The muscles that surround the hip are vulnerable to injury from direct impact (contusion) or forceful contraction of a stretched muscle (strain). This chapter will cover contusions and strains around the hip joint. Hamstring injuries is covered in Chapter 88 .
Contusions are the most common injury to the hip, thigh, and pelvis. Collisions with other athletes or falls to the ground are the most common cause of contusions. Contusions can be superficial and limited to the subcutaneous tissue, or they can be deep and involve the bone, muscle, and ligaments. When associated with muscle involvement, contusions can result in slow bleeding with significant hematoma formation. Depending on the depth of the contusion and the extent of the injury, symptoms may occur immediately or after a 24- to 48-hour delay. Often, particularly with superficial contusions, treatment is of short duration and is based on the patient’s symptoms. Patients generally have a rapid return to play. With the diagnosis of a deep contusion, however, the treatment period may be extended. Aside from icing, treatment should be delayed 48 hours to ensure that all bleeding has stopped. After 48 hours, treatment with antiinflammatory drugs, heat, massage, and physical therapy is implemented. Rehabilitation should be aimed at maintaining flexibility and muscle mass. Range of motion (ROM) should be monitored because patients are prone to the development of myositis ossificans after sustaining deep contusions involving the muscle.
Iliac Crest Contusion
Iliac crest contusion, commonly known as a hip pointer, is an anterior pelvic contusion that commonly affects athletes involved in contact sports. These contusions result from either a direct fall onto the iliac crest or from a direct blow, as seen in football or hockey.
The athlete will almost immediately note pain over the iliac crest and/or greater trochanter after a fall or collision. He or she will note an inability to ambulate without a limp and pain with side-to-side or attempted crossover movements.
Examination of the injured athlete will reveal an antalgic gait, pain with palpation of the pelvic brim, bruising, and swelling. Active ROM of the hip will be decreased. Strength testing will demonstrate a marked decrease in any or all of the following muscle groups, depending on the location of the contusion: hip flexors; sartorius and rectus femoris; the internal and external obliques; the tensor fascia lata; the gluteus medius; the latissimus dorsi; and the paraspinal muscles.
Diagnosis of a hip pointer is made primarily on the basis of the history and physical examination. Radiographs are used only to rule out further injury, such as a fracture. Adolescent athletes are susceptible to avulsion fractures and may require a radiograph should an avulsion injury be suspected. Rarely, magnetic resonance imaging (MRI) or ultrasound are needed; however, some investigators have advocated their role in the evaluation of hematoma formation in an effort to quantify return to play.
Nonoperative treatment with protection rest, ice, compression, and elevation (PRICE) is central to treatment of hip pointers. Crutches may be used for the first few days. Ice, rest, and compression should be instituted for the first 48 hours to decrease the risk of hematoma formation. Antiinflammatory agents also may be used during the first 5 to 7 days. Beginning on day 3, the athlete may begin painless ROM activities. Some investigators have advocated delivery of a cortisone injection to the affected area to decrease pain and swelling; however, the risks of such injections must be weighed. Physical therapy may be initiated once a painless ROM has been established. Therapy should include stretches, sport-specific massage, and strengthening. Surgery is rarely indicated for hip pointer injuries; however, concomitant injuries such as sports hernias must be ruled out.
Our preferred technique is to initiate PRICE and use of crutches for the initial 24 hours. A repeat physical examination in the office should be undertaken within 3 to 4 days of the injury. Provided an avulsion fracture is not suspected, ROM exercises and gentle stretches are begun. A localized cortisone injection is considered for athletes who are not progressing as rapidly as anticipated. In those instances, activities are ceased for 48 to 72 hours, and rehabilitation is then resumed in earnest. Return to play is expected in 2 to 4 weeks once the athlete has completed strength testing and sport-specific drills.
Return to Play
Return to play is anticipated 2 to 4 weeks after the time of injury. Sport-specific drills and strength testing of the affected limb must be completed prior to resumption of competitive activities. Upon returning to activities, appropriate padding should be worn to prevent reinjury.
