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Soft Tissue Injuries of Hip and


Hamstring injury in athletes

The hamstring muscle group consists of three muscles: the

semimembranosus, the semitendinosus, and the biceps
femoris (long and short heads).
These three muscles function during the early stance
phase for knee support, during the late stance phase for
propulsion of the limb, and during mid swing to control
momentum of the extremity.
Injury to the hamstrings, whether partial or complete,
typically occurs at the myotendinous junction where the
eccentric force is concentrated.

Mechanism of Injury

The two most common factors in hamstring injury are lack

of adequate flexibility and strength imbalances in the
hamstrings (flexor-to-extensor and right-to-left).
Other controllable factors such as lack of adequate warmup, lack of flexibility, overall conditioning, and muscle
fatigue should all be corrected to minimize the chance of
hamstring injury.

large tear of the hamstring muscle group

Radiograph demonstrates an avulsion

injuryof the common hamstring tendon.


Hamstring injuries are classified in three groups: mild(grade

1), moderate (grade II), and severe (grade III).
Grade I strain or "pulled muscle" signifies an
overstretching of the muscle resulting in disruption of less
than 5% of the structural integrity of the musculotendinous
Grade II represents a partial tear with a more significant
injury but an incomplete rupture of the musculotendinous
Grade III represents a complete rupture of the muscle
with severely torn, frayed ends similar to those seen in an
Achilles tendon rupture.


MRI should be infrequently used. On MRI, acute

injuries typically show up as high signal intensity on T2
weighted images as a result of (hemorrhage or
edema)within the muscle belly.Chronic muscle injuries are
less predictable in appearance.
Plain radiographs are of little value unless an avulsion
fracture of the ischial tuberosity is suspected. plain films
of the pelvis (anteroposterior view of the pelvis that
includes the ischial tuberosity) should be taken if an
avulsion fracture of the ischial tuberosity is suspected.

Signs and Symptoms of Muscle Strains

Operative management

Surgery is typically considered only after a complete

hamstring avulsion from the ischial tuberosity with a bony
avulsion displacement of 2 cm or more.
Distal avulsions are treated like proximal avulsions when
these occur in isolation (rarely occur).

Physiotherapy Management

Modified Clanton, Coupe, Williams, and Brotzman


Phase 1:Acute

Phase 2: Sub acute

Phase 3: Remodelling

Phase 4: Functional

Phase 5: return to compitition


Quadriceps tears or strains are typically caused by indirect

trauma. The patient complains of a feeling of a "pulled"
the mechanism often occurs by the patient missing a
soccer ball and striking the ground Violently with forced
stretching of the contracting quadriceps muscle.

Risk factors:Risk factors for quadriceps strains (or tears) include

inadequate stretching, inadequate warm-up before
vigorous exercise, and muscle imbalance of the lower

Signs and symptomes:

The patient typically complains of a "pulled" thigh.
Examination typically reveals tenderness on palpation of
the rectus femoris (strain) or defect (tear). This is usually
found in the muscle belly. Because the rectus femoris is
the only quadriceps that crosses the hip joint, extending
the hip with the knee flexed causes more discomfort than
flexing the hip with the knee extended. This extended hip
maneuver causes pain because of its isolation of the rectus

Treatment of Quadriceps Strains (or Tears)

Acute phase

NSAIDs if not contraindicated.
Crutches in a touch-down or partial weight-bearing
(painless) fashion.
Hold all lower extremity athletic participation.
Avoid SLR in early rehabilitation because of increased
stress on the torn rectus femoris.

Intermediate phase

Regain normal gait.
Regain normal knee and hip motion.
Usually intermediate phase begins 3-10 days post injury,
depending on severity of injury.

Initiate a gentle quadriceps and hamstring stretching
PNF patterns.
Aquatic rehabilitation program in deep water with
flotation belt.
Cycling with no resistance

Return of function phase

Terminal knee extension exercises.

