Chapter objectives
- •
Identify common muscular injuries involving the quadriceps, hamstring, and groin areas.
- •
Recall typical sports-related injuries to the thigh and apply appropriate treatment and rehabilitation strategies.
- •
Apply different rehabilitation strategies based on stages of healing for soft tissue injuries of the thigh.
- •
Recognize appropriate activities to increase muscular strength and endurance for the hamstring, quadriceps, and groin muscle groups.
- •
Identify appropriate functional activities for rehabilitation of thigh injuries.
Sports-related injuries involving the thigh are frequently sustained by athletes during practice and competition. The pathomechanics associated with a sports-related thigh injury can be the result of repetitive overuse, degeneration (age-related changes), or trauma. The nature and severity of a thigh injury will dictate how quickly an athlete is able to resume play. In some cases an athlete may miss little, if any, time from sports. In other situations an athlete may need to complete a lengthy rehabilitation program before returning to activities. For others, additional medical interventions, including surgery, may be required for the athlete to have a successful outcome. The purpose of this chapter is to identify common sports-related injuries involving the thigh and to present evidence-based or evidence-supported rehabilitation strategies for each type of injury.
Functional anatomy
The thigh is the anatomic region of the human body located between the proximal end of the pelvis and the distal knee joint. The femur, the only bone in the thigh, articulates with the proximal acetabulum to form the hip joint and distally with the superior aspect of the tibia to form the knee joint. The thigh consists of 18 muscles housed in one of three fascial compartments ( Figs. 18-1 to 18-3 ). The muscles of the thigh allow flexion, extension, rotation, abduction, and adduction of the hip and flexion, extension, and rotation at the knee ( Table 18-1 ). Primary vascularization of the thigh is provided by the femoral artery and vein, obturator artery, and popliteal vein. The femoral, obturator, tibial sciatic, and common peroneal nerves innervate the muscles of the thigh.
| Muscle | Function | General Origins (O) and Insertions (I) | Nerve Innervation | Fascial Compartment |
|---|---|---|---|---|
| Rectus femoris | Hip flexion, knee extension | O: Anterior inferior iliac spine I: Tibial tuberosity | Femoral nerve | Anterior |
| Vastus medialis | Knee extension | O: Intertrochanteric line and linea aspera I: Tibial tuberosity via patellar tendon | Femoral nerve | Anterior |
| Vastus intermedius | Knee extension | O: Anterior and lateral femur I: Tibial tuberosity via patellar tendon | Femoral nerve | Anterior |
| Vastus lateralis | Knee extension | O: Greater trochanter and linea aspera I: Tibial tuberosity via patellar tendon | Femoral nerve | Anterior |
| Psoas major | Hip flexion, stabilization | O: T12-L5 vertebrae laterally, transverse processes, and intervertebral disks I: Lesser trochanter | Ventral rami of L1-L3 | Anterior |
| Psoas minor | Hip flexion, stabilization | O: T12-L1 vertebrae and intervertebral disks I: Pectineal line, iliopectineal eminence | Ventral rami of L1-L2 | Anterior |
| Iliacus | Hip flexion, stabilization | O: Iliac crest, iliac fossa, anterior sacroiliac ligaments, ala of sacrum I: Psoas major tendon, iliopectineal eminence | Femoral nerve | Anterior |
| Tensor fasciae latae | Hip abduction, internal rotation, flexion | O: Anterior superior iliac spine, anterior portion of iliac crest I: Lateral tibial condyle via iliotibial tract | Superior gluteal nerve | Anterior |
