy  

  Thigh contusion  

  Surgery  

  Falls/fractures  

  • Overstretching 
• Arterial compromise: 

  Disease of an artery. Functional kinking of the external iliac artery from repeated movements e.g. hip hyperflexion or hypertrophy of surrounding muscles compressing the artery. This reduces blood flow to the soft tissues distally 

   

  Symptoms:  

  Weakness, cramping, pain with unilateral exercise. Felt in the hamstrings, quads, adductors or abductors and glutes  

  • Pain resides with rest 

   

  Who does it affect?  

  Athletes involved in repetitive hip flexion: Footballers, long distance runners, cyclists 
• Arterial compromise: 

  Objective findings:  

  Reduced pulse distally (femoral, tibial, dorsalis pedis)  

  Temperature differences per limb  

  Ankle-brachial plexus index before and after maximal effort of exercises  

   

  Treatment:  

  Sporting population likely to require surgical stenting  

  - Minimise repeated hyperflexion / sustained flexion  

  • Modify sporting technique to avoid pulling up from pedals – this causes psoas hypertrophy 
• Deep Gluteal syndrome: 

  Irritated sciatic nerve in the sub-gluteal space. This causes buttock pain and sciatic-type symptoms 

   

  Potential causes: 

  Gradual onset  

  Sedentary lifestyle  

  Repeated periods of hip flexion  

  Possible acute trauma 

   

  Symptoms: 

  Hip and buttock pain  

  Gluteal tenderness  

  Often unilateral but sometimes bilateral  

  Unable to sit for more than 20-30 minutes  

  Disturbed or loss of sensation in an area of the affected limb 

   

  Who does it affect?  

  Footballers, dancers, cyclists  

  Plyometric sports  

  • Manual workers with heavy lifting (lifting mechanics/manual handling) 

   
• Deep gluteal syndrome:

  Objective findings:  

  - Neuroprovocation and neurointegrity tests e.g. Straight leg raise  

  Seated or lying piriformis stretch test  

  Pace’s sign  

   

  Treatment: 

  Pain management, avoiding aggs  

  Manual therapy, soft tissue release within pain limits  

  Sciatic nerve glide - Gluteal and lateral hip rotator stretches  

  - Anaesthetic injection for pain relief  

   

  Investigations:  

  MRI  

  • Nerve conduction tests 
• Myositis ossificans: 

  Calcification occurring in the soft tissues, usually after a haematoma/contusion injury  

   

  Proposed mechanism: 

  Poorly understood  

  Injury causes inflammatory cascade  

  Inflammatory cascade differentiates fibroblasts to extra-skeletal osteoblasts = extra-skeletal bone  

   

  Population: 

  Normally occurs in athletes aged 20’s-30’s  

  Frequent occurrence in lower extremities: adductors and quadriceps  

  25% of cases is of unknown aetiology with no relevant history  
• Myositis ossificans: 

  Symptoms:  

  Pain, swelling and joint stiffness of affected limb  

  Pain normally resides longer than anticipated for sporting injury  

  • Bone calcifies over 2-3 months. Difficult to specify on imaging (XRAY, MRI, US) 
• GTPS (Greater trochanter pain syndrome): 

  Umbrella term for common, non-arthritic hip pathologies that affect the lateral hip – prevalent with gluteal tendinopathies  

   

  Mechanism: 

  Most common: Gluteal tendinopathy. Glute medius and minimus  

  Excessive hip adduction and weak abductors  

  Compression of tendon on Greater Trochanter 

   

  Population: 

  Women >40 years, especially with wider hips  

  Long distance runners 

   

  Symptoms: 

  Pain over lateral hip / GT  

  Exacerbated pain by side lying on affected limb  

  • Pain and weakness with single leg exercises and adduction  
• GTPS (Greater trochanter pain syndrome): 

  Objective testing: 