The treatment of hip pointers has yielded excellent results. Almost all athletes are able to return to their previous level of competition and performance once the injury has sufficiently healed.
Complications after hip pointers are rare. The complications most commonly seen include hematoma formation, cutaneous nerve injury, or myositis ossificans. Missed fractures or avulsions injuries are rare complications.
The quadriceps consists of the rectus femoris and the vastus musculature (medialis, lateralis, and intermedius; Fig. 87-1 ). Quadriceps contusions are the result of a direct blow or trauma to the thigh. They typically occur in the anterior or lateral compartment and are most commonly associated with football, soccer, rugby, or high-speed traumas. The pathophysiology associated with quadriceps contusions involves microtrauma to the muscle fibers with resultant swelling and edema. More significant contusions can also result in hemorrhage formation, myositis ossificans, or even tears.
Jackson and Feagin established a classification system based on knee flexion. They describe the muscle contusion as mild, moderate, or severe. Forty-eight hours after injury, mild contusions are able to flex greater than 90 degrees; moderate contusions, from 45 to 90 degrees; and severe contusions, less than 45 degrees ( Table 87-1 ). This classification helps guide counseling and treatment, and resolution occurs on days 6.5, 56, and 72, respectively. No corresponding MRI classification system has been developed. Persons with injuries classified as moderate to severe contusions were significantly more likely to experience myositis ossificans than were persons with mild contusions.
|Grade||Range of Motion|
Typically the patient will present on the field with a chief complaint of pain, lack of movement, or explosiveness and an antalgic gait. Twenty-four to 48 hours later, the patient may note similar or amplified symptoms, with noticeable limitations of knee ROM, thigh pain, loss of function, and swelling. As previously stated, the mechanism of injury is usually a helmet or a severe kick to the thigh.
Physical examination begins by evaluating the gait of the patient as he or she walks. Typically an antalgic gait is noted in persons with a moderate to severe contusion. A localized physical examination will note a tender, swollen, and oftentimes ecchymotic thigh in the area corresponding to the blunt trauma that was sustained. The thigh should be compared with the contralateral side as well. Palpation of the affected thigh may yield a palpable defect found in persons with severe contusions, indicating a partial or complete tear. In addition, a firm thigh compared with the contralateral side has been associated with longer recovery times. However, the most important component of the physical examination is the ROM of the knee, because this component correlates with the severity of the injury and the anticipated return to activity. Rarely, symptoms of an anterior thigh compartment syndrome can be identified on the basis of the physical examination.
Plain radiographs may be taken in the initial setting to rule out fracture; however, they typically have a low yield if a thorough history and physical examination are conducted. However, radiographs may have a more substantial role 2 to 4 weeks after injury if a firm mass is palpated to evaluate for developing myositis ossificans.
MRI and ultrasound also may be used to evaluate the extent of the muscular edema and hemorrhage; however, no level I studies have shown that imaging evaluations will accurately correlate with the severity of the contusion or predict return a play better than the Jackson and Feagin knee flexion classification.
The treatment of quadriceps contusions is usually managed in a nonoperative or conservative fashion ( Table 87-2 ). Depending on the severity of the injury, some athletes may be able to continue their activity and present after competition or training for evaluation. Based on military studies, knee immobilization with the knee flexed to 120 degrees for the initial 24 hours is recommended. Severe contusions may benefit from flexion immobilization for up to 48 hours. This immobilizations can be achieved with either a hinged knee brace with locking capabilities, a compressive elastic wrap, or an anteriorly placed splint. Ice and compression should also be initiated in the first 24 to 48 hours, followed by elevation (the PRICE protocol). After the initial period of flexion, active, pain-free ROM exercises should be initiated. For severe contusions, crutches may be used until quadriceps control has returned. In these cases, physical therapy may be warranted, as well as the use of electrical stimulation. Ryan et al. demonstrated a shortened recovery time for the moderate and severe groups from 56 to 19 days and from 72 to 21 days, respectively, via utilization of the aforementioned protocol. After return to pain-free motion, patients are allowed to return to noncontact sport-specific training. Return to contact sports is allowed after the thigh firmness has resolved and the muscle is not tender to palpation. If the patient is involved in a contact sport, a thigh pad with a ring should be recommended to minimize recurrence ( Fig. 87-2 ).
