CHAPTER 20

Rehabilitation of Groin, Hip, and Thigh Injuries

Doug Halverson, MA, ATC, CSCS
Bernard DePalma, MEd, PT, ATC

Figure 20-1. Angle of torsion. With the femoral head and neck superimposed on the femoral condyles, it is clear how the axis of the femoral head and neck and the axis of the femoral condyles intersect to create the angle of torsion.

This chapter describes functional rehabilitation programs that follow groin, hip, and thigh injuries. The athletic trainer and patient, together, should develop the rehabilitation program with an emphasis on injury mechanism, the athletic trainer’s functional and biomechanical evaluation, and clinical findings. Each exercise program should be presented to the patient in terms of short-term goals. One objective for the athletic trainer is to make the rehabilitation experience challenging for the patient while promoting adherence to the rehabilitation program.

FUNCTIONAL ANATOMY AND BIOMECHANICS

The pelvis and hip are made up of the pelvic girdle and the articulation between the femoral head and the acetabulum. This articulation is considered a ball-in-socket joint with convex (femoral head) and concave (acetabulum) components connecting the lower extremity to the pelvic girdle.

The biomechanics of the hip joint can be affected by 2 natural bony alignments: the angle of inclination and femoral torsion. The angle of inclination is used to describe the position of the femoral head and neck with respect to the shaft of the femur.47 An angle of inclination greater than 125 degrees, also known as coxa valga, creates a more superiorly directed femoral head and neck. This superior orientation decreases the shear forces across the femoral neck, decreases joint stability, and increases genu varum at the knee. The opposite, coxa vara, can be found with an angle of inclination less than 125 degrees in which the femoral head and neck is more horizontally directed. This will increase the shear forces across the femoral neck, increase joint stability, and increase genu valgum. This can only be assessed by measurement on X-ray.⁶ Femoral torsion is the angle formed between the neck of the femur and the femoral condyles (Figure 20-1). An angle of torsion greater than 15 degrees is known as anteversion, which produces a more anteriorly directed femoral head and neck. It affects the lower extremity by decreasing hip joint stability, increasing femoral internal rotation, and producing a toe-in gait. Retroversion, or an angle less than 15 degrees, directs the femoral head and neck more posteriorly, thereby increasing joint stability, femoral external rotation, and producing a toe-out gait.⁶ This can be assessed clinically by using Craig’s test.⁵³ Changes in both these angles could cause changes in position of the femoral head within the acetabulum that predispose the patient to chronic injuries such as stress fractures and overuse hip injuries, as well as acute injuries, such as hip subluxation and labral tears.

The hip joint is a true ball-in-socket joint and has intrinsic stability not found in other joints. The acetabulum has a fibrocartilage rim known as the labrum, which deepens the “socket” and helps stabilize the hip joint.⁴⁷ The hip joint is surrounded by 3 ligamentous structures that help to maintain the stability of an otherwise mobile joint. The iliofemoral ligament, or Y ligament of Bigelow, and pubofemoral ligament are positioned anteriorly and are taut in hip extension–external rotation and hip extension–abduction, respectively. The ischiofemoral ligament positioned posteriorly is taut in hip flexion and adduction. The ligamentum teres connects the femoral head to the acetabulum but is not considered a significant stabilizer.⁵²

This intrinsic stability does not prevent the hip joint from retaining great mobility. During normal gait, the hip joint moves in all 3 planes: sagittal, frontal, and transverse. The pelvis itself moves in 3 directions: anteroposterior tilting, lateral tilting, and rotation. The iliopsoas muscle and other hip flexors, as well as extensors of the lumbar spine, perform anterior tilting in the sagittal plane and facilitate lumbar lordosis. The rectus abdominus, obliques, gluteus maximus, and hamstrings posteriorly tilt the pelvis and cause a decrease in lumbar lordosis. During lateral tilting in the frontal plane, the hip joint acts as the center of rotation. Hip abduction or adduction is a result of pelvic lateral tilting. The hip abductors control lateral tilting by contracting isometrically or eccentrically.47 Pelvic rotation occurs in the transverse plane, again using the hip joint as the axis of rotation. The gluteal muscles, external rotators, adductors, pectineus, and iliopsoas all act together to perform this movement in the transverse plane.⁴⁷ These movements of the pelvis are important when analyzing gait, doing injury evaluation, and teaching correct gait.