  GT palpation = pain  

  - FABER Test = lateral hip pain  

  Pain on SLS for 30seconds 

   

  Treatment:  

  Remove contributing factors to ease pain e.g. habitual sitting/standing  

  Progressive loading of hip abductors / glutes  

  NSAIDS  

  • Avoiding aggs 
• Thigh muscle injury: 

  Mechanism: 

  Acute overuse, external trauma  

   

  Subjective: 

  Patients report a pull/strain sensation during activity (mechanical) +/- audible pop  

  Worse with activity, better with rest  

  Loss of muscular function that becomes progressive  

   

  Objective findings: 

  Pain on resisted muscular contraction: outer / mid / inner range  

  - Localised pain on palpation  

  Pain on active / passive stretch  

  Muscular weakness on contraction  

  +/- oedema and swelling  

  • Two-joint muscles more vulnerable 
• Quadriceps contusion: 

  Blunt trauma to the thigh, causing bleeding within the quadriceps muscle  

   

  Vastus lateralis most common area of trauma due to lateral position: Exposed to external contact compared to medial muscles  

  • Sports include: Football, rugby, American football, Martial arts 
• Hip Flexor injury Mechanism:  

  30% of groin injuries involve hip flexors  

  Movements include: Kicking, sprinting, change of direction  

   

  Muscles affected:  

  Mainly Iliopsoas and rectus femoris 

  Often associated with adductor related injuries  

  Difficult to differentiate each muscle with imaging and it will not change the management 

   

  Common areas of injury:  

  Proximal insertion of the tendon  

  2. MTJ 

   

  Testing:  

  Palpation  

  Resisted muscle test  

  • Modified Thomas test 
• Hamstring injury: 

   

  Possible predisposing factors:  

  Reduced eccentric strength  

  Short fascicle length of Biceps femoris  

  - Muscle imbalance, quads overloading  

  History of muscle injury within the same area  

   

  Symptoms:  

  Pain on resisted knee flexion  

  Passive knee extension with hip flexion e.g. SLR  

  • Loss of function involving the hamstrings 

   
• Principles of rehabilitation: 

  Consider the healing process timelines 

   

  Early stage: 

  Managing the inflammatory process  

  Pain management  

   

  Intermediate stage: 

  Promotion of remodelling process  

  Increase strength and ROM  

  Restore muscle balance  

   

  Late stage: 

  Sport / function specific exercises  

  • Continue to progress eccentric strength 
• Hamstring tear:  

  Early stage rehab:  

  Control pain and the inflammatory process  

  Time is dependent on the severity of the injury  

   

  Protect Optimal Loading Ice Compression Elevation  

  - Immobilisation / strapping / tape 

  Manual therapy 

  Maintenance of ROM  

  Avoid vigorous activity  

  • +/- CV fitness 
• Hamstring tear:  

  Intermediate stage rehab:  

  Increase strength of repair  

  Improve capacity of the muscle group 

   

  Guarded stretching 

  Isometric strength, low speed isotonic exercises  

  Introducing gradually higher resistance work. Pain limiting  

  Commencing eccentric activity  

  Introducing speed  

  • Continuing CV fitness progressions: Cross trainer, slow runs, static bike 
• Hamstring tear:  

  Late stage rehab: Increase functional demands 

  Fast eccentric / concentric work 

  Coordination drills  

  Ongoing strength progression  

  • Increasing speed for sprints 
• Proximal hamstring tendinopathy:  

  Common in sprinters  

  Compression of the tendon against the ischial tuberosity  

  Onset usually after sudden change in training e.g. increased incline  

  Dull, achy pain that intensifies with activity  

   

  Findings: 

  Pain on stretch and resisted contraction  

  Pain on palpation local to the ischial tuberosity  

  Can be confirmed with MRI/US = Swelling/matrix breakdown  

   

  Treatment: 

  Distal eccentric strengthening away from hip flexion  

  • As per rehabilitation principles