| Sartorius | Hip flexion, abduction, external rotation; knee flexion | O: Superior to anterior superior iliac spine I: Pes anserine | Femoral | Anterior |
| Biceps femoris | Hip extension; knee flexion, external rotation | O: Ischial tuberosity (posterior), sacrotuberous ligament, linea aspera I: Head of fibula | Tibial and common fibular portions of sciatic nerve | Posterior |
| Semimembranous | Hip extension; knee flexion, internal rotation | O: Ischial tuberosity I: Superior-medial tibia | Tibial division of sciatic nerve | Posterior |
| Semitendinosus | Hip extension; knee flexion, internal rotation | O: Ischial tuberosity I: Posterior portion of medial condyle (tibia) | Tibial division of sciatic nerve | Posterior |
| Pectineus | Hip adduction, flexion, external rotation | O: Superior pubic ramus I: Posterior surface of femur | Femoral nerve, branch of obturator nerve | Medial |
| Adductor longus | Hip adduction | O: Pubis (anterior) I: Linea aspera (proximal third) | Obturator | Medial |
| Adductor brevis | Hip adduction | O: Inferior pubic ramus I: Linea aspera (middle third) | Obturator | Medial |
| Adductor magnus | Hip adduction | O: Ischial ramus, ischial tuberosity I: Linea aspera, adductor tubercle | Obturator, tibial portion of sciatic nerve | Medial |
| Gracilis | Hip adduction, flexion, internal rotation | O: Pubis (anterior), inferior ramus of pubis I: Superior-medial tibia | Obturator | Medial |
| Obturator externus | Hip external rotation | O: Obturator foramen and membrane I: Trochanteric fossa (femur) | Obturator | Medial |
Functional kinesiology
The muscular functions presented in Table 18-1 describe how a muscle contracts concentrically. Traditional open kinetic chain exercises, performed with or without gym equipment, can effectively train concentric movements. However, rarely does one muscle (or muscle group) contract solely in a concentric fashion during sports. The muscles of the thigh are synergistically activated to perform concentric, isometric, and eccentric contractions during functional athletic movements such as running, jumping, cutting, and lifting. Functional and sport-specific exercises should be included during the later rehabilitation stages to optimize an athlete’s return to sport.
Closed kinetic chain exercises should be included in an athlete’s rehabilitation program. Prescribe exercises that reproduce an athlete’s functional movement patterns.
Muscle and tendon injuries of the thigh
An athletic injury occurs when forces experienced by the body, during training or competition, exceed the strength of a tissue (or tissues). Muscle injuries are classified by how they occurred: either by a direct (or external) mechanism or by an indirect (or internal) mechanism. Direct injury occurs when an external force applied to the body results in trauma. For example, a muscle contusion may be caused by a direct blow to the thigh during a football tackle. An indirect injury takes place independent of an external force. An example of an indirect injury is a strain that transpires when a muscle experiences excessive stretching or a violent, eccentric muscle contraction. A classic example of this type of injury is a running-related hamstring strain. Additional soft tissue injuries may arise when tissue is stressed repeatedly or constantly over time.
The majority of sports-related thigh injuries are muscular strains or contusions. Clinicians should also be cognizant of potential complications associated with a thigh injury or other medical conditions that would require immediate referral to a physician. Table 18-2 addresses common musculoskeletal injuries to the anterior, lateral, and medial aspects of the thigh and their differential diagnoses.
