Chapte

r 11 -
Injuries
-The Hip,
Thigh,
and
Pelvis

• Introduction

• Biomechanics

• Contusion of quadriceps

• Myositis ossificans traumatica

• Quadriceps strain and ruptures

• Avulsions of the iliac spines

• Hamstring strains

• Ischial apophysitis

• Groin strains

• Hip pointer and fracture iliac crest

• Iliac crest apophysitis and avulsion

• Trochanteric bursitis and snapping hip

• Hip strain

• Conjoint tendon strain

• Osteitis pubis

• Nerve entrapment

• Labral tears

• Stress fractures

• Fractured hip; acute slip of the upper femoral epiphysis (SUFE)

• Dislocation of the hip

• Fractured femur and pelvis

• Hip arthroscopy

• Avascular necrosis femoral head

• Osteoarthritis
1 Ireland J ‘The Hip, Thigh and Pelvis’ in Sherry E and Bokor D (eds). Manual of Sports Medicine, Chapter 13.

GMM, London, 1997.

Introduction

Injuries of the hip, thigh and pelvis are not that common from sport. They may be subtle in
presentation and diagnosis is difficult or catastrophic with serious immediate and long -term
consequences (e.g. hip fracture or pelvic fracture with shock).

Biomechanics of the hip

The hip is a ball and socket joint with simultaneous motion in all 3 planes (up to 120° of flexion,
20° of abduction and 20° of external rotation). The joint reactive forces are 3 to 6 times body
weight due to contraction of the large muscle groups about it; this is increased to with jumping or
running.

The acetabulum has a fibrocartilaginous rim (labrum) to deepen it and so add further stability.
The postero-superior surface of the acetabulum is thickest to accommodate weight-bearing. the
neck forms an angle of about 125° with the shaft and is 20° anteverted. The hip capsule drops
down across the front of the neck but only part-way at the back. It is reinforced by three
ligaments (the ilio-femoral ligament of Bigelow is the strongest). The major blood supply to the
head is from the medial circumflex branch (of the profunda femoris) which is at risk from
fractures of the neck of femur and dislocations.

Contusion of quadriceps (cork thigh, Charley Horse)

The result of a direct blow during contact which varies from mild to severe. Often worse when
the muscle is relaxed and occurs in the musculotendinous junction of the Rectus femoris
(central position of the quadriceps).

Clinical features There is pain, stiffness, a limp, and progressive swelling with bruising. The pain
is increased by resisted knee extension and hip flexion. Due to bleeding into the soft tissues
symptoms becomes worse over the subsequent 48 hours.
Classified according to that of Jackson and Feagin

Table 1. Classification of contusion quadriceps

Mild Localized tenderness in the quadriceps, knee

motion of 90 degrees or more, no alteration of gait.

The athlete is able to do a deep knee bend.

Moderate Swollen tender muscle mass, less than 90 degrees
 of knee motion and antalgic gait. The athlete is able

to do knee bends, climb stairs, or arise from a

without pain.
Severe Thigh is markedly tender and swollen and the

contours of the muscle cannot be defined. Knee

motion is less than 45 degrees and there is sever

limp. The athlete prefers to walk with crutches and

frequently has an effusion in the ipsilateral knee.

Treatment: There are three phases in the treatment.2 Measure thigh diameter and follow to
exclude small chance of compartment syndrome developing The first is limitation of motion to
minimize haemorrhage (with rest, ice, compression and elevation). The leg is maintained in
extension and quadriceps isometric exercises are allowed. Do for 24 hours, in mild contusions,
48 hours in severe. A more recent study otherwise keep hip and knee flexed (probably as
effective).

1. D W Jackson, J A Feagin. 1973. Quadriceps contusions in young athletes JBJS 55A, 95-105.

2. B. Rooger, S Bergston, G. Hagglurd. Acute compartment syndrome from anterior thigh muscle contusion: a

report of eight cases 1991. J. Orthop. Trauma 5, 57-59.

