The athlete’s hip is complex when it comes to the surrounding musculature—approximately 21 different muscles can cross the hip and pelvis region, all synchronously working to maintain pelvic stability and functional hip activities. Commonly injured muscle groups for high-level athletes include flexors, adductors, abductors, and/or proximal hamstring musculotendinous complex. These muscle groups work in harmony; however, each has an independent function and propensity for injury. Rehabilitation phases for each injury group can be broken down into 3 phases: acute management, strengthening, and return-to-sport or return-to-competition phase. Specific rehabilitation principles and modalities are described for each injury group.
Key points
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Understanding the prevalence of the more common soft tissue injuries around the hip and pelvis is essential to properly managing the athletes involved.
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The more commonly injured muscle groups involve the adductors, abductors, hip flexors, and proximal hamstring attachment.
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Utilizing modern diagnostic skills and tools can drive an efficient work-up for soft tissue injuries around an athlete’s hip.
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Portable and bedside ultrasound techniques can provide real-time diagnostics in the training room setting for the high-level sports medicine provider.
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Implementing the proper rehabilitation phases and specific therapeutic techniques is crucial in succeeding with an athlete’s recovery and return to sport.
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Three phases apply to most injury rehabilitation, as the athlete moves from a recovery to a strengthening and ultimately a return-to-sport protocol.
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Video content accompanies this article at http://www.sportsmed.theclinics.com/ .
Introduction
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There are 21 different muscles that cross the hip and pelvis.
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The complexity of these muscle groups and their differing functions aid in athletic function but also contribute to their predisposition to injury.
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Sprinting, cutting, and throwing sports all harness energy from the hip and pelvis, which makes these types of muscle injuries all too common across most sports.
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Professional baseball estimates have shown that approximately 5.5% of injuries are related to the hip or groin, which can place a player on the injured list for various amounts of lost time.
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Strain and resultant injury sometimes can be complicated in an athlete’s presentation, which requires diligent and accurate use of clinical skills and tools to arrive at the correct diagnosis and treatment protocol.
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The exact injury rate for hip and pelvic muscular strains is unknown because of the likelihood that milder injuries sometimes are unrecognized or under-reported.
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There are mixed opinions on the increased incidence of these injuries, because they sometimes are thought to be more common in the preseason time periods, due to lack of functional conditioning, but some report that later in the season injuries may increase, due to fatigue and/or overuse.
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Understanding a typical presentation for the most common muscular injuries and rehabilitation processes aids in a successful return to sport for the athlete.
Hip and pelvis bony anatomy
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The pelvis consists of the fused os coxae (ilium, ischium, and pubis) and serves as the inferior connection between the axial and appendicular skeleton. This connection occurs at the diarthrodial synovial sacroiliac joints bilaterally, which serve both to transfer torque created in the lower extremities and to dampen the torso’s vertical forces of ambulation.
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Anteriorly, the pubic symphysis is a nonsynovial amphiarthrodial cartilaginous joint that sustains significant compressive forces with motion, attenuates the impulse of the forces of ambulation, and expands during childbirth.
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Contributions from all 3 portions of the os coxae form the pelvic component of the femoroacetabular joint, the synovial ball-and-socket hip joint that serves as the structural foundation for locomotion.
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In addition, the pelvis serves a protective function for the lower internal organs and neurovascular structures and is the attachment site of many muscles of locomotion.
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Muscles of the pelvis and hip
Table 1 depicts the various muscular anatomy and functional roles around the hip and pelvis.