The forces transmitted up from the ground and through the hip joint show a very distinct pattern that can be used to understand the pathomechanics of certain injuries seen in the hip and thigh region. The forces transmitted through the femur are borne by the medial and lateral trabecular systems. The body’s center of gravity and the medial angulation of the femur produce a 3-point bending force on the femoral shaft in the frontal plane. This creates increased compressive forces along the medial trabecular system and potential for increased tension forces along the lateral trabecular system (Figure 20-2). As the forces are transmitted proximally through the femur, a similar bending situation can be seen in the femoral neck. The medial and lateral trabecular systems intersect at the inferior aspect of the femoral neck through which the compressive forces are transmitted to the hip joint. This produces a condition where there is an area of weakness in the superior aspect of the femoral neck due to the relative increase in tensile load. Bone is better at resisting compressive forces, which can be an important factor as the body attempts to absorb the increased loads that occur during activity. Forces at the hip joint are known to be 2 to 3 times body weight during level walking, 5 times body weight during running, greater than 7 times body weight with stair climbing, and over 8 times body weight during stumbling.^5,17

The most frequently injured structures of the groin, hip, pelvis, and thigh are the muscles and tendons that perform the movements. The majority of these muscles originate on the pelvis or the proximal femur. The iliac crest serves as the attachment site for the abdominal muscles, the ilium serves as the attachment for the gluteals, and then the gluteals insert to the proximal femur. The pubis and pubic bone serve as the attachments for the adductors, as does the deep posterior abdominal muscle wall, and the iliopsoas inserts distally to the lesser trochanter of the proximal femur. Due to all the attachments in a small area, injury to these structures can be very disabling and difficult to distinguish.32,38,47

The quadriceps inserts by a common tendon to the proximal patella. The rectus femoris is the only quadriceps muscle that crosses the hip joint, which not only extends the knee but also flexes the hip. This is very important in differentiating hip flexor strains (eg, iliopsoas vs rectus femoris) and the ensuing treatment and rehabilitation programs.

The hamstrings all cross the knee joint posteriorly, and all except the short head of the biceps femoris cross the hip joint. These biarticular muscles produce forces dependent upon the position of both the knee joint and the hip joint. The positions of the hip and knee during movement and injury mechanism play a very important role and provide information to use when rehabilitating and preventing hamstring injuries.

Muscles in the gluteal region, the gluteus maximus, medius, and minimus, along with the tensor fasciae latae, are superficial muscles that are collectively responsible for hip extension, abduction, and internal and external rotation in addition to dynamic stabilization. The gluteus maximus extends, laterally rotates, and abducts (middle and upper fibers) the hip. The gluteus medius and minimus work together to abduct and medially rotate with the hip in extension, But the gluteus medius becomes a lateral rotator when the hip is flexed. During walking and running both the medius and minimus act to stabilize the pelvis, preventing pelvic drop of the opposite limb. Weakness in the gluteus medius muscle that causes a decrease in hip abduction strength may result in changes in hip joint kinematics that can both increase the risk of injury and decrease sport performance in the athletic population.⁵⁴ Thus, the importance of unilateral gluteus medius strengthening exercises has been emphasized in hip rehabilitation⁷ (Figure 20-21). The tensor fasciae latae abducts, medially rotates, and assists in hip flexion while also stabilizing both the hip and knee by creating tension in the iliotibial band.

A deeper group of smaller muscles, which includes the piriformis, obturator internus, gemellus superior, gemellus inferior, and quadratus femoris, act to laterally rotate and abduct the hip.

REHABILITATION EXERCISES FOR THE GROIN, HIP, AND THIGH

Stretching Exercises

Figure 20-5. Hip flexor stretch with knee flexed to isolate the rectus femoris.

Figure 20-6. Hip flexors passive static stretch prone extension on elbows.

Figure 20-8. Hamstring stretches. (A) Standing ballet stretch (maintain lordotic curve). (B) On stability ball. (C) Standing with trunk flexion. (D) Supine.

Figure 20-10. Standing hip adductor stretches. (A) Lunge stretch. (B) Plyo bench stretch.

Figure 20-11. Hip abductor stretches. (A) Standing. (B) Supine. (C) Side-lying.

Figure 20-13. Dynamic stretching. (A) Hand-assisted knee to chest (hip extensors). (B) Hand-assisted adductor stretch (hip adductors). (C) Hand-assisted knee to opposite shoulder (hip abductors). (D) Walking quadriceps stretch (hip flexors). (E) Walking lunge arms overhead (hip flexors). (F) Walking hamstring stretch (hip extensors).

Figure 20-14. Piriformis evaluation stretch test.

Figure 20-16. Myofascial stretches using a foam roller. (A) Hamstrings and gluteals. (B) Adductors. (C) Quadriceps. (D) Piriformis.

Strengthening Exercises

Figure 20-17. Pain-free hip flexion iliopsoas progressive resistive strengthening exercises. (A) Using cuff weights. (B) Manually resisted.

Figure 20-18. Weighted-cuff resisted straight-leg raises (quadriceps and iliopsoas).

Figure 20-19. Weighted-cuff resisted hip extension (gluteus maximus and hamstring).

Figure 20-20. Weighted-cuff resisted hip adduction (adductor magnus, brevis, longus, pectineus, and gracilis).

Figure 20-23. Cuff-weight–resisted hip external rotation (piriformis and gluteus maximus).

Figure 20-24. Seated hamstring progressive resistive strengthening exercises (maintain lordotic lumbar curve). Isotonics performed on the N-K table (N-K Products).

Figure 20-25. Weighted-cuff resisted prone hamstring single-leg strengthening exercises.