The second is the restoration of movement. This depends upon the condition of the quadriceps
stabilizing and the patient being pain free at rest. Use continuous passive motion and gravity
assisted motion. Supine and prone inactive knee flexion is encouraged along with isometric
quadriceps exercises. Once a pain free passive range of motion of 0 to 90 degrees is achieved,
and good quadriceps control, to static cycling with increasing resistance. At the end there is
ROM >90° and normal free gait (without a crutch).

The third is functional rehabilitation with progressive increasing resistance exercises builds
strength and endurance. Must always be pain free.

Myositis ossificans traumatica

A severe contusion or tear in the quadriceps with haematoma followed by acute inflammation.
Fibroblasts then form osteoid. Specific risk factors have been identified1.
• Knee motion <120°.
• Injury from football.
• Previous quadriceps injury
• Delay in treatment ( > 3 days).
• Ipsilateral knee effusion.

Clinical features - pain is over the front of the thigh along with a fluctuant mass which forms into
a hard mass at the two to four weeks. (May resolve after six months if the injury is low grade and
in the musculotendinous region).

Treatment as for contusion of the quadriceps. Aspiration or open drainage of the haematoma
may be necessary. Femoral nerve blocks, NSAIDs and radiotherapy have been used.

Quadriceps strain and ruptures1

The result of a severe contraction when either accelerating or kicking (usually the rectus femoris
and distal in the thigh).

Clinical features are localized tenderness or a palpable defect (Fig 1). The pain is exacerbated
by resistance of hip flexion in extension and full knee flexion in a prone position. MRIs show a
high signal on a T2 weighted image.

Differentiate from an L3 nerve root lesion (pain is in both mid-lumbar back and leg); made worse
by straight leg raising).

Treatment as for quadriceps contusions.

1. J B Ryan, J H Wheeler, W J Hopkinson et al. 1991 Quadriceps contusions west point update Am J Sports Med

19, 299-304.

Avulsions of the iliac spines

The mechanism of injury is a sudden violent contracture of the rectus femoris muscle,
(occasionally the sartorius muscle seen in soccer players. Players tend to be in their mid teens.

Clinical features - include severe pain point tenderness and bruising (sometimes dramatic)
diagnostic. Treatment includes rest, ice, compression and elevation. If there is persisting
functional impairment then surgery may be necessary to fix the apophysis or avulsed fragment.
Sometimes the bone fragment needs to be excised (at later date).

Hamstring strains

In the late swing phase of the gait cycle, hamstrings decelerate the limb. with sudden
acceleration from the stabilizing flexion to active extension, strain is put on the hamstring
muscles. This injury is most likely to occur with sudden hamstring contraction in athletes when
they are cold or have not done adequate stretching. Common situations are at the starting
blocks, sprinters at take off, (or high jumpers and long jumpers) an sudden acceleration or
resisted extension by football players(Fig 2).

The short head of the biceps femoris is most commonly affected. Occasionally dystrophic
calcification is seen.

The patient may describe a twinge or a snap and localize an area, (such as the short head of
the biceps). Swelling and a palpable defect are common.

Treatment includes rest, ice, compression, elevation and physiotherapy (local cryotherapy and
ultrasound). A stretching programme is commenced once pain has subsided.

Recovery is from days to week (depending upon the severity).

The key to treatment is to remedy poor training techniques and improve flexibility. The athlete
must carry out an adequate warm-up and stretching programme prior to a return to sporting
activities. The significant imbalance between quadriceps and hamstrings needs to be overcome,
and adequate return hamstring strength before returning to sport. A firm elasticized support is
useful.

Re-injury may occur with longer recovery; therefore exercise good judgement about when to
return to sport.

Ischial apophysitis (Weaver’s bottom, ischial bursitis) and avulsions

The result of excessive running, (especially in adolescents). Repetitive strain is put upon the
apophysis; worsened by tight hamstrings. Severe contracture of the hamstrings musculature
may avulse the tuberosity.

There is a dull ache and tenderness in the area and associated tightness of the hamstrings.
Ecchymosis and a palpable defect are present.

X-ray will show fragmentation or avulsion of the apophysis.

Treatment includes rest, ice, compression, elevation and physiotherapy and a flexibility
programme as per a hamstring strain. Significant displacement or functional disability may
necessitate surgical fixation.

