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CHAPTER 10:
The Thigh and Hip

The thigh contains the major leg muscles. The hamstring muscle in the back of the thigh is the driving force in all running sports. Your hamstrings help determine how fast and strong a runner you are. The large quadriceps muscle in the front of the thigh straightens the knee, which helps you stand tall. This is the main muscle used in jumping, and it also provides the power when you pedal a bicycle.

HAMSTRING PULL

The hamstring muscles are often ignored in the weight room in deference to their stronger, more aesthetically appealing counterparts, the quadriceps muscles. The hamstrings are implicated in maladies ranging from low-back pain to jumper's knee.

      Probably the most common injury in the thigh and hip area, and the most common muscle pull, is the hamstring pull. Any rapid running subjects the hamstring muscles to great force; consequently, they are prone to pull. These muscles have an extremely wide range of motion, and they stretch out rapidly during the long running stride as you throw your foot forward.

      When you see a great athlete sprinting on television suddenly grab the back of a leg and fall in full flight, the runner has probably pulled a hamstring muscle. Although a hamstring will sometimes tear as a sprinter drives out of the starting blocks, a hamstring usually pulls from overstretching, not overcontracting, the muscle. It's not the first part of the stride, when the muscle contracts, but the second part of the stride, as the leg stretches out, that causes problems.

      If you pull a hamstring, it may feel as if the muscle has "popped." You will feel sharp pain and see swelling in the thigh--and maybe even bleeding, depending on the degree of muscle damage. The back of the thigh may turn black and blue, usually right below the area of pain, because blood works its way down by gravity. If you touch the back of the thigh, you may feel a gap in the muscle where the fibers have torn. You will not be able to raise your leg straight off the ground more than 30º to 40º without feeling severe pain.

      Rehabilitation begins with the classic combination of rest, ice, and compression. The amount of rest depends on the severity of the pull or tear and is typically two to three days. This should be followed by limited activity until you are free of pain and fully restretched. Icing the muscle for 20 minutes three or four times a day will reduce the chances of aggravating the condition. Then you can start on a gentle stretching program.

      You need to start stretching as soon as possible while the muscle is recovering. As long as the stretch is gentle and steady, you can start as early as the second day after your injury, unless you have a major tear. Go into the stretch slowly without jerking the muscle in order to avoid pulling or tearing it again. Stretch to the point of discomfort but not pain.

      The best hamstring stretch is the hurdler stretch. This can be done either sitting or standing. See Hurdler Stretch (sitting), in Chapter 1; and Hurdler Stretch (standing), in Chapter 7.

      To prevent another pull or tear, you need to warm up adequately and stretch before any activity and, as always, restretch afterward.

      Try to keep up your aerobic conditioning and overall muscle tone during your rehabilitation. Cycling and swimming are safe and effective exercises and should be done pain-free to prevent overstressing the injured muscle.

      The symptoms of sciatica can mimic a hamstring pull, with pain in the back of the thigh. I see many patients who complain of a pulled hamstring but who really have sciatica.

      Sciatica is simply a signal that something is irritating the sciatic nerve. Possible causes include a disc in the lower spine pushing on the nerve root where it comes out of the spinal cord; an arthritic spur on the spine pushing on the nerve root; a muscle spasm in the large lower-back muscles, which pull and stretch the nerve; or a nerve entrapped in the buttock area.

      If the thigh pain extends below the knee or if you feel any numbness in your lower leg or foot, the problem is not a hamstring pull but sciatica. If the pain in the back of your leg becomes worse with stretching, then it's probably sciatica and you should see a doctor.

A BRUISED QUAD

A blow to the large quadriceps muscle in the front of the thigh can cause bleeding into the muscle. A blow can crush the muscle fibers against the large, heavy femur bone below. This muscle is prone to heavy bleeding because it is contains many blood vessels. The bleeding causes swelling and sometimes severe pain, and you may be unable to bend your knee fully.

      The immediate treatment is to ice the muscle for 20 to 30 minutes with the knee bent as far as it will go. Sports doctors used to think that the leg should not be bent because this would cause complications, including more bleeding and later calcium deposits. Now we know that's not true. With the Giants, we apply ice packs to the thigh and then wrap the leg with the knee fully bent using an elastic bandage to pull the leg back against the hamstring. This compresses the quadriceps muscle and puts enough pressure on the blood vessels to stop the bleeding. We instruct the player to ice the thigh several times a day for as long as he has any discomfort or swelling, and to keep stretching the muscle by flexing the knee as far as it will go.

      If you have more than mild swelling or pain, see a doctor for a physical therapy prescription. Blood in the quadriceps will cause calcium deposits to form, which is called myositis ossificans. If this condition is not treated vigorously, the calcium will not allow the fibers in the muscle to extend fully, and you won't be able to bend your knee all the way. This is a difficult condition to treat and can disable you for up to a year.