Figure 20-26. Manual resistance hamstring strengthening to fatigue. Patient lies prone with knee over the edge of treatment table. With the patient in full knee extension, resistance is applied to the back of the heels as the patient contracts concentrically to full knee flexion for a count of 5 seconds. After a 2-second pause at full flexion, resistance is applied into extension for a count of 5 as the patient contracts the hamstrings eccentrically.

Figure 20-27. Hamstring strengthening exercise on stability ball. Patient moves stability ball away, extending the hip.

Figure 20-29. Seated quadriceps double-leg extension on a knee machine. (Reprinted with permission from Body-Solid.)

Figure 20-30. Multidirectional hip strengthening using cable or resistance band. (A) Hip flexion (with knee flexed iliopsoas; with knee extended rectus femoris). (B) Hip extension (with knee extended semimembranosus, tendinosis, and gluteus maximus; with knee flexed biceps femoris and gluteus maximus). (C) Hip abduction (gluteus medius, gluteus minimus, tensor fascia lata). (D) Hip adduction (adductor longus-magnus-brevis, pectineus, gracilis).

Closed Kinetic Chain Strengthening Exercises

Figure 20-32. Hamstring-strengthening closed chain. Slightly flexed knee stiff-legged dead lifts. Rotate at the hip joint into flexion and keep back arched in lordotic curve until there is tightness in the hamstring muscles. Then use the hamstring muscles to extend the hip joint to the upright position.

Figure 20-33. Leg press with feet high on the foot plate and shoulder-width apart to work the upper hamstring while keeping knees over the feet (not over the toes or in front of the toes). Seat setting should be close so that, at the bottom of the motion, the hips are lower than the knees (quadriceps, upper hamstrings, and gluteus maximus).

Figure 20-35. Smith press squats with feet behind the patient’s center of gravity and hip in extension (as on a hip sled; quadriceps, lower lateral hamstring, and gluteus maximus). The patient descends while keeping a lordotic curve in the low back.

Figure 20-36. Lunges (quadriceps, hamstrings, gluteus maximus, groin muscles, and iliopsoas) stepping onto 4- to 6-inch step height. Once the foot hits the step, the patient should bend the back knee straight down toward the floor to work the upper hamstring of the front leg and the hip flexors of the back leg.

Figure 20-37. Standing running pattern, manual resistance. Resistance is applied to the back of the heel, resisting hip flexion and knee flexion to terminal position, then resisting hip extension and knee extension back down to starting position. The patient contracts as fast as possible through the entire range of running motion.

Figure 20-39. Hamstring leans—kneeling eccentric hamstring lowering exercises. With the patient kneeling on a treatment table and feet hanging over the end, the athletic trainer stabilizes the lower legs as the patient lowers the body, eccentrically contracting the hamstrings. The patient should maintain a lumbar lordotic curve and stay completely erect, avoiding any hip flexion.

Figure 20-40. Lateral step-ups (quadriceps, hamstrings, gluteus maximus, gluteus medius, and tensor fasciae latae).

Isokinetic Exercises

Figure 20-41. Seated isometric hip internal and external rotation strengthening. (Reprinted with permission from Biodex Medical Systems.)

Figure 20-42. Seated isokinetic quadricep and hamstring strengthening. (Reprinted with permission from Biodex Medical Systems.)

Figure 20-43. Supine isokinetic hip flexion and extension strengthening. (Reprinted with permission from Biodex Medical Systems.)

Figure 20-44. Side-lying isokinetic hip abduction and adduction. (Reprinted with permission from Biodex Medical Systems.)

Plyometric Exercises

Figure 20-45. Slide board or Fitter (Fitter International), keeping knees bent and maintaining a squat position for the entire workout (increases hamstring activity).

Figure 20-46. Plyometric jump-down exercises.

Figure 20-47. Lateral bounding.

Figure 20-48. Ice skaters.

REHABILITATION TECHNIQUES FOR ACUTE GROIN, HIP, AND THIGH INJURIES

Preferred treatment and rehabilitation of these injuries are broken down into phases. The early phase of rehabilitation consists of treatments using ice, compression, elevation, and modalities to reduce pain. Initiation of pain-free active range of motion (ROM) should begin as early as possible. Try to avoid any movement that causes pain, especially passive started too early. Oral anti-inflammatory medication is also beneficial in the early stages to reduce pain and inflammation and facilitate early ROM. After the acute phase, the athletic trainer should use modalities in combination with active ROM and active resistive pain-free strengthening exercises. The resistive exercises should include both open and closed kinetic chain, as well as concentric and eccentric contractions. Pain-free stretching is also started in this phase. The later phases of the rehabilitation allow the athletic trainer to progress the patient into plyometric activities, sport-specific functional training with agility, and ground/power-based activities. Keep in mind that the time sequences for programs and phases are approximations and should be adjusted depending upon the degree of injury, the sport, and the individual patient.