|Grade||Muscle Tearing||Strength Loss||Pain||Physical Examination: Muscle Defect|
|II||Moderate||Moderate/severe||Moderate/severe||Possible palpable defect|
|IIIA||Severe||Severe||Severe||Frequent palpable defect (complete rupture of musculotendinous unit)|
|IIIB||Severe||Severe||Severe||Frequent palpable defect (avulsion fracture at the tendon’s origin or insertion)|
Nonsteroidal antiinflammatory drugs (NSAIDs) are used initially to decrease pain and swelling, but long-term use is discouraged. However, for persons with severe contusions or contusions with firm masses that do not dissipate in the initial 7 to 10 days, NSAIDs may be used to prevent heterotopic bone formation or myositis ossificans. Although randomized controlled studies have not been performed to examine the effectiveness of NSAIDs in the treatment of myositis ossificans, their presumed effectiveness is based on animal studies and reports of their usage in patients who have had a total hip replacement.
Operative treatment of quadriceps contusions is primarily reserved for persons with compartment syndromes. Aspiration or surgical decompression of a thigh hematoma has been reported; however, no literature is available to support the effectiveness of these treatments. Aspiration of knee effusions associated with severe contusions may decrease painful ROM, but support of this treatment is anecdotal. Other surgical considerations are reserved for partial or complete quadriceps tears or avulsion off the patella. Operative treatment of myositis ossificans should be reserved for patients with symptomatic loss of motion, pain, and strength once bone maturation has been demonstrated on a three-phase bone scan. Such treatment usually is performed 12 to 24 months after the time of injury.
Postoperatively, compressive dressings, ice, rest, elevation, and standard surgical site care should be instituted. Again, early ROM is critical to increase healing and decrease the risk of heterotopic bone formation.
The ROM classification system by Jackson and Feagin currently serves as the gold standard for the treatment and prognosis of thigh contusions. As a rule, nonoperative treatment should be pursued when possible, provided compartment syndrome has not been identified. The aforementioned military studies have demonstrated the quickest return to activity with immediate flexion of the affected knee to 120 degrees during the initial 24 to 48 hours from the time of injury. Subsequent early range of active ROM should follow to prevent heterotopic bone formation and to increase rates of return to play. Heterotopic bone formation should be managed with the previously outlined contusion rehabilitation protocol and may be monitored with triple-phase bone scans to evaluate for skeletal maturity. Surgical intervention should only be considered for myositis ossificans if loss of strength and ROM has not resolved during the ensuing months. Bony maturation must be identified prior to excision to prevent local recurrence.
Timely evaluation of the patient should be undertaken to assess the severity of the contusion and to rule out more severe sequelae such as compartment syndrome. Ice, knee flexion, and a gentle compressive wrap are instituted if assessment takes place on the field. For patients with moderate to severe contusions, we prefer to institute immediate knee flexion to 120 degrees with a locked, hinged knee brace. Use of ice and a compressive wrap or sleeve is also instituted with rest. The patient is reevaluated within 24 to 48 hours by one of us or a therapist, and active ROM of the knee is begun, with a greater than 120-degree return to ROM desired as soon as possible. Electrical stimulation is added as warranted. If no contraindication exists, NSAIDs are begun at prescription-strength dosage for 5 to 7 days around the clock. However, they are discontinued if the patient cannot tolerate them. Noncontact training is permitted once quadriceps control and painless full ROM has returned, which is typically seen in 10 to 14 days. Full contact is permitted at the 3- to 4-week mark provided no further setbacks occur and if a thigh pad is worn. For patients who demonstrate worsening symptoms at the 14- to 21-day mark, radiographs are repeated and return to sporting activities is tabled.