| Region of the Thigh | Primary Soft Tissue Injuries | Secondary Soft Tissue Injuries | Differential Diagnosis |
|---|---|---|---|
| Anterior | Quadriceps strain Quadriceps contusion Coxa saltans Iliopsoas strain Iliotibial band syndrome Patella tendinitis Patella tendinosis | Sartorius strain Gracilis strain Trochanteric bursitis Iliopsoas bursitis Iliopsoas tendinitis Lacerations Muscular avulsions Greater trochanteric pain syndrome Compartment syndrome | Myositis ossificans Legg-Calvé-Perthes disease Osteomyelitis Osteitis pubis Femoral stress fracture Femoral nerve entrapment Obturator nerve entrapment Tumors Labral tears Arthritis Infection Avascular necrosis of the hip |
| Posterior | Hamstring strains Hamstring tendinitis | Proximal hamstring avulsion Distal hamstring avulsion | Myositis ossificans Lumbar radiculopathy Sacroiliac dysfunction Piriformis syndrome Infection Tumors |
| Medial | Adductor muscle, group strain | Hip bursitis | Sports hernia Stress fracture Osteitis pubis Obturator nerve entrapment Ilioinguinal neuralgia Genitourinary disorders Intraabdominal disorders |
Tendon injuries are classified by the tissue’s pathologic state ( Table 18-3 ). The most common primary tendon injuries are either tendinitis (an acute inflammatory condition) or tendinosis (a chronic degenerative condition). Symptoms associated with tendinitis include pain, loss of function (strength, range of motion [ROM]), and the other inflammatory signs (warmth, swelling, redness). An athlete who has been diagnosed with tendinitis may be describe having performed either a novel or intense workout or an excessive amount of repetitive activity within the past 1 to 7 days. If an athlete, however, has tendon pain without inflammatory signs, it is likely that tendinosis is present. The degenerative tendon changes associated with tendinosis are the result of strain levels that over time damage the tendon’s microstructure. A patient in whom tendinosis is diagnosed frequently reports that the pain has been present for prolonged periods (months to years) before seeking medical attention.
| Pathology | Definition |
|---|---|
| Tendinitis | Acute tendon injury with associated inflammatory response |
| Tendinosis | Degeneration of the tendon not associated with an inflammatory process and caused by one or more factors (e.g., microtrauma, age-related changes) |
| Tenosynovitis | Inflammation of the tendon’s synovial membrane |
| Tenovaginitis | Inflamed, thickened tendon sheath |
| Peritenonitis | Inflammation of only the peritenon |
General soft tissue treatment
Selection of treatment or treatments for an injured athlete should be based on the findings from musculoskeletal evaluation and the current healing stage (time frame after injury). Soft tissue healing progresses through three stages: acute, subacute, and chronic ( Table 18-4 ). Prescription of inappropriate therapeutic measures can delay healing or exacerbate the injured athlete’s condition (or both).
| Stages of Healing | Time Frame (Approximate) | Treatment Goals | Treatment |
|---|---|---|---|
| Acute (inflammatory response) | 1-3 days | Modulate pain | Modalities PRN |
| Decrease swelling | Modalities PRN | ||
| Maintain or improve ROM | Gentle ROM: PROM, AAROM, passive stretching | ||
| Limit muscle atrophy | Isometric strengthening | ||
| Subacute (repair and healing phase) | 3-27 days | Modulate pain | Modalities PRN Joint mobilizations: grades I-II |
| Increase ROM | Joint mobilization grades III-V Soft tissue mobilization Increase ROM: PROM → AROM, stretching | ||
| Increase strength | Strengthening exercises: endurance (15-25 repetitions per set) and strength-training parameters | ||
| Restore cardiovascular fitness | Stationary bicycling, stairmaster | ||
| Chronic (maturation and remodeling phase) | 27 days-1 year | Increase strength, functional strengthening | Stretching and eccentric exercises Strengthening: strength training (sets of 8-12 repetitions) Functional training |
| Plyometrics, sport-specific conditioning | Plyometrics Sport-specific training |
During the acute healing stage, treatments are directed toward controlling or reducing the effects of inflammation, modulating pain, initiating controlled (gentle) movement to restore ROM, and reducing loss of muscular strength with isometric exercises.
In the course of the subacute healing phase, immature (functionally weak) collagen fibers are deposited in the injured region. The clinician should prescribe exercises that stress the newly formed tissue. The orientation and tensile strength of collagen are influenced by the therapeutic exercise program prescribed. Pain, however, should be avoided during exercise and, if incurred, may be an indication that the exercise is damaging the newly deposited collagen.
In the subacute stage of healing the athlete initially performs exercises with the goal of improving muscular endurance (performing each set with high repetitions and low weights). This allows the athlete to gradually increase strength while protecting tissues from potentially injurious loads. In addition to the prescription of therapeutic exercises, electrical stimulation may further assist in restoration of muscular strength.