Groin strains (adductor strain)

The groin is an ill-defined area and most part injuries here involve the adductor muscles.
Important: Exclude fractures, avulsions, hip joint injuries, inflammation of the pelvic joints,
bursitis about the hip, snapping hip, nerve entrapment and various forms of referred groin pain
from hernias, prostatitis, urinary infections, gynaecological disorders, rheumatological diseases,
bone infections and tumours.

Occurs in sports where cutting, side stepping or pivoting are required (as in soccer and rugby).
There is a violent external rotation with the leg in a widely abducted position. Occurs at the
musculotendinous junction. Injuries are often acute-on-chronic disruptions due to increased
collagen at the musculotendinous junction, and therefore reduced extensibility.

The athlete describes a sudden knife like pain in the groin area. Bruising and swelling are noted
and tenderness is well localized. The pain is exacerbated by adduction against resistance. In
chronic cases the symptoms are vaguer and diffuse. Renstrom1 described pain with exercise as
most common but also at rest often associated with stiffness in the morning, and some
weakness.

MRI identifies adductor longus as the solely affected muscle.

Treatment includes rest, ice, compression and elevation. After the initial 24 to 48 hours
haemorrhage should have ceased and physiotherapy modalities (cryotherapy and ultrasound)
started. Anti-inflammatory medication is useful for short periods in chronic cases. A stretching
programme is started with isometric without resistance followed by the gradual introduction of
resistance (within the limits of pain).

Attention should be directed to a lack of flexibility and to improving training techniques. Use of
an elasticized tape for support is useful. Steroids occasionally are of benefit in chronic cases.

Surgery is only contemplated after conservative management for six to twelve months. A
release of the adductor longus tendon is carried out with the hip in a flexed and abducted
position. Any degenerate nodule should be debrided, failing this a tenotomy is often useful.
Inguinal and femoral hernias may need repair (return to sport in 6 to 8 weeks).

A Grade III complete rupture is very uncommon (it occurs at the femoral attachment). In
selected cases surgical repair is undertaken.

1. PAHF Renstrom 1992. Tendon and muscle injuries in the groin area. Clin. Sports Med 11, 815-831.

Hip pointer and fracture iliac crest

The result of a direct blow to the iliac crest resulting in bruising (muscle or bone) or fracture.
From contact sports after a tackle or fall on to the iliac crest.

Clinical features include maximum tenderness usually over the mid point of the iliac crest
corresponding to the divergence of abdominal and lumbar musculature (the muscle fibre
separation). Otherwise the area of tenderness of point contact. Swelling and Ecchymosis are
progress over 24 hours. X-rays needed to rule out a fracture and subsequent x-rays may show
periostitis or exostosis formation.
Treatment includes rest, ice packs, compression and elevation (first 24 hours). Occasionally
aspiration and injection of local anaesthetic needed. After bleeding has ceased, ultrasound and
other physical therapy modalities useful. Protective padding when return to contact sports.
Rarely is surgical fixation required for displaced iliac crest fractures (where skin tenting).

Iliac crest apophysitis and avulsion

May result from repetitive stress in adolescents especially running with a cross-over style of arm
swing. Severe contraction or a direct blow may also avulse the iliac crest.

Clinical features are tenderness (anteriorly or posteriorly) on the iliac crest depending upon
whether tensor fascia lata, gluteus medius or oblique abdominal muscles are involved typically.
Resistance to abduction and contralateral flexion of the trunk frequently exacerbates the pain.

X-rays are needed to exclude avulsion of the iliac apophysis.

Treatment includes rest, ice, compression and elevation and physical therapy. It may be
necessary to change the athletes running style and gradually re-introduce activities.
Occasionally surgery is necessary to reduce the avulsed iliac crest.

Trochanteric bursitis and snapping hip

An inflammation of the bursa over the greater trochanter region as a result of increased shear
stress caused by the ilio-tibial band over the trochanter. Often a broad pelvis and large
quadriceps angle (Q-angle). Leg length discrepancies, pelvic tilt or cross over type running style
may be present. A snapping hip is due to thickening of the posterior part of ilio-tibial band which
produces a painless snapping sensation (snapping ilio-tibial band syndrome).