| Muscle | Primary Function | Secondary Function(s) | Origin | Insertion | Innervation (Spinal Nerve) |
|---|---|---|---|---|---|
| Anterior compartment | |||||
| Iliacus | Hip flexion | Hip internal rotation | Iliac fossa | Femur–lesser trochanter | Femoral nerve (L1-3) |
| Psoas | Hip flexion | Hip external rotation; ipsilateral trunk lateral flexion | Transverse processes T4-12 | Femur–lesser trochanter | Lumbar plexus (L1-3) |
| Rectus femoris | Knee extension | Hip flexion | Anterior-inferior iliac spine | Patella; tibial tuberosity | Femoral nerve (L2-4) |
| Sartorius | Hip flexion (weak) | Hip abduction, external rotation; knee flexion | Anterior-superior iliac spine | Anteromedial aspect of proximal tibia | Femoral nerve (L2-4) |
| Medial compartment | |||||
| Pectineus | Hip adduction | Hip flexion, internal rotation | Pubis–pectineal line | Femur–lesser trochanter; proximal linea aspera | Femoral nerve (L2, L3); obturator nerve in some patients (L2-4) |
| Adductor longus | Hip adduction | Hip flexion | Pubis—below pubic crest | Linea aspera | Obturator nerve, anterior branch (L2-4) |
| Adductor brevis | Hip adduction | Hip flexion | Pubis–body and inferior ramus | Femur–lesser trochanter; linea aspera | Obturator nerve (L2-4) |
| Adductor magnus | Hip adduction | Hip flexion, extension | Pubis–inferior ramus; ischial ramus and tuberosity | Gluteal tuberosity; linea aspera; femur–adductor tubercle | Obturator nerve (L2-4); small contribution from tibial nerve (L5-S1) |
| Gracilis | Hip flexion | Hip external rotation; knee flexion | Pubis–body and inferior ramus; ischium–ramus | Anteromedial aspect of proximal tibia | Obturator nerve (L2-4) |
| Gluteals | |||||
| Gluteus maximus | Hip extension | Hip external rotation | Ilium–gluteal surface; sacrotuberous ligament; lumbar fascia; posterolateral sacrum | Femur–greater trochanter; iliotibial tract | Inferior gluteal nerve (L5, S1, S2) |
| Gluteus medius | Hip abduction | Hip internal rotation and flexion (anterior fibers); hip external rotation and extension (posterior fibers) | Ilium–gluteal surface | Femur–greater trochanter | Superior gluteal nerve (L4, L5, S1) |
| Gluteus minimus | Hip abduction | Hip internal rotation | Ilium–gluteal surface | Femur–greater trochanter | Superior gluteal nerve (L4, L5, S1) |
| Tensor fascia latae | Hip abduction | Hip flexion, internal rotation; knee external rotation | Outer lip of anterior iliac crest; anterior-superior iliac spine | Iliotibial tract | Superior gluteal nerve L4, L5, S1 |
| Hamstrings | |||||
| Semimembranosus | Hip extension | Knee flexion; tibial internal rotation (flexed knee); hip internal rotation (extended hip) | Ischial tuberosity | Tibia–medial condyle | Tibial nerve (L5, S1, S2) |
| Semitendinosus | Hip extension | Knee flexion; Tibial internal rotation (flexed knee), external rotation (extended knee) | Ischial tuberosity | Anteromedial aspect of proximal tibia | Tibial nerve (L5, S1, S2) ura |
| Biceps femoris (long head) | Hip extension | Knee flexion; hip external rotation | Ischial tuberosity; linea aspera | Fibular head | Tibial nerve (L5, S1, S2) |
| Deep hip external rotators | |||||
| Piriformis | Hip external rotation | Hip abduction (flexed hip) | Anterior sacrum | Femur–greater trochanter | Nerve to piriformis (L5, S1, S2) |
| Obturator externus | Hip external rotation | Hip adduction | Obturator foramen; obturator membrane | Femur–trochanteric fossa | Obturator nerve, posterior branch (L3, L4) |
| Obturator internus | Hip external rotation | Hip abduction | Ischiopubic ramus; greater sciatic notch; obturator membrane | Femur–greater trochanter | Nerve to obturator internus (L5, S1, S2) |
| Gemellus superior | Hip external rotation (extended thigh) | Hip abduction (flexed thigh) | Ischiopubic ramus; obturator membrane | Femur–greater trochanter | Nerve to obturator internus (L5, S1, S2) |
| Gemellus inferior | Hip external rotation (extended thigh) | Hip abduction (flexed thigh) | Ischiopubic ramus; obturator membrane | Femur–greater trochanter | Nerve to obturator internus (L5, S1, S2) |
| Quadratus femoris | Hip external rotation | Hip adduction | Ischial tuberosity | Femur–intertrochanteric crest | Nerve to quadratus femoris (L4, L5, S1 |
| Trunk stability | |||||