Strengthening exercises prescribed during the subacute phase should be performed with low loads and high repetitions. The risk of reinjuring tissue is reduced by performing high repetitions (15 or more per set). The level of resistance may be gradually increased when the athlete is able to perform the desired number of repetitions per set.
Finally, during the chronic stage of healing, collagen alignment is influenced by the stress applied to the body while the tissue is maturing and remodeling. Exercise prescription can now include multijoint, closed kinetic chain exercises using strength-training variables (sets of 8 to 12 repetitions). If, however, the athlete experiences discomfort with increasing loads, continue with previous exercises that address muscular endurance. Advance the athlete to closed kinetic chain exercises, plyometrics, power training, and sport-specific training when pain-free full active ROM is restored. A more detailed description of tissue healing and its associated stages can be found in Chapters 2 and 7 .
Anterior thigh injuries
The quadriceps is at risk for overuse, traumatic, and degenerative injury. The majority of sports-related injuries involving the anterior aspect of the thigh are muscular strains and contusions. Other common injuries that an athlete may experience in this area include iliopsoas strain, coxa saltans, abrasions, and lacerations.
Quadriceps Strains
An athlete will experience a range of physical loads and stress during practice or competition. A muscular strain can occur in response to a one-time supraphysiologic load that is greater than the tissue’s tolerance or in response to repeated subfailure loads experienced during the course of a game or practice. Potential risk factors associated with a quadriceps strain include muscular fatigue, lack of flexibility, previous history of strains, muscular weakness, muscular imbalance, or inadequate warm-up routine.
A strain may occur anywhere along the length of the quadriceps muscle or tendon, or both; however, the majority of strains occur at the myotendinous junction. Strains are clinically described by the degree of muscle damage. Table 18-5 presents the characteristics of first-, second-, and third-degree strains.
| Injury Charcteristic | First Degree | Second Degree | Third Degree |
|---|---|---|---|
| Extent of muscle damage | Tear of a few muscle fibers | Tear of approximately half of the muscle fibers | Rupture of the entire muscle |
| Functional loss | None to minor | Moderate | Major |
| Pain | Minor | Moderate to severe | None |
| Motor weakness | Minor | Moderate | Major |
| Swelling | Minimal to none | Noticeable degree of swelling | Significant degree of swelling |
Treatment of a strain begins as soon as possible after the onset of injury. Immediate management will take place either on the sideline or in the athletic training facility/clinic ( Table 18-6 ). Immediate treatment of an athlete suffering a strain is rest, ice, compression, and elevation (RICE).
| Phase | Time Frame | Treatment Goals | Treatment |
|---|---|---|---|
| Immediate management | First 24 hours | Decrease swelling and pain | Protection, rest, cryotherapy (ice), compression, elevation |
| Protect injured region | Crutches if injury severe | ||
| Acute stage (inflammatory response) | 1-3 days | Decrease swelling and pain |
|
| Restore ROM | Gentle ROM exercises (e.g., passive hip and knee ROM, kneeling hip flexor stretch [ Fig. 18-4 ], standing quadriceps stretch [ Fig. 18-5 ]) | ||
| Restore neuromuscular function | Isometric exercises: quadriceps and hamstring sets ( Fig. 18-6 ) | ||
| Subacute stage (repair and healing phase) | 3-27 days | Continue ROM activities; improve muscular flexibility | ROM and flexibility exercises |
| Increase strength | Progressive resistance exercises:
| ||
| Improve cardiovascular fitness | Stationary bicycle Elliptical machine | ||
| Chronic stage (maturation and remodeling phase) | 27 days and on | Increase strength, progress to functional training Improve cardiovascular fitness Increase power | Cardiovascular fitness: stationary bicycle, Elliptical machine, Stairmaster Return to running program Endurance training: continue progressive resistance exercises as necessary Strength training: squats, lunges, step-downs, knee extensions (machine) Total body strengthening: address lower kinetic chain muscular weakness Plyometrics Agility drills Sport-specific training |
Cross et al reported success using a specific rehabilitation protocol to return injured Australian Rules football players back to sport after suffering a sport-related quadriceps strain. Athletes who completed the two-phase rehabilitation program were able to return to sport without reoccurrence of injury.