Iliac Crest Contusions (Hip Pointer)

Pathomechanics

A hip pointer can best be described as a subcutaneous contusion. In most cases, the contusion can cause separation or tearing of the origins or insertions of the muscles that attach to the prominent bony sites.19 Usually the patient has no immediate concern, but within hours of the injury, bleeding, swelling, and pain can severely limit the patient’s movement. In rare cases, a fracture of the crest may occur.⁴²

Injury Mechanism

A hip pointer is usually caused by a direct blow to the iliac crest or the anterosuperior iliac spine (ASIS). A common differential diagnosis that should be considered is a strain of the abdominal muscles at their attachment to the anterior and inferior iliac crest. This can be differentiated from a contusion by obtaining a good history of the mechanism of injury at the time it occurs. Muscle injuries typically result from a forceful eccentric contraction.¹⁹

Rehabilitation Concerns

An X-ray should be taken to rule out iliac crest fractures or avulsion fractures, especially in younger patients.¹⁹ If the hip pointer is not treated with early acute injury management options within 2 to 4 hours, the patient may experience increasing pain and limited ROM of the trunk.¹⁹

As in most contusions, the hip pointer is graded. A patient with a grade 1 hip pointer might have both normal gait cycle and normal posture. The patient might complain of slight pain on palpation with little or no swelling. This patient might also present with full ROM of the trunk, especially when checking for lateral side bending to the opposite side of the injury.

A patient with a grade 2 hip pointer might have moderate to severe pain on palpation, noticeable swelling, and an abnormal gait cycle. The gait cycle might be changed because of a short swing-through phase on the affected side; the patient might take a short step and be reluctant to keep the foot off the ground. The patient’s pelvis and therefore posture might be slightly tilted to the side of the injury. Active hip and trunk flexion might cause pain, especially if the ASIS is involved because of the insertion of the sartorius muscle. ROM might be limited, especially lateral side bending to the opposite side of the injury and trunk rotation in both directions.

A patient with a grade 3 hip pointer might have severe pain on palpation, noticeable swelling, and possible discoloration. The patient’s gait cycle could be abnormal, with very slow, deliberate ambulation and extremely short stride length and swing-through phase. The patient’s posture might present a severe lateral tilt to the affected side. Trunk ROM could be limited in all directions. Active hip and trunk flexion might reproduce pain.

With all hip pointers, start with ice, compression, and rest. Subcutaneous steroid injection has been known to decrease inflammation and enable early ROM exercises. Transcutaneous electrical nerve stimulation may be helpful on the day of injury to decrease pain and allow early ROM exercises. To regain normal function and speed recovery, use ice massage with pain-free trunk ROM exercises at the same time. Concentrate on lateral hip shifts to the side opposite of the injury (Figure 20-3). Other modalities such as ultrasound and electrical stimulation are beneficial for increasing ROM and functional movement.⁴³ Pain-free active motion and active resistance ROM exercises are vital to the functional recovery process. Active motion helps promote healing and decreases the time the patient is prohibited from practice and competition. Exercises focused on regaining hip muscle strength as shown in Figures 20-17 through 20-23, 20-30, and 20-31 should be used to progress the patient. Trunk-strengthening exercises may also be added.

Rehabilitation Progression

A grade 1 hip pointer usually does not prevent the patient from competing. A patient with a grade 2 hip pointer could miss 5 to 14 days, and a patient with a grade 3 hip pointer could miss 14 to 20 days of competition. A patient with a grade 2 or 3 hip pointer can progress to active resistive strengthening exercises, if pain-free, after the initial 2 days of ice, compression, and active ROM.

Criteria for Full Return

The patient is capable of returning to competition when full hip and trunk ROM and strength are obtained and the patient can perform all sport-specific activities, such as cutting and changing directions (see Figures 16-4 through 16-14). Compression should be maintained throughout the period, and on returning to competition the patient should wear a custom-made protective relief doughnut pad with a hard protective shell over the top.

Injury to the Anterosuperior Iliac Spine and Anteroinferior Iliac Spine

Pathomechanics

Pain at the site of the ASIS might indicate contusion or apophysitis, an inflammatory response to overuse. Severe pain associated with disability requires an X-ray to rule out an avulsion fracture.⁴¹

As with the ASIS, the anteroinferior iliac spine (AIIS) can also present with apophysitis or a contusion. An avulsion fracture should also be ruled out with severe pain. These injuries are seen more often in younger patients.⁴⁸

Injury Mechanism

The ASIS serves as an attachment for the sartorius, and the AIIS serves as an attachment for the rectus femoris. In both cases a violent, forceful passive stretch of the hip into extension or a violent, forceful active contraction into flexion can cause avulsion injuries.⁴¹ Apophysitis or a contusion to these 2 sites may accompany a hip pointer to the iliac crest.

Rehabilitation Concerns, Rehabilitation Progression, and Criteria for Full Return

After ruling out an avulsion fracture, rehabilitation for a contusion or apophysitis should follow the same guidelines as for a hip pointer. A more conservative approach, including a period of nonweightbearing or partial weight-bearing, may need to be considered when treating apophysitis to prevent avulsion injuries in the more immature skeleton.⁴¹ Return to play can occur as quickly as pain-free motion, strength, and function are achieved.

