Hip and Thigh Contusions and Strains

History

The athlete will almost immediately note pain over the iliac crest and/or greater trochanter after a fall or collision. He or she will note an inability to ambulate without a limp and pain with side-to-side or attempted crossover movements.

Physical Examination

Examination of the injured athlete will reveal an antalgic gait, pain with palpation of the pelvic brim, bruising, and swelling. Active ROM of the hip will be decreased. Strength testing will demonstrate a marked decrease in any or all of the following muscle groups, depending on the location of the contusion: the hip flexors, sartorius and rectus femoris, internal and external obliques, tensor fascia lata, gluteus medius, latissimus dorsi, and paraspinal muscles.

Imaging

Diagnosis of a hip pointer is made primarily on the basis of the history and physical examination. Radiographs are used only to rule out further injury, such as a fracture ( Fig. 87.2 ). Rarely, magnetic resonance imaging (MRI) or ultrasound are needed; however, some investigators have advocated their role in the evaluation of hematoma formation in an effort to quantify RTP.

Treatment Options

Nonoperative treatment with protection, rest, ice, compression, and elevation (PRICE) is central to the treatment of hip pointers. Crutches may be used for the first few days. Ice, rest, and compression should be instituted for the first 48 hours to decrease the risk of hematoma formation. Antiinflammatory agents may also be used during the first 5 to 7 days. Beginning on day 3, the athlete may begin painless ROM activities. Some investigators have advocated delivery of a cortisone injection to the affected area to decrease pain and swelling; however, the risks of such injections must be weighed. Physical therapy may be initiated once a painless ROM has been established. Therapy should include stretches, sport-specific massage, and strengthening. Surgery is rarely indicated for hip pointer injuries; however, concomitant injuries such as sports hernias must be ruled out.

Authors’ Preferred Technique

Iliac Crest Contusion

Our preferred technique is to initiate PRICE and use of crutches for the initial 24 h. A repeat physical examination in the office should be undertaken within 3–4 days of the injury. Provided that an avulsion fracture is not suspected, ROM exercises and gentle stretches are begun. A localized cortisone injection is considered for athletes who are not progressing as rapidly as anticipated. In those instances, activities are stopped for 48–72 h, after which rehabilitation is resumed in earnest. RTP is expected in 2–4 weeks once the athlete has completed strength testing and sport-specific drills.

Return to Play

RTP is anticipated 2 to 4 weeks after the time of injury. Sport-specific drills and strength testing of the affected limb must be completed prior to resumption of competitive activities. Upon returning to activities, appropriate padding should be worn to prevent reinjury.

Results

The treatment of hip pointers has yielded excellent results. Almost all athletes are able to return to their previous level of competition and performance once the injury has sufficiently healed.

Complications

Complications after hip pointers are rare. Those most commonly seen include hematoma formation, cutaneous nerve injury, or myositis ossificans. Missed fractures or avulsions injuries are rare complications. Occasionally, as a result of severe impact, there can be an internal degloving injury, known as a Morel-Lavallée lesion, whereby the subcutaneous tissue is stripped of its connection to the underlying fascia. The resulting hematoma can be painful and may expand to fill a large cavity. Untreated, this cavity can form a cystic lesion, allowing the fluid collection to recur, and the hematoma can even serve as a nidus for bacterial colonization and infection. In the acute setting, conservative management—with cold therapy, compression, early ROM, and observation—is appropriate. If symptoms worsen or persist, advanced imaging studies can be helpful in directing treatment options, which include aspiration and either percutaneous or open drainage. A high index of suspicion is necessary to diagnose this condition, which is rare but has been reported in National Football League (NFL) players after a direct blow or slide on the ground.

History

Typically the patient will present on the field with a chief complaint of pain, lack of movement, or explosiveness and an antalgic gait. Twenty-four to 48 hours later, the patient may note similar or amplified symptoms, with noticeable limitations of knee ROM, thigh pain, loss of function, and swelling. As previously stated, the mechanism of injury is usually collision with a helmet or a severe kick to the thigh.

Physical Examination

Physical examination begins by evaluating the gait of the patient as he or she walks. Typically an antalgic gait is noted in persons with a moderate to severe contusion. A localized physical examination will note a tender, swollen, and often ecchymotic thigh in the area corresponding to the blunt trauma that was sustained. The thigh should be compared with the contralateral side as well. Palpation of the affected thigh may yield a palpable defect in persons with severe contusions, indicating a partial or complete tear. In addition, a firm thigh compared with the contralateral side has been associated with longer recovery times. However, the most important component of the physical examination is the ROM of the knee, because this component correlates with the severity of the injury and the anticipated return to activity. Rarely, symptoms of an anterior thigh compartment syndrome can be identified on the basis of the physical examination.

Imaging

Plain radiographs may be taken in the initial setting to rule out fracture; however, they typically have a low yield when a thorough history and physical examination is conducted. Radiographs, to evaluate for developing myositis ossificans, may have a more substantial role 2 to 4 weeks after injury if a firm mass is palpated.

MRI and ultrasound may also be used to evaluate the extent of the muscular edema and hemorrhage ( Fig. 87.3 ); however, no level I studies have shown that imaging evaluations will accurately correlate with the severity of the contusion or predict RTP better than the Jackson and Feagin knee flexion classification.