Treatments performed during the first phase of recovery (“acute management period”—the first 48 hours after injury) include RICE. The second phase, the remodeling phase, is a four-stage program involving a return to running and kicking ( Table 18-7 ) combined with a progressive therapeutic exercise routine and “soft tissue therapy.” The injured athlete is allowed to begin the running program once full pain-free ROM and the ability to hop on the involved leg for three sets of 10 repetitions are demonstrated. The athlete is allowed to progress from one stage to the next when the previous stage’s goal has been completed (see Table 18-7 ).
| Stage | Goal |
|---|---|
| 1 | Able to jog 2 sets for 10 minutes each. |
| 2 | 80-m striding intervals (3 sets of 5 repetitions) performed at 40%-60% of maximum ability. Stretch and rest between sets. |
| 3 | 80-m sprints while sprinting at 90%-100% of ability during the middle 30-m of the run. This must be performed for 3 sets of 5 repetitions. Stretch and rest between sets. Begin a kicking program by progressing from a small ball and kicking for short distances. |
| 4 | 80-m sprints while sprinting at 90%-100% of ability for 60-80 m. Sport-specific drills include shuttle runs, figure-of-eight s, and kicking the ball. Perform 3 sets of 5 repetitions each. Kick a normal-sized ball for all distances. Stretch and rest between sets. |
Quadriceps Contusions
A muscular contusion is caused by a traumatic force that damages the injured region’s musculature. The damage to the region’s capillaries leads to a collection of blood that, depending on its severity, may cause pain. In addition to the muscular pain or soreness associated with the contusion, the athlete may have a palpable mass and swelling, experience pain with movement, and have loss of motion at the adjacent joint or joints.
Anterior thigh contusions have been reported in soccer, football, rugby, and the martial arts; however, any athlete is at risk for a quadriceps contusion when participating in contact or collision sports. Although many contusions may go unreported or cause minimal dysfunction, some athletes can experience significant loss of time from sports after sustaining a moderate to severe contusion. In 1973 Jackson and Feagin reported that the average time lost from sports was 45 days (range, 2 to 180 days). Since then, intervention strategies have evolved to allow athletes to return to sports sooner.
Typical conservative management of a thigh contusion includes RICE and therapeutic exercises. Aronen et al were able to return injured midshipmen back to sports with no limitations in an average of 3.5 days (range, 2 to 5 days) by following the treatment plan presented in Table 18-8 . Furthermore, within 24 hours, all injured individuals had maintained pain-free active ROM to 120° of knee flexion, and more than 75% could perform a pain-free quad set and a straight leg raise without a lag. Within 3 days, all individuals demonstrated full pain-free active ROM equal to that on the uninvolved side. On return to sports, each midshipman was required to wear a thigh pad.
| Injury Time Line | Intervention |
|---|---|
| Immediate management: sideline management | Immobilize the knee in 120° of knee flexion with an elastic wrap technique. Transfer the injured individual to the clinic. |
| Immediate management: in the clinic | Remove the elastic wrap. Replace with a knee brace and immobilize the knee at 120°. Provide crutches and instruct the patient to wear the brace for next 24 hours. |
| Twenty-fours hours after injury | Remove the brace. Initiate pain-free active quadriceps stretching and quad sets. The patient performs the prescribed exercises and continues crutch ambulation until able to demonstrate full pain-free active range of motion and restoration of quad function equal to that on the ipsilateral side. |
Related posts:
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