Increase aquatic program (deep-water running [DWR]).
Begin knee extension with light weights, progress.
SLR, quad sets progressing to PRE (progressive
resistance exercises) with 1- to 5-pound weight on the

Increase low-impact exercises to progress endurance and

Progress bicycle resistance and intensity of workout.
Elliptical trainer.
Thera-bands for hip flexion, extension, abduction,
Walking progression to jogging (painless).
30-degree mini-squats (painless).
Initiate sport-specific drills and agility training.
Isokinetic equipment (at higher speeds) with patient


The commonly accepted definition of a groin strain

focuses on injury to the hip adductors and includes the
iliopsoat, rectus femoris, and sartorius musculotendinous

Risk factors
Contact sports
Poor muscle conditioning
Sports that require quick starts

Sign and symptomes

Acute pain over proximal muscles of medial thigh region
Occasional bruising

After Groin (Adductor) Strain

Phase 1: Immediate post injury

Relative rest from athletic injury until patient is
asymptomatic and rehabilitation protocol complete.
Avoid lateral movements, pivoting, twisting, reverse of
Initiate PRICE regimen (protection, rest, ice,
compression,elevation above heart).

Employ crutches weight-bearing as tolerated until
patient walks with a normal, nonantalgic gait
Cryotherapy postexercise.
Pulsed ultrasound.
Electric stimulation

Aquatic deep-water pool running.
Stationary bicycling with no resistance.
Active ROM exercises of hip
Flexion, extension, abduction, gentle adduction.
Isometric exercises
Hip adduction.
Hip abduction.
Hip flexion.
Hip extension.
SLR, quad sets.

Phase 2: intermediate phase

Criteria for Progression to Phase 2

Minimal to no pain on gentle groin stretching.
Good, painless gait.
Swelling minimal.
Progressive Resistance Exercises (1- to 5-pound weight)
Hip abduction, adduction, flexion, extension.
Continue modalities (ultrasound, moist heat).
Proprioceptive exercises.
Initiate gentle groin stretches

Wall groin stretch .

Groin stretch .
Straddle groin and hamstring stretch .
Side-straddle groin/hamstring stretch
Hamstring stretches.
Passive rectus femoris stretch.
Passive hip flexor stretch.
a) Progress stationary bicycling resistance.
b) DWR in pool.
c) PNF patterns.
d) Jogging/ running
e) Box drill.
) Protective wrapping or commercial hip spica type protection.

Bursitis & Tendinitis around hip

Trochanteric bursitis:
Pain over the lateral aspect of the hip & thigh may be due
to local trauma or overuse resuting in inflammation of the
trochanteric bursa which lies deep to the tensor fascia lata.
Gluteus medius tendinitis:
Acute tendinitis may cause pain and localized tenderness
just behind the greater trochanter. Perticularly seen in
dancers and athletes.

Adductor longus strain or tendinitis:

Adductor muscle strains are a common injury in sports that
involve sudden changes of direction. Often seen in
footballers and athletes. The patient complains of pain in the
groin and tenderness can be localized to the adductor longus
Iliopsoas bursitis:
Pain in the anterior thigh and groin may be due to an
iliopsoas bursitis. The condition may arise from synovitis of
hip as hip joint and bursa are interconnected. The most
typical feature is a sharp pain on adduction and internal
rotation of the hip.

Snapping hip pain:

Snapping hip is a disorder in which the patient complains of the
hip jumping out of place or catching during walking. The
snapping is caused by a thickened band in the gluteus maximus
aponeurosis flipping over the greater trochanter.
In the swing phase of walking the band moves anteriorly than in
the stance phase as the Gmax contracts and pulls the hip into
extension, the band flips back across the trochanter causing an
audible snap.
Often if discomfort is marked the band can be either divided or
lenghthened by a z-plasty.
Treatement of other tendinitis and bursitis include rest and local
anesthetic and corticosteroid injection.


Protection phase

Controll inflammation and promote healing- by not

stressing the involved tissue. and the patient avoid the
provoking activity; and if necessary, decrease the amount
and time walking or use an assistive device.

Develop Support in Related Areas-Initiate exercises to

develop neuromuscular control for alignment of the pelvis
and hip.

Controlled motion phase

Develop a Balance in Length and Strength of the Hip

Stretch any muscles that are restricting motion with gentle,
progressive neuromuscular inhibition techniques.
Instruct the patient to do self-stretching with proper
stabilization to ensure that the stretches are performed safely
and effectively.
Begin developing neuromuscular control to train the
involved muscles to contract and control alignment of the
femur. Initially, the emphasis is on control, not

Once the patient is aware of proper muscle control and is

able to maintain alignment, progress to strengthening the
weakened muscles through the range.
Muscles not directly injured should be stretched and
strengthened if they are contributing to asymmetrical
forces. The patient may not have sufficient trunk
coordination or strength, which may be contributing to the
overuse because of compensations in the hip.


Apleys system of orthopedics and fracture.

Clinical orthopedic rehabilitation.
Therapeutic exercise.

Thank you