Clinical features are pain over the lateral aspect of the thigh when lying on the affected side (in
the posterior and lateral aspect of the trochanter). Abducting against resistance in an internally
rotated position will exacerbate the pain. A snapping sensation may be noted with the patient
standing on the extended knee and pushing the hip into an adducted and flexed position.

Other snapping hip is seen with repetitive rubbing of the capsule in running or ballet (involves
the iliopsoas tendon) so called Iliopsoas Bursitis.1

Clinical features include pain around the medial aspect of the groin which occurs with rotation of
the hip. Resistance to flexion of the hip from 90 degrees of flexion leads to increased pain and
tenderness in the groin. Clicking is reproducible to note that pain may be referred from the
lumbo-sacral spine or sacroiliac joint.

1. M. Jacob, B. Young 1973 Snapping hip phenomenon among dancers Am Correct Ther J 32, 92.
Treatment includes rest, ice, compression, and elevation followed by ultrasound (low frequency
pulsed) and stretching of the ilio-tibial band and iliopsoas to overcome contractures. Correct any
leg length discrepancy or abnormal running style, Orthotics can help. Steroid injections and anti
inflammatories may be useful in an acute bursitis. Surgery has a limited place and only after a
prolonged period of conservative management ( technique involves Z-plasty of the ilio-tibial
band or lengthening of iliopsoas in iliopsoas bursitis). Other bursitis iliopectioneal - pain over
anterior hip with antalgic gait. R.I.C.E, NSAIDs, stretching, flexibility.

Hip strain (pericapsulitis, synovitis, irritable hip)

The result of a direct blow, twisting injury, or from overuse of the hip. Inflammation of the lining
or a strain of capsular ligaments occurs may be cause of hip pain in young athletes.

There is pain in the groin, radiating into the thigh. Athlete comfortable in flexion, abduction and
external rotation (increases volume of joint capsule so decompressing). Pain is worsened by
extension and internal rotation. Antalgic gain may be noted.

Exclude infection (especially in children and SUFE). X-rays may show joint widening. Bone scan
is often useful (positive).

Treatment includes R.I.C.E. and non-weightbearing. Bed rest (with springs and slings) in
children, until complete resolution of symptoms. If capsular tightening occurs then a flexibility
programme is required. Rarely is his arthroscopy necessary.

Conjoint tendon strain

Results from stress on the abdominal musculature (from a mark in football or heading in
soccer).

Pain and tenderness over the superior pubic ramus. Hip movements are full. X-rays are normal.
The bone scan is occasionally positive.

Treatment R.I.C.E., physical therapy and a flexibility programme. Only occasionally surgery.

Osteitis pubis

A self limiting necrosis in the bone of the pubis and synchondrosis.1

Results from repetitive shear stress across the symphysis in running and kicking sports
(subacute periostitis).

Clinical features are a gradual onset of groin pain worsened by activity. Severe pain when
jumping. Tenderness is maximal over the symphysis, the body and rami of the pubis;
aggravated by pelvic compression, full flexion, wide abduction of the hips and even sit ups.
Exclude hernias, groin strains and prostatitis in males. X-rays changes are delayed for at least a
month but show a periosteal reaction and demineralization of the subchondral bone leading to a
‘moth eaten’ appearance around the symphysis. (In severe cases erosion can lead to instability;
detected in single leg weight bearing views of the pelvis).

1 J M Cochrand 1971 Osteitis Pubis in athletes Br J Sports Med 5, 233.

Bone scans are often positive in the early stages (Gallium scans to exclude an infection).

Treatment includes rest, NSAIDs and occasionally steroid injections. Then gradual re-
introduction of a flexibility programme and increased weight bearing. May take up to 12 months
to recover.

