|
The Hip is Made for Movement
Unlike the pubic
symphysis and the sacroiliac
joint, the hip
is made for movement. The hip ligaments
are subjected to tremendous forces during sports and even during activities of
daily living. When the forces are too great for the ligaments
themselves, they are principally transmitted to the hip
abductor, the gluteus medius, and the gluteus minimus muscles. Studies show
that normal walking creates a force of 1.5 to 2 times body weight, where
standing on one leg creates a force of 2.5 times body weight, climbing produces
a force of 2 to 3 times body weight, and running forces, of 4.5 to 5 times body
weight.
Because the groin
or lower
back pain of an athlete is diagnosed as muscle strain, it will be important
to know the various muscles around the hip and then
explain why they are seldom the cause of chronic pain
problems for the athlete.
The hip
joint has tremendous mobility which, on average, consists of 45 degrees of
external rotation and internal rotation, 45 degrees of abduction, 20 degrees of
adduction, 135 degrees of flexion, and 30 degrees of extension. The primary hip
extensors consist of the gluteus maximus and the ischial portion of the
adductor magnus; the secondary hip extensors are the hamstrings.
The primary hip flexor is the iliopsoas, which inserts into the lesser tuberosity,
with the secondary hip flexors being the rectus femoris, pectineus, tensor
fascia lata, and sartorius.
Hip
abduction is performed principally by the gluteus medius and minimus, which
insert into the greater tuberosity
and secondarily by the tensor fascia lata. Adduction is performed primarily by
the adductor longus, with secondary adduction power supplied by the adductor
brevis and magnus, as well as the pectineus. The
hip is externally rotated by the short rotators (pyriformis, obturator
internus and externus, superior and inferior gemelli, and the quadratus
femoris) that insert into the posterolateral portion of the greater trochanter.
Internal rotation is relatively weak and supplied by portions of the
semitendinosus, semimembranosus, adductor magnus, gracilis and gluteus medius
and minimus.
Hip and Groin Pain Is
Seldom Just Related to the Hip
Seldom is the cause of an athlete's hip
and/or groin
pain just in the hip joint.
The sacroiliac
and pubic
symphysis areas are often overlooked because some physicians are not
familiar with the ligament referral patterns
from the lower
back and pubic
symphysis.
Recall that the referral patterns of the ligaments from the lower back and hip
are as follows: iliolumbar refers to the groin, testicles,
vagina,
and inner thigh. Posterior sacroiliac (upper two-thirds) refers to the buttock,
anterior thigh, leg
(outer surface); posterior sacroiliac (lower outer fibers) refers to the
posterior thigh, and the leg
(outer calf), foot
(lateral toes),
accompanied by sciatica;
hip (pelvic
attachment) refers to the posteromedial thigh; hip (femoral attachment) refers
to the posterior thigh; lateral lower leg refers to the big toe
and second toe; and sacrospinus and sacrotuberus refers to the posterior thigh,
posterior lower leg, and then to the heel.
Again, the most common and accurate method of determining what structure is
causing an athlete's pain is his/her description of the injury, pain referral
pattern, and the
palpatory examination. Sometimes the description of the injury and the pain
referral pattern are vague so one must rely on the palpatory examination for
proper diagnosis.
Prolotherapy
doctors are used to examining all of the above ligaments to find the areas of
tenderness. Generally, the pain-producing structure can be found and a positive
jump sign elicited. Because athletes have such significant muscles that
surround the lower back and hip in these areas, a positive jump sign cannot
always be elicited. The thumb may not generate enough force on the hip
ligaments, for instance, because of all the muscles. When this occurs, a
diagnosis is made relying on the history and the rest of the physical
examination to determine the most likely injured structure that is causing the
pain.
|