| Rectus abdominus | Knee extension | Hip flexion | Anterior-inferior iliac spine; superior aspect of iliac acetabulum | Patella; tibial tubercle | Femoral nerve (L2-4) |
| Internal oblique | Trunk rotation–ipsilateral | Abdominal flexion with bilateral activation | Anterior iliac crest; iliopectineal arch; thoracolumbar fascia | Inferior ribs 10–12; linea alba; pubic crest; conjoint tendon | Thoracoabdominal nerves T7-11; subcostal nerve (T12); iliohypogastric nerve (L1); ilioinguinal nerve (L1) |
| External oblique | Trunk rotation–contralateral | Abdominal flexion with bilateral activation | Ribs 5–12 | Anterior iliac crest; pubic crest and tubercle; linea alba; inguinal ligament; anterior-superior iliac spine | Thoracolumbar nerves (T7-11) Subcostal nerve (T12) |
| Pyramidalis | Linea alba tension | Pubic symphysis and crest | Linea alba | Subcostal nerve (T12) | |
| Latissimus dorsi | Arm adduction | Arm internal rotation, extension; ipsilateral trunk rotation | T7-L5 spinous processes; thoracolumbar fascia; iliac crest; inferior ribs; inferior angle of scapula | Humerus–intertubercular sulcus | Thoracodorsal nerve (C6-8) |
| Multifidus | Back extension with bilateral activation | Contralateral trunk rotation and ipsilateral side bending with unilateral activation | Sacrum; posterior superior iliac spine; iliac crest | Spinous processes C2-L5 | Medial branch nerve of the posterior ramus of spinal nerve at each level |
| Quadratus lumborum | Ipsilateral lumbar lateral flexion with unilateral activation | Trunk extension and rib cage depression with bilateral activation | Posterior iliac crest | Rib 12; transverse processes L1-5 | T12 L1-4 ventral rami |
| Erector spinae—lumbar portion | |||||
| Iliocostalis | Ipsilateral lumbar lateral flexion with unilateral activation | Trunk extension with bilateral activation | Sacrum; posterior iliac crest; spinous processes of lumbar and lower thoracic vertebrae | Ribs 5–12; transverse processes L1-4 | Lateral branch nerve of posterior ramus of spinal nerve at each level |
| Longissimus | Trunk extension with bilateral activation | Ipsilateral lumbar rotation with unilateral activation | Spinous and transverse processes of L1-5; lumbodorsal fascia; posterior iliac crest | Accessory and transverse processes L1-5 | Lateral branch nerve of posterior ramus of spinal nerve at each level |
| Pelvic floor | |||||
| Ischiococcygeus | Coccyx flexion | Support of pelvic viscera | Sacrospinous ligament; ischial spine | Coccyx; sacrum | Pudendal nerve (S2-4) Spinal nerves S4, S5 |
| Iliococcygeus | Support of pelvic viscera | None | Pubis–posterior body | Coccyx; anococcygeal ligament | Levator ani nerve (S4) Inferior rectal nerve (S3, S4) Coccygeal plexus |
| Pubococcygeus | Control of urinary flow | Support of pelvic viscera | Pubis–posterior body | Coccyx; anococcygeal ligament | Levator ani nerve (S4) Inferior rectal nerve (S3, S4) Coccygeal plexus |
| Puborectalis | Permission of defecation | Support of pelvic viscera | Ischial spine; obturator internus fascia | None (comprises puborectal sling) | Levator ani nerve (S4) S3, S4 spinal nerves |
Role of the hips and pelvis during dynamic movements
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Absorption, transfer, and production of force (examples)
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Trunk power is an independent predictor of pitching velocity in baseball.
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Energy transfer from pelvic torque force generation is a major contributor to rotational forces in the baseball pitching motion.
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Improving lumbosacral postural stabilization with as little as 6 weeks’ training has been associated with improved baseball pitching accuracy and endurance.
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Sacroiliac extension torque is higher than any other joint during the block start in track events.
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A core stabilization training program has been associated with improved isometric shoulder strength in young female athletes.
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Lumbopelvic stability training improved performance on climbing-specific strength tasks in elite climbers.
