Rehabilitation of Thigh Injuries




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.




Figure 18-1


Anterior view of the muscles of the thigh.



Figure 18-2


Posterior view of the muscles of the thigh.



Figure 18-3


Muscles of the medial aspect of the thigh.


Table 18-1

Functional Anatomy 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.


Clinical Pearl #1




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.



Table 18-2

Sports-Related Musculoskeletal Injuries to the Thigh and Their Differential Diagnosis
























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.



Table 18-3

Tendon Injury Classifications






















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).



Table 18-4

General Rehabilitation Strategies for Soft Tissue Injuries













































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

AAROM, Active assisted range of motion; PRN, as needed; PROM, passive range of motion; ROM, range of motion.


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.


Clinical Pearl #2


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.



Table 18-5

Signs and Symptoms 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).



Table 18-6

Quadriceps Strain Rehabilitation Progression












































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


  • Cryotherapy



  • Electrical stimulation

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:


  • Four-way SLR exercises (hip flexion, extension, abduction, and adduction)



  • Short-arc quads



  • Large-arc quads



  • Leg press, shuttle, or Total Gym (double and single leg)



  • Total body strengthening: address lower kinetic chain muscular weakness

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

ROM, Range of motion; SLR, straight leg raise.



Figure 18-4


Kneeling hip flexor stretch.



Figure 18-5


Standing quadriceps stretch.



Figure 18-6


Isometric hamstring set.


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 ).



Table 18-7

Four-Stage Program for Return to Running and Kicking



















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.

From Cross, T.M., Gibbs, N., Houang, M.T., and Cameron, M. (2004): Acute quadriceps muscle strains: Magnetic resonance imaging features and prognosis. Am. J. Sports Med., 32:710–719.


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.



Table 18-8

Quadriceps Contusion Treatment Protocol
















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.

From Aronen, J.G., Garrick, J.G., Chronister, R.D., and McDevitt, E.R. (2006): Quadriceps contusions: Clinical results of immediate immobilization in 120 degrees of knee flexion. Clin. J. Sports Med., 16:383–387.

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Apr 13, 2019 | Posted by in PHYSICAL MEDICINE & REHABILITATION | Comments Off on Rehabilitation of Thigh Injuries
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