Posterosuperior Iliac Spine Contusion

Pathomechanics

Contusions to the posterosuperior iliac spine (PSIS) must be differentiated from vertebral fractures and more serious internal organ injuries.42 Depending upon the patient’s pain and ROM, an X-ray can be taken to rule out vertebral fractures, vertebral transverse process fractures, and fractures of the PSIS. Unlike the ASIS and AIIS, other injuries to this area are not common because of the lack of muscle attachments.³⁵ Avulsion fractures are rare in this area, although a fracture of the PSIS should be ruled out. The injury can be painful but usually does not cause disability.

Injury Mechanism and Rehabilitation Concerns

A contusion to the PSIS is usually caused by a direct blow or fall. A patient with a contusion might complain of pain on palpation and have swelling that is usually not extensive. The patient’s gait cycle may look normal except in severe cases, when the patient may take short, choppy steps to avoid the pain associated with landing at heel strike. In severe cases, the patient’s posture may show a slight forward flexion tilt of the trunk. This patient might show full active ROM of the trunk, with mild discomfort. In moderate to severe cases, up to 3 days of rest may be needed before return to competition.

Rehabilitation Progression and Criteria for Full Return

The same treatment can be followed that is used for hip pointers. Pain-free active and passive ROM exercises of the trunk and hip can be used. Guidelines for return to competition are the same as for a hip pointer, and protective padding is recommended.

Quadriceps Contusion

Pathomechanics

Because the quadriceps muscle is in the front of the thigh, a direct blow to the area that causes the muscle to compress against the femur can be very disabling.^2,37 A direct blow to the anterior portion of the muscle is usually more serious and disabling than a direct blow to the lateral quadriceps area because of the differences in muscle mass present in the 2 areas. Blood vessels that break cause bleeding in the area where muscle tissue has been damaged.³⁷ If not treated correctly or if treated too aggressively, a quadriceps contusion can lead to the formation of myositis ossificans (see the following section on myositis ossificans). At the time of injury, the patient may develop pain, loss of function to the quadriceps mechanism, and loss of knee flexion ROM. How relaxed the quadriceps were at the time of injury and how forceful the blow was determine the grade of injury.

Injury Mechanism

A patient with a grade 1 contusion may present a normal gait cycle, negative swelling, and only mild discomfort on palpation. The patient’s active knee flexion ROM while lying prone should be within normal limits. Resistive knee extension while sitting and lying supine with the knee bent over the end of a table might not cause discomfort.

A patient with a grade 2 contusion may have a normal gait cycle, but before notifying the athletic trainer of the injury might attempt to continue to participate while the injury progressively becomes disabling. If the gait cycle is abnormal, the patient will splint the knee in extension and avoid knee flexion while bearing weight because the knee feels like it will give out. This patient might also externally rotate the extremity to use the hip adductors to pull the leg through during the swing-through phase. This move might be accompanied by hiking the hip at push-off, which causes tilting of the pelvis in the frontal plane. Swelling may be moderate to severe, with a noticeable defect and pain on palpation. While the patient is lying prone, active ROM in the knee may be limited, with possibly 30 to 45 degrees of motion lacking. Resistive knee extension while sitting and lying supine with the knee bent over the end of a table may be painful, and a noticeable weakness in the quadriceps mechanism may be evident. A grade 2 quadriceps contusion to the lateral thigh area is usually less painful because of the lack of muscle mass involved at the injury site. The patient might experience pain on palpation but not have disability. While the patient is lying prone, knee flexion ROM will show a small limitation but should fall within normal limits. Resistive knee extension while the patient is sitting and lying supine with the knee bent over the end of a table may cause mild discomfort with good strength present.

A patient with a grade 3 contusion might herniate the muscle through the fascia to cause a marked defect, severe bleeding, and disability. The patient may not be able to ambulate without crutches. Pain, severe swelling, and a bulge of muscle tissue may be present on palpation. When the patient is lying prone, knee flexion active ROM may be severely limited. Active resistive knee extension while the patient is sitting and lying supine with the knee bent over the end of a table might not be tolerated, and severe weakness may be present.

Rehabilitation Concerns and Rehabilitation Progression

Initial injury management of quadriceps contusions involving knee flexion can significantly decrease a patient’s total time lost.2 Aronen et al found a dramatic improvement in time to return to play when the patient was initially treated with ice and immobilization of the knee at 120 degrees of flexion regardless of the severity of the injury. This immobilization lasted for 24 hours.²

A patient with a grade 1 quadriceps contusion should begin ice and 24-hour compression immediately. Twenty-four–hour compression should be continued until all signs and symptoms are absent. Gentle, pain-free quadriceps stretching exercises (Figures 20-4 and 20-5) may be performed on the first day. Quadriceps progressive resistive strengthening exercises may also be performed as soon as possible, usually on the second day, in the order given and pain-free (Figures 20-18, 20-28, and 20-29), hip flexion with knee both extended and flexed (Figures 20-30A and B, 20-31 through 20-38, and 20-40), and isokinetics (Figures 20-42 and 20-43). This patient’s active ROM should be carefully monitored. If motion decreases, the injury should be updated to a grade 2 contusion and treated as such.

