FUNCTIONAL ANATOMY AND EXAM OF THE HIP, GROIN AND THIGH

FUNCTIONAL ANATOMY AND EXAM OF THE HIP, GROIN AND THIGH

Peter G Gerbino, MD, FACSM Orthopedic Surgeon Monterey Joint Replacement and Sports Medicine Monterey, CA TPC, San Diego, 2017

The lecturer has no financial relationship to any manufacturer or product discussed in this presentation. DISCLOSURE

At the conclusion of this lecture, participants should be able to: Differentiate among hip, groin and thigh anatomic injury sites Examine each of these sites Order imaging studies appropriate for each site and possible diagnosis OBJECTIVES

Bones Pelvis Femur Joints Sacroiliac Hip Symphysis pubis ANATOMY

Sciatic nerve Hip labrum Psoas tendon Ilio-tibial tract Gluteus medius and minimus tendon insertions Inguinal fascia insertions on pelvis Adductor longus tendon Apophyseal attachments Thigh muscles SOFT TISSUES (COMMONLY INJURED)

EXAMINATION Based on mechanism of injury: trauma or overuse Based on location: buttock, groin, lateral thigh, thigh muscles, combination

1. Pelvis (fracture, contusion, apophysitis) A. Palpate all bony parts B. Stress pelvis by pushing on both sides 2. Femur A. Palpate greater trochanter B. Stress shaft by indirect 3-point bending C. Stress femoral neck by forced flexion, internal and external rotation HOW TO EXAMINE:

3. Sacroiliac joint A. Stress pelvis by compression B. FABER test: flexion, abduction, external rotation 4. Hip joint A. Range of motion in 3 planes B. Asymmetric FABER tests C. Click with extension following flexion with internal or external rotation D. Heel tap, Log-roll, Stinchfield tests for irritable joint

5. Symphysis pubis A. Direct palpation of joint B. Pelvic compression 6. Sciatic nerve A. Palpation of nerve in sciatic notch B. Neurotension test with straight leg elevation C. Piriformis test by resisting external rotation, abduction D. Test motor, sensory and reflex function

7. Hip labrum A. Flexion, internal rotation followed by extension causes painful click B. Flexion, external rotation followed by extension causes painful click (this could also be from snapping psoas tendon)

8. Psoas tendon A. See B. above B. Tendon palpation at rest and during snapping maneuver 9. Ilio-tibial tract A. Tenderness at greater trochanter and ITB B. Ober test may or may not show ITB tightness

10. Gluteus medius and minimus A. Tenderness at greater trochanter B. Pain with resisted hip external rotation C. Trendelenberg test shows pelvic drop or pain on effected side 11. Inguinal fascia at pelvis A. Classic tests for direct and indirect hernia B. Tenderness lateral to symphysis at pelvic brim C. Pain with resisted abdominal crunches

TRENDELENBERG TEST

12. Adductor longus tendon A. Tenderness in tendon, especially at pelvic origin B. Pain with resisted adduction 13. Apophyseal attachments A. Skeletally immature athlete B. Tender at ASIS, AIIS, ischial tuberosity, lesser trochanter

14. Thigh muscles A. Quadriceps, adductor and hamstring muscle palpation. B. Origin and insertion sites of each group C. Pain with resisted muscle function

1. Pelvis A. Trauma 1) A-P, inlet, outlet views of pelvis 2) For acetabulum, Judet (oblique) views 3) CT for detailed analysis of fractures, blood in pelvis B. Avulsions, osteitis pubis, sacroiliitis 1) A-P pelvis IMAGING

2. Femur A. A-P and lateral of femur or hip as required B. MRI or bone scan to find occult stress fracture 3. Hip A. A-P and lateral for routine evaluation B. Dunne, false-profile views for dysplasia, FAI C. MRI without contrast ok for FAI if 3 Tesla magnet D. MRI with gado, Ropivicaine for FAI E. 3-D CT for detailed bony anatomy pre-operatively

4. Soft tissues A. MRI can show muscle tears, tendinopathy B. Dynamic ultrasound shows snapping structures

Hip, groin and thigh includes bones, joints, nerves and other soft tissues. Pain can originate and multiple sites. Each site has specific methods of evaluation for physical exam and imaging. Femeroacetabular impingement and gluteal tendinosis are two new areas to understand anatomy, examination and imaging techniques. SUMMARY