Nerve entrapment

The nerves usually involved are the ilio-inguinal nerve, obturator nerve, genito-femoral nerve
and lateral cutaneous nerve of the thigh. Hypertrophy of muscles (hypertrophied abdominal
muscles may entrap theilio-inguinal nerve; enlarged hip adductors in skaters may entrap the
obturator nerve) or scarring are the most likely causes. Meralgia paraesthetica is caused by
compression of the lateral femoral cutaneous nerve. A knowledge of the distribution of the
nerves will help to make a diagnosis. These areas are likely to exhibit pain and paraesthesia.
Tenderness may be experienced over the sub cutaneous emergence of the nerve Tineb positive
EMG.
Treatment: NSAIDs, stretches and local steroid injections are the first tried, but if symptoms
persist then surgical release is necessary. Make sure athlete is not wearing tight braces, pads
etc nor using long periods of hip flexion.

Labral tears

Typically seen in dysplastic hips where there are abnormal loads (shear and strain) on the
labrum. Also from excessive twisting action.

A sharp pain or a catching sensation on a background of a dull ache. (Aggravated by flexion and
internal rotation of the hip). X-rays may show acetabular dysplasia. Tears are confirmed by
arthrography or arthroscopy (usually in the posterior aspect of the hip joint).

Treatment is rest and surgical excision / repair (difficult).

Stress fractures

First described by Briethaupt in 1855 in German soldiers (Stechow noted on x-rays in 1897).
Stress fractures of the neck of femur were described by Blecher in 1905. Much of the early
literature in regard to stress fractures was from the military. Nowadays stress fractures seen in
athletes; the highly motivated athletes in peak condition and at maximal performance. Risk
factors are endocrine disorders especially in amenorrhoeic female athletes (see Chapter 23)
clearly on overuse injury.

The mechanism is a partial or complete fracture of bone due to an inability to withstand non
violent stress applied in a rhythmic/repeated sub maximal mode.
Controversy exists as to whether they are due to fatigue of muscles leading to increased load or
(as Stanitski believes)1 an increased muscular force plus increased rate of remodeling leading
to resorption and rarefaction and ultimately to stress fractures. This will manifest as a periosteal
or endosteal response giving an appearance of a stress fracture which may ultimately progress
to a linear fracture and in time displace.

1. C.L. Stanitski, J H McMaster, P.E. Scranton. 1978. On the nature of stress fractures. Am J Sports Med. 6, 391.

The clinical and x-ray criteria for diagnosis of a stress fracture are:

• Premorbid normal bone

• No direct trauma/inciting activity

• Pain and tenderness (on percussion and antalgic limp) prior to x-ray changes - useful
clinical sign.

• Subsequent x-rays show resolution and modeling

• Positive bone scan

Assess the opposite limb clinically and by x-ray to exclude a stress fracture (as not always
symptomatic). Differential diagnosis includes tumour (particularly osteosarcoma and Ewings
tumour), osteomyelitis or periostitis from TB or syphilis. Jumping sports have a strong often
injure the femur and pelvis but stress fractures have been noticed amongst hikers and fencers
(especially in the pelvis).

Typically classified into those of the femoral neck or shaft.

Femoral neck (Hajeck)1

• Compressive of inferior cortex - young patients/early internal callus/sclerosis may

complete non-weight bear/modify training.

• Transverse of superior cortex - older patients/initial crack in superior cortex may

displace.

Femoral shaft (Blickenstaff)2

 • medial proximal femur

• displaced spiral oblique

• transverse distal

crutches (4 to 8 weeks), may complete, often need to operate.

Treatment involves decreased weight bearing and modified training. May be all that is required
early femoral shaft stress fractures and compressive type of femoral neck fractures. In the older
patient it is wise to pin at an early stage (as a risk of progression). Be aware: to ensure that both
elite athletes and amateurs do not suffer significant stress fractures. Finite element analysis
evidence suggests that a maximum 100 miles over a three month period is the limit for a first
time jogger.

1 MR Haje K, HB Noble. 1982 Stress fractures of the femoral neck in joggers. Am J Sports Med 10, 112.

2 LD Blicken Staff, JM Morris 1966. Fatigue fracture of the femoral neck. JBJS 48A, 1031.

Fractured hip; acute slip of the upper femoral epiphysis (SUFE)

These occur from a sever force applied while the foot is planted and the hip twisted. (Seen in
cross country and downhill skiers from a low velocity fall ‘Skier’s HIP’). Hip fracture may occur or
SUFE in child (Fig 3).

