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类型The Thigh, Hip,Groin, and Pe.ppt

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    The Thigh Hip Groin and Pe.ppt
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    1、Chapter 21: The Thigh, Hip, Groin, and Pelvis,Anatomy of the Thigh,Nerve and Blood Supply,Tibial and common peroneal are given rise from the sacral plexus which form the largest nerve in the body the sciatic nerve complex The main arteries of the thigh are the deep circumflex femoral, deep femoral,

    2、and femoral artery The two main veins are the superficial great saphenous and the femoral vein,Fascia,The fascia lata femoris is part of the deep fascia that invests the thigh musculature Thick anteriorly, laterally and posteriorly but thin on the medial side Iliotibial track (IT-band) is located la

    3、terally serving as the attachment for the tensor fascia lata and greater aspect of the gluteus maximum,Functional Anatomy of the Thigh,Quadriceps insert in a common tendon to the proximal patella Rectus femoris is the only quad muscle that crosses the hip Extends knee and flexes the hip Important to

    4、 distinguish between hip flexors relative to injury for both treatment and rehab programs,Hamstrings cross the knee joint posteriorly and all except the short of head of the biceps crosses the hip Bi-articulate muscles produce forces dependent upon position of both knee and hip Position of the knee

    5、and hip during movement and MOI play important roles and provide information to utilize w/ rehab and prevention of hamstring injuries,Assessment of the Thigh,History Onset (sudden or slow?) Previous history? Mechanism of injury? Pain description, intensity, quality, duration, type and location? Obse

    6、rvation Symmetry? Size, deformity, swelling, discoloration? Skin color and texture? Is athlete in obvious pain? Is the athlete willing to move the thigh?,Palpation: Bony and Soft Tissue,Medial and lateral femoral condyles Greater trochanter Lesser trochanter Anterior superior iliac spine (ASIS) Sart

    7、orius Rectus femoris Vastus lateralis,Vastus medialis Vastus intermedius Semimembranosus Semitendinosus Biceps femoris Adductor brevis, longus and magnus Gracilis Sartorius,Palpation: Soft Tissue (continued),Pectineus Iliotibial Band (IT-band) Gluteus medius Tensor fasciae latae,Special Tests If a f

    8、racture is suspected the following tests are not performed Beginning in extension, the knee is passively flexed A normal muscle will elicit full range of motion pain free (one w/ swelling or spasm will have restricted motion) Active movement from flexion to extension Strong and painful may indicate

    9、muscle strain Weak and pain free may indicate 3rd degree or partial rupture Muscle weakness against an isometric resistance may indicate nerve injury,Prevention of Thigh Injuries,Thigh must have maximum strength, endurance, and extensibility to withstand strain In collision sports thigh guards are m

    10、andatory to prevent injuries,Recognition and Management of Thigh Injuries,Quadriceps Contusions Etiology Constantly exposed to traumatic blunt blow Contusions usually develop as a result of severe impact Extent of force and degree of thigh relaxation determine depth and functional disruption that oc

    11、curs Signs and Symptoms Pain, transitory loss of function, immediate effusion with palpable swollen area Graded 1-4 = superficial to deep with increasing loss of function (decreased ROM, strength),Quad Contusion,Management RICE, NSAIDs and analgesics Crutches for more severe cases Aspiration of hema

    12、toma is possible Following exercise or re-injury, continued use of ice Follow-up care consists of ROM, and PRE w/in pain free range Heat, massage and ultrasound to prevent myositis ossificans,General rehab should be conservative Ice w/ gentle stretching w/ a gradual transition to heat following acut

    13、e stages Elastic wrap should be used for support Exercises should be graduated from stretching to swimming and then jogging and running Restrict exercise if pain occurs May require surgery of herniated muscle or aspiration Once an athlete has sustained a severe contusion, great care must be taken to

    14、 avoid another,Myositis Ossificans Traumatica Etiology Formation of ectopic bone following repeated blunt trauma (disruption of muscle fibers, capillaries, fibrous connective tissue, and periosteum) Gradual deposit of calcium and bone formation May be the result of improper thigh contusion treatment

    15、 (too aggressive) Signs and Symptoms X-ray shows calcium deposit 2-6 weeks following injury Pain, weakness, swelling, tissue tension and point tenderness w/ decreased ROM Management Treatment must be conservative May require surgical removal due to pain and decreased ROM,Quadriceps Muscle Strain Eti

    16、ology Sudden stretch when athlete falls on bent knee or experiences sudden contraction Associated with weakened or over constricted muscle Signs and Symptoms Peripheral tear causes fewer symptoms than deeper tear Pain, point tenderness, spasm, loss of function and little discoloration Complete tear

    17、may live athlete w/ little disability and discomfort but with some deformity,Management RICE, NSAIDs and analgesics Manage swelling, compression, crutches With increased healing, progress to isometrics and stretching Neoprene sleeve may provide some added support,Hamstring Muscle Strains (second mos