A patient with a grade 2 contusion should be treated very conservatively. Crutches should be used until a normal gait can be accomplished free of pain. Ice, 24-hour compression, and electrical muscle stimulation modalities may be started immediately to decrease swelling, inflammation, and pain and to promote ROM.⁴⁰ Compression should be applied at all times to counteract bleeding into the area. Pain-free quadriceps isometric exercises may be performed as soon as possible, usually within the first 3 days. Between days 3 and 5, ice is continued with pain-free active ROM, while the patient is sitting and lying prone. Active ROM lying supine with the knee bent over the end of a table can be added. Passive stretching is not used until the later phases of rehabilitation. Massage and heat modalities are also contraindicated in the early phases because of the possibility of promoting bleeding and eventually myositis ossificans. At about day 5, the patient may perform straight-leg raises without weights and then progress to weights, pain-free (Figure 20-18). As active ROM increases and approaches 95 to 100 degrees of knee flexion, swimming, aquatic therapy, and biking may be performed if the bicycle seat height is adjusted to the patient’s available pain-free ROM. Between days 7 and 10, heat in the form of hot packs, ultrasound, or whirlpool may be used, as long as swelling is negative and the patient is approaching full active ROM while lying prone. Pain-free quadriceps progressive resistive strengthening exercises may be performed in the order given (Figures 20-18, 20-28, and 20-29), hip flexion with knee both extended and flexed (Figures 20-30A and B, 20-31 through 20-38, and 20-40), and isokinetics (Figures 20-42 through 20-44). Ice or heat modalities, with active ROM, should be continued before all exercises as a warm-up. Pain-free quadriceps stretching exercises should not be rushed and can be started between 10 and 14 days (Figures 20-4 and 20-5). Jogging, slide board (Figure 20-45), plyometrics (Figures 20-46 through 20-48), and sport-specific functional drills (see Figures 16-4 through 16-14) may be used after the 14th day.

A patient with a grade 3 quadriceps contusion should use crutches, rest, ice, 24-hour compression, and electrical muscle stimulation modalities immediately to decrease pain, bleeding, and swelling and counteract atrophy.37 After surgery has been ruled out, the patient may begin pain-free isometric quadriceps exercises between days 5 and 7. Ice and 24-hour compression should be continued from day 1 through day 7. Pain-free active ROM exercises may be performed while the patient is sitting and lying prone around day 7. Active ROM while lying supine with the knee bent over the end of a table can also be added. At about day 10, the patient may perform straight-leg raises without weights and then progress to weights by day 14 (Figure 20-18). Electrical muscle stimulation modalities may be very helpful in this phase to counteract muscle atrophy and reeducate muscle contraction. Again, as active ROM increases and approaches 95 to 100 degrees of knee flexion, swimming, aquatic therapy, and biking may be performed if the bicycle seat height is adjusted to the patient’s pain-free available ROM. After day 14, the patient may use heat in the form of hot packs or whirlpool, as long as the swelling has decreased and the patient has gained active ROM. At about the third week of rehabilitation, pain-free quadriceps progressive resistive strengthening exercises may be performed in the order presented (Figures 20-18, 20-28, and 20-29), hip flexion with knee both extended and flexed (Figures 20-30A and B, 20-31 through 20-38, and 20-40), and isokinetics (Figures 20-42 and 20-43). Pain-free quadriceps stretching may also be performed (Figures 20-4 and 20-5) if the patient is careful not to overstretch the quadriceps muscles. In general, the patient may be able to progress to jogging, slide board (Figure 20-45), plyometrics (Figures 20-46 through 20-48), and sport-specific functional drills (see Figures 16-4 through 16-14) around 3 weeks post injury. The rehabilitation timetables presented for grades 2 and 3 quadriceps contusions may be modified, depending upon the severity of the injury within its grade.

Criteria for Full Return

All patients need to achieve equal passive knee flexion and regain quadriceps tone, control (vastus medialis), and strength prior to being returned to play. They also need to pass functional testing of sport-specific drills by the athletic trainer. Protective padding should always be used to protect the injured area after return to play and prevent the incidence of myositis ossificans.²

A patient with a grade 1 quadriceps contusion might not miss competition, but compression and protective padding should be worn until the patient is symptom-free.

A patient with a grade 2 quadriceps contusion might miss 3 to 20 days of participation, depending upon the severity of the injury. Compression and protective padding should be worn during all competition until the patient is symptom-free. A patient with a grade 2 quadriceps contusion to the lateral thigh area might not miss competition but should wear compression and protective padding during participation.

A patient with a grade 3 quadriceps contusion might miss 3 weeks to 3 months of competition time. Again, compression and protective padding should be worn during all competition until the patient is symptom-free. Grade 3 lateral quadriceps contusions are very rare due to the lack of muscle belly tissue. If a grade 3 lateral quadriceps contusion is diagnosed, a femoral contusion and possible fracture should be ruled out.