There is severe pain and an inability to weightbear, with shortening and external rotation in the
hip. Exclude a past history of ache or an antalgic gait with an acute or chronic slipped upper
femoral epiphysis.

Treatment is immediate immobilisation and then immediate operative stabilization and drainage
of the capsular haematoma.

Dislocation of the hip

Dislocations result from a direct impact to the flexed knee and hip (anterior or posterior)(Fig 4).

There is severe pain and typical deformity with the leg in a flexed and internally rotated position
(posterior dislocation) or externally rotated (anterior dislocation). The sciatic nerve may be
involved.

Immobilize the athlete give analgesia and plan immediate reduction (open if necessary) of the
hip to reduce the likely development of AVN and later OA. This is a surgical emergency with
serious long term consequences for a young athlete.

Fractured femur and pelvis

High velocity injuries. Significant pain and deformity occurs. Exclude neurological or vascular
compromise. There often are associated head, neck, chest (pneumothorax) and abdominal life
(splenic/hepatic/renal/bladder/urethral rupture) threatening injuries which must be found and
treated urgently.

Apply MAST suit immediately. Note blood at tip penis (indicates urethral rupture)1. Resuscitate
the athlete with special attention to head injury, immobilize the neck, exclude need for chest
tube peritoneal lavage/exploratory laparotomy. Optimize volume replacement (up to 40 units of
blood can disappear into a fractured pelvis) and give adequate analgesia. Surgery is almost
always required to reduce and hold fractures of the femur (neck/shaft) and quite often for the
pelvis (external fixateur to tamponade bleeding in displaced and unstable pelvic fracture.
Consider applying pelvic clamp in ER (if >10 minutes to get to OR and BP is low). Such athletes
have high chance of long term back pain, leg length discrepancy, pelvic pain and impotence.

Hip arthroscopy -Bowman first reported hip arthroscopy in 1937. It has recently become more
widely used but the uses, apart from diagnostic, are fairly limited. It is a difficult, technique
dependant procedure.

1 E Sherry 1993 Skiing Trauma in Australia. MD thesis UNSW.

Possibly useful where there is unexplained hip pain, where of synovitis or early osteoarthrosis
can be used for lavage in early osteoarthrosis and for treatment of labral tears, removal of loose
bodies (from fractures, osteochondromatosis and villonodular synovitis). Several techniques
have been described.
Avascular necrosis femoral head

A partial or complete disruption of the blood supply to the femoral head resulting in necrosis of a
segment which may then under go collapse before revascularization has occurred. A
catastrophe for a young athlete.

Most commonly follows a fracture of the head or femoral neck or dislocation/subluxation

(especially if associated with delay in reduction; Posterior dislocations in particular disrupt the
superior retinacular vessels). Perthe’s Disease, results from an increased intracapsular pressure
following a synovitis which compromises the vascular supply to the femoral head. AVN is
classified according to that of Ficat1 with diagnostic and surgical intervention noted. (Table 2)
Table 2. Ficat’s classification of AVN
Stage Pain Exam XR Bone Scan MRI Treatment
0 None Normal Normal Normal Normal Normal
1 Minimal I.Rot Normal No help Some ?core

changes decompression
2 Moderate ROM Positive Positive Graft
 Porosis/ sclerosis
3 Advanced ROM Flat, Positive Positive Joint

crescent replacement

sign
4 Severe Pain Positive Joint

Acetabular replacement

changes

Positive

Osteoarthritis

High correlation with high impact sports especially track and field and racquet sports. Work
performed by Radin shows that compression of the joint with oscillating repetitive high impact
loads leads to microfractures. Conditions associated with avascular necrosis will advance the
onset of osteoarthrosis. Athletes with extensive sports participation have a 4 to 5 fold increased
incidence of OA2 (up to 8.5 if also involved in an occupation risk of OA. Patients who have had
hip replacements should not play impact.

1 RP Ficat, J Arlet. 1980 Ischaemia and Necrosis of Bone. Baltimore. Williams and Williams.

2 E Vingard, L Alfredsson, I Goldi, C Hogstedt. 1993. Sports and osteoarthrosis of the hip. Am JSports Med 21,

195-200.