    18、t common thigh injury) Etiology Multiple theories of injury Hamstring and quad contract together Change in role from hip extender to knee flexor Fatigue, posture, leg length discrepancy, lack of flexibility, strength imbalances Signs and Symptoms Muscle belly or point of attachment pain Capillary he

    19、morrhage, pain, loss of function and possible discoloration Grade 1 - soreness during movement and point tenderness (20% of fibers torn) Grade 2 - partial tear, identified by sharp snap or tear, severe pain, and loss of function (70% of fiber torn),Signs and Symptoms (continued) Grade 3 - Rupturing

    20、of tendinous or muscular tissue, involving major hemorrhage and disability, edema, loss of function, ecchymosis, palpable mass or gap 70% muscle fiber tearingManagementRICE, NSAIDs and analgesics Grade I - dont resume full activity until complete function restored Grade 2 and 3 should be treated con

    21、servatively w/ gradual return to stretching and strengthening in later stages of healing,Management (continued) Modalities and isometrics need to gradually be introduced during healing process When soreness is eliminated, isotonic leg curls can be introduced (focus on eccentrics) Recovery may requir

    22、e months to a full year Greater scaring = greater recurrence of injury,Acute Femoral Fractures Etiology Generally involving shaft and requiring a great deal of force Occurs in middle third due to structure and point of contact Signs and Symptoms Pain, swelling, deformity Muscle guarding, hip is addu

    23、cted and ER Leg with fx may also be shorter Management Treat for shock, verify neurovascular status, splint before moving, reduce following X-ray Analgesics and ice Extensive soft tissue damage will also occur as bones will displace due to muscle force,Femoral Stress Fractures Etiology Overuse (10-2

    24、5% of all stress fractures) Excessive downhill running or jumping activities Often seen in endurance athletes Signs and Symptoms Persistent pain in thigh/groin X-ray or bone scan will reveal fracture Walk with antalgic gait (abduction lurch) Positive Trendelenburgs sign Management Prognosis will var

    25、y depending on location Fx lateral to femoral neck tend to be more complicated Shaft and medially located fractures tend to heal well with conservative management,Anatomy of the Hip, Groin and Pelvic Region,Functional Anatomy,Pelvis moves in three planes through muscle function Anterior tilting chan

    26、ges degree of lumbar lordosis, lateral tilting changes degree of hip abduction Hip is a true ball and socket joint w/ intrinsic stability Hip also moves in all three planes, particularly during gait (bodys relative center of gravity),Tremendous forces occur at the hip during varying degrees of locom

    27、otion Muscles are most commonly injured in this region Numerous injuries attach in this region and therefore injury to one can be very disabling and difficult to distinguish,Assessment of the Hip and Pelvis,Bodys center of gravity is located just anterior to the sacrum Injuries to the hip or pelvis

    28、cause major disability in the lower limbs, trunk or both Low back may also become involved due to proximity History Onset (sudden or slow?) Previous history? Mechanism of injury? Pain description, intensity, quality, duration, type and location?,Observation Symmetry- hips, pelvis tilt (anterior/post

    29、erior) Lordosis or flat back Lower limb alignment Knees, patella, feet Pelvic landmarks (ASIS, PSIS, iliac crest) Standing on one leg Pubic symphysis pain or drop on one side Ambulation Walking, sitting - pain will result in movement distortion,Palpation: Bony,Iliac crest Anterior superior iliac spi

    30、ne (ASIS) Anterior inferior iliac spin (AIIS) Posterior superior iliac spine (PSIS),Pubic symphysis Ischial tuberosity Greater trochanter Femoral neck Poster inferior iliac spine,Palpation: Soft Tissue,Rectus femoris Sartorius Iliopsoas Inguinal ligament Gracilis Adductor magnus, longus & brevis Pec

    31、tineus,Gluteus maximus, medius & minimus Piriformis Hamstrings Tensor fasciae latae Iliotibial Band,- Major regions of concern are the groin, femoral triangle, sciatic nerve, lymph nodes,Special Tests,Functional Evaluation ROM, strength tests Hip adduction, abduction, flexion, extension, internal an

    32、d external rotation Tests for Hip Flexor Tightness Kendall test Test for rectus femoris tightness Thomas test Test for hip contractures,Kendalls Test,Thomas Test,Femoral Anteversion (A) and Retroversion (B),Relationship between neck and shaft of femur Normal angle is 15 degrees anterior to the long

    33、axis of the femur and condyles Internal rotation in excess of 35 degrees is indicative of anteversion, 45 degrees of external rotation is an indicator of retroversion,Test for Hip and Sacroiliac Joint,Patrick Test (FABER) Detects pathological conditions of the hip and SI joint Pain may be felt in th