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Core endurance has been associated directly with superior isokinetic shoulder internal and external rotation and knee flexion strength in elite athletes of Olympic disciplines.
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Core stability, balance, and resistance exercises have been shown to improve club head speed in golfers after an 8-week training program. ,
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Superior trunk control has been associated with higher performance on rapid change-of-direction activities.
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Horizontal arm swing velocity, critical in baseball, golf, and racquet sports, is directly dependent on trunk rotation of the arm and also indirectly by exerting interaction torque necessary for rapid elbow extension.
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Helps to control body segments below the region
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Increased knee valgus, a known risk factor for ACL injury, has been associated with decreased hip internal rotation, knee flexion, and trunk rotation strength.
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Altered trunk kinematics also are seen in patients with chronic ankle instability compared with controls, thought to be compensatory in nature. Those compensatory mechanisms have been associated with improvements in balance testing. ,
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Relationship between trunk instability and inflexibility and injury risk
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Overhead athletes with ulnar collateral ligament injuries of the elbow have been shown to have decreased trunk stability and balance but not hip range-of-motion (ROM) deficits. ,
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These balance deficits can be remedied, and a lower extremity neuromuscular control home exercise program has been shown to improve balance postoperatively in those with an ulnar collateral ligament tear.
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Increased hip, hamstring, and groin injury risk in professional baseball players with decreased hip internal rotation and total arc hip ROM.
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A training module, including leg and trunk stabilization, proprioceptive training with landing from a jump, postural stability, and lower extremity flexibility, led to a significant reduction of severe knee injury in elite soccer players.
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Core strength is an independent predictor of shoulder dysfunction in overhead athletes of all disciplines. ,
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Classifications of injuries
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Acute versus chronic onset
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Acute injuries are more likely to occur during competition whereas those with an insidious onset are more likely to occur during training, where a vast majority of athletic exposures occur. ,
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Acute injuries are more likely to involve tendon avulsion whereas chronic-onset injuries are more likely to involve degenerative tendinopathy.
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Presentation
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Hip flexor injuries can involve the iliopsoas or rectus femoris, most commonly. These injuries typically are a product of an acute concentric or eccentric strain or a progressive overuse musculotendinous injury. The presentation usually involves a complaint of anterior hip pain that is located near the lesser trochanter and/or at the level of the anterior hip joint, whereas most of the anatomic makeup is musculotendinous structures. Less commonly, the pain can be more proximal in the lower abdomen involving more muscle belly fibers of the iliacus or psoas. Pain from rectus injuries usually is located at the joint or distal down the anterior thigh. Palpation is sensitive for rectus injuries, whereas the iliopsoas typically is deeper than allows for direct pressure to the injured structure. Pain is reproduced with concentric and eccentric resisted activity with hip flexion but also can be present with active or passive hip extension, which places the injured muscle on stretch.
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Hip flexor strain key points
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Acute or acute-on-chronic anterior hip pain after forced hip flexion
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High rate of injury in competition, although higher overall incidence in training
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Equal incidence in men and women
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Most commonly noncontact
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Typically results in less than 1 week’s missed time from sport
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Adductor injuries present with a similar mechanism but tend to be located anywhere from the pubic ramus down into the middle of the inner thigh. Pain is present more so with direct palpation, because the muscle groups are in more proximity to the superficial fascial layers. Sometimes, in higher-grade injuries, a palpable defect can be felt as well as the potential for ecchymosis and swelling with acute hemorrhage. With tendinous injuries, whether they are associated with a chronic tendinopathy or an acute avulsion, there typically is pain directly on the pubic bone. Pain and weakness can be present with adductor muscle testing and passive abduction of the hip.
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Adductor strain key points
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Acute or acute-on-chronic medial proximal thigh (groin) pain or pain over ipsilateral pubis
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High rate of injury in competition, although higher overall incidence in training
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Higher incidence in men than women
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Most commonly noncontact
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Typically results in less than 1 week’s missed time from sport
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Gluteal tendon injuries tend to be more overuse or related to a chronic process rather than an acute injury, which may have resulted in a tendinopathy. Acute avulsions of the tendons from the greater trochanter and traumatic bursal or muscular injuries, however, also can occur with athletic injuries. The more commonly affected muscles are the gluteus medius and minimus. Both structures attach to the greater trochanter and function as hip abductors and stabilizers of the femoroacetabular joint as well as multiplanar pelvic control. Pain typically presents at the lateral aspect of the hip around the trochanter or proximal. Due to the more superficial location, just under the iliotibial fascia, there usually is pain to palpation and pain with active or resisted abduction and active or passive adduction. With acute, traumatic tendinous avulsions or bursal ruptures, there are swelling and ecchymosis at times.