Return to Play
A mild contusion may be managed symptomatically with ROM exercises and NSAIDs, thus allowing the athlete to continue to competition or training. Noncontact training is permitted once quadriceps control and painless full ROM has returned, which is typically seen in 10 to 14 days. Full contact is permitted at the 3- to 4-week mark provided no further setbacks occur and if a thigh pad is worn. The patient should be seen and cleared by a physician, and dedicated strength testing may be warranted to ensure the patient’s safety.
A review of the literature on management and outcomes after thigh contusions is mostly based on case studies or anecdotal evidence, with some exceptions. Nonetheless, most reports note good to excellent results, with almost all athletes retuning to play. Ryan et al. demonstrated a shortened recovery time for the moderate and severe groups from 56 to 19 days and from 72 to 21 days, respectively, with utilization of immediate flexion of the knee to 120 degrees, followed by early ROM exercises. These findings were echoed by Aronen et al.
Myositis ossificans and the sequelae of thigh compartment syndromes are two significant complications associated with quadriceps contusions. In their military studies, Ryan et al. identified the greatest risk factors for myositis ossificans: knee flexion less than 120 degrees, sustaining the injury while playing football, having a previous quadriceps injury, experiencing a delay in treatment greater than 3 days, and having an ipsilateral knee effusion. Myositis ossificans is generally associated with a severe contusion and has a reported occurrence rate of 9% to 14%.
Thigh compartment syndrome is rare, and treatment of this condition remains controversial. Most authors advocate emergent fasciotomies, but some reports in the literature advocate nonsurgical intervention, even when compartment pressure standards are met for a diagnosis of compartment syndrome. The rationale for this proposal is derived from Robinson et al. and others, who note that in cases of sports-related thigh compartment syndromes with pressures greater than 55 mm Hg, no adverse sequelae were identified at 1 year with a return to preinjury strength and ROM. Standard compartment syndrome measurement should be taken, and identification is made on the basis of one of the following criteria: compartment pressures of 30 mm Hg, 45 mm Hg, or less than 30 mm Hg from diastolic pressure, as identified in different studies.
Future consideration should be given to the pursuit of level I and II studies on the management of quadriceps contusions. Additionally, exploration of the nonoperative management of thigh compartment syndrome is also warranted.
Groin contusions involve the adductor musculature and usually occur from a direct blow to the inner thigh. They are often seen in soccer players and cyclists ( Fig. 87-3 ). Aside from standard contusion treatment of ice, antiinflammatory drugs, physical therapy, and gradual return to play, the treating clinician should be aware of the possibility that vascular complications may develop, such as phlebitis and thrombosis. Ultrasound is a useful noninvasive method of diagnosing vascular complications.
Myositis ossificans is heterotopic ossification in an area of muscle, soft tissue, or disrupted periosteum ( Fig. 87-4 ). Although this disease process can occur without a history of trauma, athletes can usually describe a sentinel event that causes a hematoma formation. The hematoma organizes, and calcium deposits are formed by the body. In a process that is not entirely understood, osteoblasts invade the formed hematoma and begin to make bony spicules. This process tends to occur near joints and at tendon origins, but it can occur anywhere along the course of a muscle. The process can start as soon as 1 week after injury and can be detected on plain films a minimum of 3 weeks after injury. Patients present with a rapid enlargement within the soft tissues, decreased range of motion, and significant pain 1 to 2 weeks after injury. The patient has swelling and warmth at the site, as well as an increased erythrocyte sedimentation rate and serum alkaline phosphatase level. Any treatment modalities implemented should not promote hematoma formation. Massage and manipulation should be avoided. Therapy should consist of active stretching and strengthening. Passive ROM should be delayed for at least 3 to 6 months. For patients with refractory loss of ROM, surgery should be considered. Surgery, if warranted, should be delayed for at least 9 to 12 months to allow the lesion to mature. A bone scan can help ascertain the maturity of the lesion. Despite surgical removal, patients and clinicians should be aware that the lesion may recur.
