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Chapter 14
INJURIES TO THE HIP AND PELVIS
Anatomy Review. The three distinct parts of the bony pelvis are the
ilium, ischium and pubis.
A. The bony pelvis is an attachment site for the lower
extremities and numerous muscles and protects internal organs. In the
mature female, the pelvis is important in the birth process.
B. The major articulations of the bony pelvis include the hip
joint, sacroiliac joints, and the symphysis pubis. All of these joints
have strong ligamentous support.
C. Several nerves and blood vessels course through the bony
pelvis. Some of the more important nerves are made up from the cauda
equina. Nerves exiting the spinal cord below the L-1 level typically
pass through the bony pelvis. These nerves include the formation of
the lumbar plexus, the sacral plexus, the coccygeal plexus, and other
individual nerves (refer to Figure 14.2 on page 206). The sciatic
nerve is the largest nerve in the body; made up of nerve roots L-4
through S-3, it passes through the posterior portion of the bony
pelvis and down the posterior aspect of the leg. The blood vessels in
the region include the iliac artery and vein (refer to Figure 14.3 on
page 207).
D. Many of the muscles attached to the bony pelvis provide
musculature for the leg, back, and abdomen (refer to Figures 14.4 and
14.5 on pages 207 and 208). The main muscles of hip extension are the
gluteals and the hamstrings.
I. Common Sports Injuries. Sports-related injuries to the hip and
pelvis are not common. Injuries to soft-tissues in this region are
more common and can be debilitating. Sports-related injuries to this
area often involve collision sports or forceful movements in an
activity that requires power or speed of the lower extremities.
Overuse injuries, however, can also occur.
A. Skeletal Injuries.
1. Fractures of the Pelvis. One of the most devastating
injuries to the pelvic region is the fracture of one of the pelvic
bones. This injury is uncommon in sports because it typically takes a
great deal of force to cause such a fracture. Pelvic fractures,
however, may occur in hockey, pole-vaulting, and football, sports in
which direct compression from another athlete may happen. In
adolescents, skeletal injuries to the pelvis can be very serious,
especially if the injury involves an open epiphysis. Any skeletal
injury to this region requires referral to a physician immediately.
a. Signs and symptoms of a fractured pelvis include
abnormal pain in the pelvic region after the injury; possible swelling
in the area that is rarely accompanied by visual or palpable
deformity; and pain when the iliac crests are pressed together.
b. Since internal organ injuries are possible, the
athlete should be evaluated by medical personnel. If present,
hematuria must be immediately reported.
c. First aid care involves treating for possible
shock and internal bleeding and monitoring the athlete's vital signs
regularly.
d. Transport the athlete to the hospital on a long
spine board with the foot elevated. Pelvic fractures are serious
injuries that need to be evaluated by a physician immediately. Under
no circumstances should an athlete with a suspected pelvic fracture
return to participation before seeing a physician.
2. Other Adolescent Fractures.
a. Femoral Neck Stress Fracture. This injury occurs
more commonly in the thin amenorrheic athlete involved in an endurance
sport. This injury results from a loss of shock-absorbing capacity of
fatigued muscles in the hip area. Poor footwear, hard running
surfaces, or hip deformities can also contribute to the injury.
1) Typically the athlete complains of severe
anterior thigh or groin pain and experiences pain when walking.
b. Slipped Capital Femoral Epiphysis. This condition
occurs most commonly in 10 to 15-year old boys, particularly tall boys
who have experienced a recent growth spurt, or in boys who are
overweight and in whom secondary sexual characteristics are late in
appearing.
1) The affected boy typically exhibits a flexed
hip, lack of hip motion, and pain in the anterior groin, hip, thigh,
or knee. Any child under the age of 12 who complains of knee pain
should be evaluated by a physician.
c. Hip Pointer. Probably the most common injury to
the area is a contusion to the superior/anterior portion of the iliac
crest, which is referred to as a hip pointer. This injury can be
extremely painful and debilitation but does not require immediate
emergency attention or cause major complications.
1) Signs and symptoms include swelling, pain,
and discoloration at the injury site. The athlete may walk with a
slight limp.
2) First aid care involves the immediate
application of ice to the injury. The athlete should rest and avoid
activities that involve the lower extremities. Crutches may be
necessary if the injury is severe.
3) Long-term care involves limited
participation within 1 to 2 weeks. To prevent recurrence, special
padding over the area is recommended (refer to Figure 14.6 on page
210).
d. Other Hip Problems. Athletes who run excessively
can experience "snapping hip syndrome," which is attributed to one of
the muscles in the lateral hip riding over the top of the greater
trochanter of the femur. Treatment usually consists of stretching
tightened muscles and correction of any biomechanical deviations in
the area. The physician may recommend anti-inflammatory medications;
surgery is rarely suggested.
1) Trochanter bursitis is rarely a problem for
most athletes. It is more common in middle-aged people, but runners
are becoming more prone to develop the problem. The bursitis usually
results from acute trauma to the area or repeated microtrauma to the
tendon attachments of the bursae in the area. The athlete will
complain of pain over the greater trochanter followed by pain
radiating down the anterior or lateral thigh and to the buttock. Most
athletes benefit from stretching the iliotibial band, taking
nonsteroidal anti-inflammatories, and using thermotherapies. Surgery
may be necessary in some cases.
e. Osteitis Pubis. Osteitis pubis results from
continued stress and possibly some degeneration in the symphysis pubis
joint. This injury is commonly the result of overuse; athletes who
perform repetitive pelvic movements are more susceptible to the
problem, which is difficult to diagnose.
1) The athlete complains of pain in the groin
area with insidious onset that worsens progressively. Male athletes
may have testicular or scrotal pain along with discomfort in the
anterior pubic, suprapubic, or hip areas. Athletes with these symptoms
should be referred to a physician. Rest, ice, and OTC anti-
inflammatories may be helpful. It may take 3 months to a year to
recover from this injury.
f. Injury of the Sacroiliac Joint. The sacroiliac
joint is a common site of pain in the posterior pelvis. Joint movement
becomes limited, so the athlete requires specific movement techniques
provided by a trained professional to restore the joint's normal
motion.
g. Hip Dislocation. Although this injury is rarely
experienced in sports, it is very serious. Typically the injury occurs
during a collision and results when the hip joint is in flexion and
the force is applied to the femur. The hip often dislocates
posteriorly, and the athlete experiences extreme pain and loss of
movement in the affected leg.
1) Signs and symptoms include abnormal pain at
the injury site, swelling at the site that is palpable, and the knee
of the involved leg is angled toward the opposite leg.
2) Treat for possible shock, immobilize the
athlete and transport to the nearest medical facility. Monitor the
athlete's blood flow to the leg at all times.
B. Soft-Tissue Injuries. In sports, soft-tissue injuries are not
common. Several muscles, however, are susceptible to avulsion.
1. Avulsion Fractures. The possibility of muscle avulsions
during forceful activity always exists in sports. Skeletally immature
athletes are more prone to avulsion fractures around the hip because
their tendons are stronger than their growth centers. The mechanism of
this injury is a sudden near-maximal muscle contraction, resulting in
a small piece of bone tearing off at the attachment site. In the
mature adult, this action usually results in a torn muscle or tendon
because the bone is stronger than the tendon.
a. Avulsion fractures commonly occur in athletes who
participate in soccer, tennis, sprinting, or jumping. The injured
athlete complains of severe localized pain and ecchymosis at the site
of injury, which is commonly the anterior inferior iliac spine, where
the rectus femoris attaches, a