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Gluteal tendon disorders key points
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Typically, insidious onset and involves pain over the posterolateral hip
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Can occur acutely after fall on the greater trochanter
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Higher prevalence in older population
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Proximal hamstring injuries also can involve acute injuries related to avulsions or strains but also can include more chronic processes like insertional tendinopathy. A common overlapping clinical presentation in this region may be a lumbar radicular or sciatic nerve issue, so the clinical awareness of both entities is crucial. Proximal muscle strains and chronic tendinopathy issues can resolve with nonsurgical treatment but do tend to require a lengthier treatment protocol and sometimes time loss from their sport. With acute ruptures of the proximal hamstring attachment, there typically is a surgical reattachment performed for tears that involve at least 2 tendons and have a retraction of greater than 2 cm in high-level athletes. The recovery time from this surgery can take up to 9 months to return to sport.
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Proximal hamstring injury key points
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Less common than midbelly hamstring injury
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Multifold increase in risk during competition compared with training
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More prevalent in older athletic populations
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Incidence in male athletes associated with increased age (although younger than female athletes) and sport participation
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Incidence in female athletes associated with increased age and occurrence during activities of daily living
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5% co-incidence of sciatic nerve involvement
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Clinical assessment
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General assessment of soft tissue injuries of the hip and pelvis
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Subjective
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Pain of muscular etiology typically most prominent with activation of the affected structure, especially in the stretched state (ie, activation of the hip flexor while supine in bed). Affected individuals typically can locate muscular pain with palpation.
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Muscular pain is most pronounced more commonly after a period of rest, then abates before becoming more prevalent again with prolonged activity.
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Patients with hip flexor (and its associated bursa) pathology may complain of snapping over the anterior hip, and this can present similarly over the lateral hip in external rotator/abductor tendinopathy or proximal iliotibial band friction syndrome, respectively.
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Hip labral provocation with deep hip flexion, especially flexion and rotation movements, such as getting in and out of a vehicle
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Pain not associated with motion or pain associated with urination/defecation suggests nonmusculoskeletal etiology
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Diffuse discomfort or associated neurologic symptoms distally in the lower extremity should raise suspicion for a radiculopathic component as cause of the patient’s symptoms.
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Objective
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Inspection
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Evaluate for presence of ecchymosis/abrasions that may provide clues to the injured structure and mechanism of injury.
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Muscle wasting
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Pelvic tilt
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Gait abnormalities
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Palpation
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Examine for area of maximal tenderness
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Palpable tendinous defect in rupture/avulsion
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Posterior-superior iliac spine for concomitant sacroiliac joint pathology
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Firm pressure over gluteal musculature for reproduction of radicular pain in piriformis syndrome
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Lateral femoral condyle in iliotibial band friction syndrome for distal component
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Knee joint for referred pain
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Passive testing
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Important to evaluate hip ROM in the seated, supine, and prone positions
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Evaluation of affected and unaffected sides is critical.
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Special consideration to structures that cross 2 joints, such as the hamstring and iliotibial band (hip and knee)
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Special testing
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Critical to assess bilaterally and serially to determine asymmetry and changes over time
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Intra-articular pathology
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Assess with log roll, scour, flexion-adduction-internal rotation testing
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Extra-articular pathology
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Thomas test/modified Thomas test
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Hip flexor ROM restriction
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Must control for pelvic tilt
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Ober test
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Iliotibial band and/or tensor fascia latae ROM restriction
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May be affected by tightness of gluteus medius/minimus
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Trendelenburg test
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Ipsilateral hip abductor strength in single-leg stance
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Assess after exercise to fatigue to tease out mild strength deficits
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Neurologic testing
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Strength, sensation, and lower extremity reflexes are important to evaluate bilaterally for the presence of a neurologic component, such as with lower lumbosacral radiculopathies, which also provide motor input to hip girdle musculature.