Muscle strains are among the most common athletic injuries, representing 30% to 50% of all injuries. Most strains occur at the myotendinous junction in fast-twitch type 2 muscle fibers of biarticular muscles undergoing an eccentric contraction. Although most strains occur at this interface, muscle strains can occur anywhere along the length of the muscle. While following up on a professional soccer team, Volpi and colleagues noted that 32% of strains involved the quadriceps, 28% involved the hamstring, 19% involved the adductor, and 12% involved the gastrocnemius.
The clinical classification system depends on the severity of the muscle injury: mild, moderate, or severe (see Table 87-2 ). Mild (grade I) sprains involve tearing of a few muscle fibers with mild pain and minimal loss of strength. Moderate (grade II) sprains involve increased tearing of muscle fibers with some strength loss. Severe (grade III) sprains include tearing of the entire muscle with complete loss of strength. More commonly in adolescents and a small subset of adults, the tendons of origin or insertion may be avulsed and are classified as grade IIIB.
The only biarticular muscle in the quadriceps is the rectus femoris, but all muscles receive innervation from the femoral nerve. The indirect head of the rectus femoris gives rise to a central tendon in the proximal thigh, allowing strains to occur proximal to the musculotendinous junction. The primary function of these muscles is knee extension.
Quadriceps strain typically affects the rectus femoris. These strains can occur proximally or distally. The quadriceps is commonly affected for several reasons; it crosses two joints, has a high percentage of type II fibers, and has a complex musculotendinous architecture. Sudden forceful eccentric muscle contraction of the quadriceps is required during hip extension and knee flexion and can lead to increased forces across the muscle-tendon interface, resulting in strains.
Athletes with a quadriceps strain typically are found in sports that require cutting, jumping, or kicking, such as soccer, rugby, football, and basketball. A thorough history will tend to reveal the onset of anterior thigh pain either during the maximal extension phase of the thigh, after a sudden change in direction, or during deceleration after a forceful kick. Oftentimes patients will have an antalgic gait, loss of knee flexion, or an anterior thigh mass. Most commonly, quadriceps strains occur distally at the musculotendinous junction; however, they also can occur proximally or centrally. Pain may be reported immediately after the injury has occurred, but often the athlete may be able to continue playing through a practice or game, with the onset of symptoms occurring after a cooling-down period.
Initially, physical examination is best carried out with the patient lying supine and concludes with a prone examination. With the patient prone, a thorough palpation of the muscle should be undertaken to assess for tenderness, swelling, masses, or defects. Ecchymosis may occur 24 hours or more after the onset of injury, after which ROM of the knee and hip should be performed and compared with the contralateral side. Next, evaluation of knee extension should be undertaken with the hip flexed to 90 degrees and then with the hip in extension. Weakness identified in hip flexion indicates injury to the rectus, whereas weakness seen in hip extension points toward a vastus injury. It should be noted that rectus injuries have a slower recovery time than do those that occur in the vastus. Once the supine examination is complete, the patient is positioned prone and strength is retested, which can help isolate the quadriceps for motion and strength evaluation. For moderate to severe strains, pain is usually felt with resisted knee extension.
Imaging in quadriceps strains is typically used more as an adjunct than for diagnosis. Radiographs, ultrasound, and MRI may all be used and can provide information regarding the length of recovery. Radiographs are routinely normal; however, in the young athlete they can be particularly important in identifying avulsion fractures or stress fractures. Ultrasound and MRI are most beneficial in predicting recovery time. Finlay and Friedman reported that ultrasound is a highly sensitive and specific method for evaluating acute quadriceps injuries. The use of dynamic ultrasound with the knee in flexion and extension can allow differentiation between hematoma and muscle tears; however, ultrasound is highly operator-dependent. MRI is still considered to be the gold standard for quadriceps evaluation ( Fig. 87-5 ). However, its use in the initial evaluation phase is usually restricted to high-level or professional athletes to better predict a return to play. For recreational athletes, MRI is indicated if the symptoms do not improve after 2 to 3 weeks of rehabilitation or for evaluation of chronic (>8 weeks) strains. Cross et al. reported that MRI can estimate the size of the quadriceps strain and predict the duration of rehabilitation. Furthermore, involvement of the central tendon signifies a significantly longer rehabilitation interval.