Treatment Options

Decision-Making Principles

The ROM classification system proposed by Jackson and Feagin currently serves as the gold standard for the treatment and prognosis of thigh contusions. As a rule, nonoperative treatment should be pursued when possible provided compartment syndrome has not been identified. The aforementioned military studies have demonstrated the quickest return to activity, with immediate flexion of the affected knee to 120 degrees during the initial 24 to 48 hours from the time of injury. Subsequent passive and active ROM should follow to prevent heterotopic bone formation and increase rates of RTP. Heterotopic bone formation should be managed with the previously outlined contusion rehabilitation protocol and may be monitored with triple-phase bone scans to evaluate for skeletal maturity. Surgical intervention should be considered for myositis ossificans only if loss of strength and ROM has not resolved during the ensuing months. Bony maturation must be identified prior to excision to prevent local recurrence.

Authors’ Preferred Technique

Quadriceps Contusion

Timely evaluation of the patient should be undertaken to assess the severity of the contusion and rule out more severe sequelae, such as compartment syndrome. Ice, knee flexion, and a gentle compressive wrap are instituted if assessment takes place on the field. For patients with moderate to severe contusions, we prefer to institute immediate knee flexion to 120 degrees with a locked, hinged knee brace. Use of ice and a compressive wrap or sleeve is also instituted with rest. The patient is reevaluated within 24–48 h by the treating physician or a therapist, and active ROM of the knee is begun, with a greater than 120-degree return to ROM desired as soon as possible. Electrical stimulation is added as warranted. If no contraindication exists, NSAIDs are begun at prescription-strength dosage for 5–7 days around the clock. However, they are discontinued if the patient cannot tolerate them. Noncontact training is permitted once quadriceps control and painless full ROM has returned, which is typically seen in 10–14 days. Full contact is permitted at the 3- to 4-week mark provided no further setbacks occur and if a thigh pad is worn. For patients who demonstrate worsening symptoms at the 14- to 21-day mark, radiographs are repeated and return to sporting activities is tabled.

Return to Play

A mild contusion may be managed symptomatically with ROM exercises and NSAIDs, thus allowing the athlete to continue in competition or training. For moderate or severe injuries, noncontact training is permitted once quadriceps control and painless full ROM has returned, which is typically seen in 10 to 14 days. Full contact is permitted at the 3- to 4-week mark provided that no further setbacks occur and a thigh pad is worn. The patient should be seen and cleared by a physician, and dedicated strength testing may be warranted to ensure the patient's safety.

Results

With some exceptions, the literature on management and outcomes after thigh contusions is mostly based on case studies or anecdotal evidence. Nonetheless, most reports note good to excellent results, with almost all athletes retuning to play. Ryan et al. demonstrated a shortened recovery time for the moderate and severe groups from 56 to 19 days and from 72 to 21 days, respectively, with utilization of immediate flexion of the knee to 120 degrees, followed by early ROM exercises. These findings were duplicated by Aronen et al.

Myositis Ossificans

Myositis ossificans is heterotopic ossification in an area of muscle, soft tissue, or disrupted periosteum ( Fig. 87.4 ). It is generally associated with a severe contusion and has a reported occurrence rate of 9% to 14%. In their military studies, Ryan et al. identified the greatest risk factors for myositis ossificans: knee flexion less than 120 degrees, sustaining the injury while playing football, having had a previous quadriceps injury, experiencing a delay in treatment greater than 3 days, and having an ipsilateral knee effusion.

Although this disease process can occur without a history of trauma, athletes can usually describe a sentinel event that caused a hematoma formation. The hematoma organizes, and calcium deposits are formed by the body. In a process that is not entirely understood, osteoblasts invade the formed hematoma and begin to make bony spicules. This process tends to occur near joints and at tendon origins, but it can occur anywhere along the course of a muscle. The process can start as soon as 1 week after injury and can be detected on plain films a minimum of 3 weeks after injury. Patients present with a rapid enlargement within the soft tissues, decreased ROM, and significant pain 1 to 2 weeks after injury. The patient has swelling and warmth at the site as well as an increased erythrocyte sedimentation rate and serum alkaline phosphatase level. Any treatment modalities implemented should not promote hematoma formation. Massage and manipulation should be avoided. Therapy should consist of active stretching and strengthening. Passive ROM should be delayed for at least 3 to 6 months. For patients with refractory loss of ROM, surgery should be considered. Surgery, if warranted, should be delayed for at least 9 to 12 months to allow the lesion to mature. A bone scan can help ascertain the maturity of the lesion. Patients and clinicians should be aware that the lesion may recur despite surgical removal.

Complications

Thigh compartment syndrome is a rare complication associated with quadriceps contusion, and treatment of this condition remains controversial. Most authors advocate emergent fasciotomies, but some reports in the literature advocate nonsurgical intervention, even when compartment pressure standards are met for a diagnosis of compartment syndrome. The rationale for this proposal is derived from Robinson et al. and others, who note that in cases of sports-related thigh compartment syndromes with pressures greater than 55 mm Hg, no adverse sequelae were identified at 1 year with a return to preinjury strength and ROM. Standard compartment syndrome measurement should be taken, and identification is made on the basis of one of the following criteria as identified in various studies: compartment pressures of 30 mm Hg, 45 mm Hg, or less than 30 mm Hg difference between compartment pressure and diastolic blood pressure.

Future Considerations

Future consideration should be given to the pursuit of level I and II studies on the management of quadriceps contusions. Additionally, exploration of the nonoperative management of thigh compartment syndrome is also warranted.