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Straight leg raise test to evaluate for radiculopathy
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Active testing
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Strength testing
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Stinchfield test
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Resisted hip flexion past 30° to 45°
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Aids in ruling out intra-articular pathology as a source of a patient’s pain
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Resisted internal rotation
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More sensitive but less specific than Trendelenburg sign for detection of gluteus medius tears
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The evaluation of compound movements, such as the squat, lunge, and step-up/down, allows for the gross assessment of biomechanics but only when assessed by experienced practitioners.
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This evaluation also can help elucidate a possible femoroacetabular impingement component to the patient’s symptoms.
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More ballistic, dynamic movement evaluation allows the practitioner to evaluate the interconnected kinematics between joints in the activities that most closely replicate the mechanism of injury. Although the most intensive of these require a laboratory setting with motion capture software, they also allow for evaluation of deficiencies that would not be detected with the typical office evaluation. Some examples of dynamic testing include the following:
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Nine months post–anterior cruciate ligament (ACL) reconstruction, double-leg drop jump, single-leg drop jump, single-leg hop for distance, and hurdle hop all showed biomechanical deficiencies.
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Also showed biomechanical alterations in change of direction activities
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Knee valgus
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Knee internal rotation and flexion angle
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Knee extension and external rotation moment
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Ankle external rotation moment
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Single-leg triple hop
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Increased anterior pelvic tilt, knee valgus, and contralateral pelvic drop in female athletes with patellofemoral pain
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Single-leg hop
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Simple in-office test to assist in evaluation of femoral neck and sacral stress injury. Avoid in patients experiencing pain with weight bearing.
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Injury Rates
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Of all injuries sustained by Major League Baseball athletes, 5%
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Of noncontact injuries during defensive fielding, 74%
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Days missed for extra-articular injuries, on average: 12
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Days of lost time for intra-articular injuries, on average: 123
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There was an overall hip injury rate of 5.18 per 10,000 athlete exposures in National College Athletic Association football over a 10-year period. The most common were adductor strains (38.6%) and then hip flexor strains (28.5%), and these injuries were more common during the preseason. A similar study investigated collegiate soccer players with similar results, and in addition they showed that they these injuries were noncontact injuries, 77.3%.
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Hip and groin injuries led to lost time in one-fifth of professional soccer players.
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In professional soccer players, 14% of all injuries
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In professional dancers versus student dancers, 27.7% of all injuries versus 14.1% of injuries, respectively
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Collegiate athlete exposures: 53.06 hip/groin injuries per 100,000
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Most common in men’s soccer (110.84) and men’s (104.9) and women’s (76.88) ice hockey
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In sex-comparable sports, men with greater rate of hip/groin injury (59.53 vs 42.27)
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Noncontact, 48.4%
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Overuse/gradual, 20.4%
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Resulted in missed time from sport, 39.3%
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Resulted in surgery, 1.3%
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Rehabilitation principles
There is much overlap when considering the end goal of rehabilitation for hip flexor strains, adductor strains, proximal hamstring strains, and gluteal tendinopathy. Most sports involve various amounts of acceleration, deceleration, cutting, jumping, and sprinting at high speeds. All these components need to be trained during the rehabilitation process in order for an athlete to safely return to competitive sports. Phase 3 (return to competition) of the rehabilitation process might look similar for a soccer player who experienced an adductor strain and another soccer player who experienced gluteal tendinopathy. The reason for this is because phase 3 consists mostly of activities involving linear running, change of direction activities, sport-specific drills, and a graded return-to-game progression. Once athletes are physically able to perform phase 3 drills, they no longer are experiencing pain and should be either at normal or near normal in terms of their strength and coordinated movement strategies that once were affected by the injury.
On the other hand, the rehabilitation outlined for phase 1 and phase 2 of each of the 4 injuries in this article looks much different. The body needs to be put through specific movements and positions to properly strengthen and condition the injured tissue. Precise exercise prescription is required during these first 2 phases in order to overcome the specific deficits that an athlete presents to the clinician. Fig. 1 provides a detailed overview of each phase (see Fig. 1 ) .