Myositis Ossificans

Pathomechanics and Injury Mechanism

With a severe direct blow or repetitive direct blows to the quadriceps muscles that cause muscle tissue damage, bleeding, and injury to the periosteum of the femur, ectopic bone production may occur.^42,58 Calcium formation will typically become visible on X-ray films between 3 to 6 weeks post injury. If the trauma was to the quadriceps muscles only and not the femur, a smaller bony mass may be seen on X-ray films.⁵⁸

If quadriceps contusions and strains are properly treated and rehabilitated, myositis ossificans can be prevented. Myositis ossificans can be caused by trying to “play through” a grade 2 or 3 quadriceps contusion or strain and by early use of massage, active ROM into pain, passive stretching exercises into pain, ultrasound, and other heat modalities.⁴³

Rehabilitation Concerns, Rehabilitation Progression, and Criteria for Full Return

After 1 year, surgical removal of the bony mass may be helpful. If the bony mass is removed too early, the trauma caused by the surgery can actually enhance the condition. After diagnosis by X-ray film, treatment and rehabilitation should follow the guidelines for a grade 2 or 3 quadriceps contusion or quadriceps strain (see treatment and rehabilitation for grades 2 and 3 quadriceps contusions and strains). The bony mass usually stabilizes after the sixth month.58 If the mass does not cause disability, the patient should be closely monitored and follow the treatment and rehabilitation programs outlined in grades 2 and 3 quadriceps contusions and strains. It has also been recommended that myositis be treated using acetic acid with iontophoresis.¹⁶

Quadriceps Muscle Strain

Pathomechanics

A strain to the large quadriceps muscles in the front of the thigh can be very disabling, especially when the rectus femoris muscle is involved due to its involvement at 2 joints.²⁵ The 4 quadriceps muscles share the same innervation and tendon of insertion. The rectus femoris is the only quadriceps muscle that crosses the hip joint; therefore, it is considered a biarticular muscle. The quadriceps muscles are very similar to the hamstrings in that they produce a great deal of force and contract in a rapid fashion.³⁷ Most strains occur at the musculotendinous junctions. A strain shows acute pain, possibly after a workout has been completed, swelling to a specific area, and loss of knee flexion. If the rectus femoris is involved, knee flexion ROM lying prone (hip in extended position) will be severely limited and painful. Rectus femoris involvement is more disabling than a strain to any of the other quadriceps muscles.

Injury Mechanism

Muscle strains and contusion will present similar signs and symptoms, but with no history of direct contact to the quadriceps area, the injury should be treated as a muscle strain. A quadriceps strain that involves the rectus femoris usually occurs because of a sudden, violent, forceful contraction of the hip and knee into flexion, with the hip initially extended. An overstretch of the quadriceps, with the hip in extension and the knee flexed, can also cause a quadriceps strain. Tight quadriceps, imbalance between quadriceps muscles, and leg length discrepancy can predispose someone to a quadriceps strain.⁵⁹

A patient with a grade 1 quadriceps strain may complain of tightness in the front of the thigh. The patient may be ambulating with a normal gait cycle and present with a history of the thigh feeling fatigued and tight. Swelling might not be present, and the patient usually has very mild discomfort on palpation. With the patient sitting over the edge of a table, resistive knee extension might not produce discomfort. If the patient is lying supine with the knee flexed over the edge of a table, resistive knee extension may produce mild discomfort if the rectus femoris is involved. With the patient lying prone, active knee flexion may produce a full pain-free ROM, with some tightness at extreme flexion.

A patient with a grade 2 quadriceps strain may have an abnormal gait cycle. The knee may be splinted in extension. The patient may present an externally rotated hip to use the adductors to pull the leg through and avoid hip extension, during the swing-through phase from push-off, especially when the rectus femoris is involved. In severe cases, it may also be accompanied by hiking the hip during the swing-through phase, which causes a tilting of the pelvis in the frontal plane. The patient may have felt a sudden twinge and pain down the length of the rectus femoris during activity.²⁵ Swelling may be noticeable, and palpation may produce pain. A defect in the muscle may also be evident in a grade 2 strain. Resistive knee extension, both when sitting and when lying supine, may reproduce pain. Lying supine and resisting knee extension may be more painful when the rectus femoris is involved. With the patient lying prone, active knee flexion ROM may present a noticeable decrease, in some cases a decrease up to 45 degrees. With a quadriceps strain, any decrease in knee flexion ROM should classify the injury as a grade 2 or 3 strain.

A patient with a grade 3 quadriceps strain may be unable to ambulate without the aid of crutches and will be in severe pain, with a noticeable defect in the quadriceps muscle. Palpation will usually not be tolerated, and swelling will be present almost immediately. The patient may not be able to extend the knee actively and against resistance. An isometric contraction will be painful and may produce a bulge or defect in the quadriceps muscle, especially if the rectus femoris is involved. With the patient lying prone, active knee flexion ROM may be severely limited and might not be tolerated.