    34、e hip or SI joint,Gaenslens Test Test works to push SI joint into extension Test is positive if hyperextension on affected side increases pain,Testing the Tensor Fasciae Latae and Iliotibial Band,Rennes test Athlete stands w/ knee bent at 30 - 40 degrees Positive response of TFL tightness occurs whe

    35、n pain is felt at lateral femoral condyle,Nobels Test Lying supine the athletes knee is flexed to 90 degrees Pressure is applied to lateral femoral condyle while knee is extended Pain at 30 degrees at lateral femoral condyle indicates a positive test,Obers Test Used to determine presence of contract

    36、ed TFL or IT-band Thigh will remain in abducted position, not falling into adduction,Trendelenburgs Test - Iliac crest on unaffected side should be higher when standing on one leg - Test is positive when affected side is higher indicating weak abductors (glut medius),Piriformis Test Hip is internall

    37、y rotated Tightness or pain is indicative of piriformis tightness,Elys Test Used to assess tightness of rectus femoris Athlete is prone, w/ pelvis stabilized and knee on the affected side is flexed If hip on that side extends as the knee is flexed, rectus femoris is tight Measuring Leg Length Discre

    38、pancy With inactive individual, difference of more that 1” may produce symptoms Active individuals may experience problems w/ as little 3mm (1/8”) difference Can cause cumulative stresses to lower limbs, hips, pelvis or low back,True or anatomical Shortening may be equal throughout limb or localized

    39、 w/in femur or lower leg Measurement taken from medial malleolus to ASIS Apparent or functional Result of lateral pelvic tilt or from a flexion or adduction deformity Measurement is taken from umbilicus to medial malleolus,Leg Length Discrepancy Measures,Recognition and Management of Specific Hip, G

    40、roin, and Pelvic Injuries,Groin Strain Etiology One of the more difficult problems to diagnose Injury to one of the muscles in the regions (generally adductor longus) Occurs from running , jumping, twisting w/ hip external rotation or severe stretch Signs and Symptoms Sudden twinge or tearing during

    41、 active movement Produce pain, weakness, and internal hemorrhaging,Groin Strain (continued) Management RICE, NSAIDs and analgesics for 48-72 hours Determine exact muscle or muscles involved Rest is critical; daily whirlpool and cryotherapy, moving into ultrasound Delay exercise until pain free Resto

    42、re normal ROM and strength - provide support w/ wrap,Trochanteric Bursitis Etiology Inflammation at the site where the gluteus medius inserts or the IT-band passes over the trochanterSigns and Symptoms Complaint of lateral hip pain that may radiate down the leg Palpation reveals tenderness over late

    43、ral aspect of greater trochanter IT-band and TFL tests should be performed,Management RICE, NSAIDs and analgesics ROM and PRE directed toward hip abductors and external rotators Phonophoresis if pain doesnt respond in 3-4 days Must look at biomechanics and Q-angle Runners should avoid inclined surfa

    44、ces,Sprains of the Hip Joint Etiology Due to substantial support, any unusual movement exceeding normal ROM may result in damage Force from opponent/object or trunk forced over planted foot in opposite direction Signs and Symptoms Signs of acute injury and inability to circumduct hip Similar S & S t

    45、o stress fracture Pain in hip region, w/ hip rotation increasing pain,Management X-rays or MRI should be performed to rule out fx RICE, NSAIDs and analgesics Depending on severity, crutches may be required ROM and PRE are delayed until hip is pain free,Dislocated Hip Etiology Rarely occurs in sport

    46、Result of traumatic force directed along the long axis of the femur (posterior dislocation w/ hip flexed and adducted and knee flexed) Signs and Symptoms Flexed, adducted and internally rotated hip Palpation reveals displaced femoral head posteriorly Serious pathology Soft tissue, neurological damag

    47、e and possible fx Management Immediate medical care (blood and nerve supply may be compromised) Contractures may further complicate reduction 2 weeks immobilization and crutch use for at least one month,Avascular Necrosis Etiology Result of temporary or permanent loss of blood supply to proximal fem

    48、ur Can be caused by traumatic conditions (hip dislocation disruption of circumflex artery), or non-traumatic circumstances (steroids, blood coagulation disorders, excessive alcohol use compromising blood vessels) Signs and Symptoms Early stages - possibly no S&S Joint pain w/ weight bearing progress

    49、ing to pain at times of rest Pain gradually increases (mild to severe) particularly as bone collapse occurs May limit ROM Osteoarthritis may develop Progression of S&S can develop over the course of months to a year,Avascular Necrosis (continued) Management Must be referred for X-ray, MRI or CT scan

    50、 Must work to improve use of joint, stop further damage and ensure survival of bone and joint Most cases will ultimately require surgery to repair joint permanently Conservative treatment involves ROM exercises to maintain ROM; electric stim for bone growth; non-weight bearing if caught early Medication to treat pain, reduce fatty substances reacting w/ corticosteroids or limit blood clotting in the presence of clotting disorders may limit necrosis,

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