Rehabilitation Concerns and Rehabilitation Progression

A patient with a grade 1 quadriceps strain should start ice, compression, pain-free active ROM, and isometric quadriceps exercises immediately.59 Pain-free quadriceps progressive resistive strengthening exercises may be performed within the first 2 days, in the order given (Figures 20-18, 20-28, and 20-29), hip flexion with knee both extended and flexed (Figures 20-30A and B, 20-31 through 20-38, and 20-40), and isokinetics (Figures 20-41 through 20-44). The N-K table (Figure 20-28) is used because of its ability to change the force on the quadriceps muscles by changing the lever arm, and therefore the torque and forces placed upon the injured muscle(s). It is very important that this patient be able to stretch pain-free and begin pain-free stretching as described in Figures 20-4 and 20-5. Compression should be used at all times until the patient is free of pain and no longer complaining of tightness.

A patient with a grade 2 quadriceps strain should begin ice, 24-hour compression, and crutches immediately for the first 3 to 5 days. Electrical muscle stimulation modalities may be used acutely to decrease swelling, inflammation, and pain and promote ROM.⁴³ At about day 3, or sooner if pain-free, the patient may perform quadriceps isometric exercises and pain-free quadriceps active ROM exercises, both sitting and lying prone. These active ROM exercises are then progressed to the supine position with the knee bent over the end of a table to allow more efficiency and ROM to the rectus femoris muscle, but with no resistance or weight. Ice used in conjunction with active ROM, as described previously, is very helpful in regaining motion and strengthening the quadriceps muscles without pain. Passive stretching exercises to the quadriceps muscles are not recommended in the rehabilitation program until later phases because a passive stretch might have been the cause of the strain. Twenty-four–hour compression is continued until full pain-free ROM is achieved. A pain-free normal gait cycle is reviewed and emphasized, with and without crutches.

At about days 3 to 7, the patient may begin heat before exercise even though ice is still preferred if the patient has not obtained full pain-free ROM. During this phase of rehabilitation, pain-free progressive resistive exercises such as straight-leg raises may be implemented (Figure 20-18). Weights should be added as strength increases.

At about days 5 to 7 and within pain-free limits, this patient may begin the slide board (Figure 20-45), plyometrics (Figures 20-46 through 20-48), and sport-specific functional drills (see Figures 16-4 through 16-14).

Continue pain-free quadriceps progressive resistive strengthening exercises on days 7 through 14. The patient should be progressed, in the order given and pain-free, through the exercises shown in Figures 20-18, 20-28, and 20-29, hip flexion with knee both extended and flexed (Figures 20-30A and B, 20-31 to 20-38, and 20-40), and isokinetics (Figures 20-41 through 20-44). Swimming and biking can also be performed as long as the patient avoids forceful kicking. The bike seat should be adjusted to accommodate a pain-free ROM. Pain-free passive quadriceps stretching exercises are not performed until days 7 to 14 (Figures 20-4 and 20-5). All exercises should be pain-free.

A patient with a grade 3 quadriceps strain should be on crutches for 7 to 14 days or longer to allow for rest and normal gait before walking without crutches. Twenty-four–hour compression, ice, and electrical muscle stimulation modalities should be used immediately. Quadriceps stretching exercises are not performed until later phases. Twenty-four–hour compression is maintained until the patient has full pain-free ROM. When pain-free, the patient may begin quadriceps isometric exercises. Gentle pain-free quadriceps active ROM exercises, while the patient is lying prone and/or sitting, should be performed if special attention is paid to avoiding an overstretch of the quadriceps muscles. Ice, in conjunction with active ROM while sitting over the end of a table, is very useful in regaining ROM. Heat (hot packs, whirlpool, or ultrasound) may be used if the patient is approaching full ROM and signs of acute inflammation have decreased. Pain-free straight-leg raises without weight may be performed. Weight may be added after days 10 to 14 (Figure 20-18).

Depending upon active ROM, swimming and biking may be added to the rehabilitation program. The bicycle seat height should be adjusted to accommodate the patient’s available ROM. Also, depending upon active ROM, pain-free quadriceps active progressive resistive strengthening exercises may be performed after the third week, in the order given (Figures 20-18, 20-28, and 20-29), hip flexion with knee both extended and flexed (Figures 20-30A and B, 20-31 through 20-38, and 20-40), and isokinetics (Figures 20-41 through 20-44).

Depending on the severity of the injury, the patient should have full active ROM by the fourth week. Only when full active ROM is accomplished should quadriceps stretching exercises be added (Figures 20-4 and 20-5).

At about day 14 or later, and within pain-free limits, this patient may begin the slide board (Figure 20-45), plyometrics (Figures 20-46 through 20-48), and sport-specific functional drills (see Figures 16-4 through 16-14).

Criteria for Full Return

A patient with a grade 1 quadriceps strain might not miss competition but should be watched closely and started on a rehabilitation and strengthening program immediately.

A patient with a grade 2 quadriceps strain might miss 7 to 20 days of competition, depending upon the amount of active ROM present. The lack of ROM and the number of competition days missed are usually directly correlated.

A patient with a grade 3 quadriceps strain might miss 3 to 12 weeks of competition. In severe cases, surgery may be a consideration.

In all situations, the patient should not return to competition until plyometrics (Figures 20-46 through 20-48) and sport-specific functional drills (see Figures 16-4 through 16-14) are accomplished pain-free.⁵⁹

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