A QUAD PULL OR TEAR

A quadriceps pull is usually a running or jumping injury. A pull or tear to a quadriceps muscle is less common than a hamstring pull or tear. But the treatment is the same: Rest the muscle for a few days, and then ice and stretch it. Prevention is also the same: Warm up correctly and stretch the muscle in the front of the thigh through an exercise such as the following.

FEMUR FRACTURE

The thigh bone (femur) is the largest bone in the body. Femur fractures in sports are rare because the bone is so strong. Also, much of the rotary force of the leg is absorbed by the knee and is not transferred to the thigh bone.

      This injury causes sharp pain in the leg and usually requires surgery to fix the bone. You will need to rest the leg until it heals, which usually takes several months.

THE HIP

The hip is a very tight, stable ball-and-socket joint. Because the ball of the hip fits so tightly into the hip socket, it doesn't dislocate as easily as the shallow shoulder joint and is much less prone to injury. To dislocate a hip, you almost have to be hit by a truck.

      Because a hip dislocation requires immense force, it is very rarely seen in athletics. In all my years of attending football games, I have seen only three hip dislocations. Two occurred on the field during professional games where huge bodies collided with great force. The third one happened to the quarterback for the Newark Bears minor league team. While driving home for the off-season, he was hit by a coal truck in Pennsylvania.

OSTEOARTHRITIS

Osteoarthritis is a degenerative process in the hip caused by wear and tear or by an injury. The surfaces of the joint become rough, causing pain from hip movement. There is no apparent swelling, as with osteoarthritis of the knee, because the tight hip joint has little space for fluid accumulation. Also, the joint is buried beneath very deep muscles, so any swelling is invisible.

      All you can do for osteoarthritis of the hip is to take anti-inflammatory agents and decrease your activity. You may need a hip replacement later in life.

THE BO JACKSON INJURY

Avascular necrosis was a little-known sports injury until super-athlete Bo Jackson developed it. It is usually caused by a blow to the knee or foot with the leg extended. Bo did not actually take a hit to the hip. He was hit high and knocked off balance while carrying the football. All of his weight came down on one leg, locked at the knee. The full impact of his landing on one foot was transmitted up to his hip. This caused the ball of the hip joint to hit the wall of the socket with great force, compromising the blood supply in the area and causing gradual deterioration of the surrounding cartilage and bone.

      You should suspect avascular necrosis if the pain in your hip does not go away after a few weeks or becomes progressively worse. The only means of early diagnosis is an MRI scan. By the time a physician is able to see the changes in a regular x-ray, the disease has become very advanced.

      You need to rest without putting any weight on the hip for 6 to 12 months. Bo being Bo, he came back a little sooner than that. There are some surgical procedures that can help your recovery. If the hip doesn't get better, the bone in the ball will eventually be destroyed and you will need a hip replacement, just as Bo eventually did.

BROKEN HIP

A broken hip causes severe pain and the inability to move the hip or walk. If you are lying on your back on the field after breaking your hip, your leg may appear to be shortened and your foot rolled to the outside while the other foot points up.

      Usually, a broken hip needs to be repaired surgically. This injury is rare among young athletes and usually occurs in the elderly, who have brittler bones. However, a violent force can break even a young athlete's hip.

BUTTOCK PULL

A pull of the muscle in the buttock (gluteal muscle) will cause pain there, particularly in reponse to any physical effort. It will hurt to do a straight leg raise. Doing the Hurdler Stretch (see Chapters 1 and 7) will help relieve this minor problem, which should go away within a week or two.

GROIN PULL

If you make a sudden lateral movement while rotating your leg when running or skating, you can pull a groin muscle. Several different groups of muscles attach to the groin area. The flexor muscles bend the hip, the adductor muscles bring one leg in against the other, and the rotator muscles bring the knee across the opposite leg. To determine which muscle is involved, you must find out which motion brings on the pain.

      You must rest a groin pull for several days and then begin a gentle stretching program. This should be followed by a gradual return to activity. As always, the best prevention is a good stretching program before and after activity.

      You must first determine which muscles are injured. If it is the flexor muscles, do the Hip Extension exercise described in Chapter 7. If it is the adductor muscles, use the Side Straddle Stretch. The rotator muscles respond to a Yoga Lotus Stretch.

ILIOTIBIAL BAND SYNDROME

Dorothy had been running for two years as part of her program for recovery from cancer when she developed a severe pain in her hip. The pain persisted for two weeks, so she went to see her internist, who in turn sent her to a local medical center. There she had an x-ray of her hip, a computerized hip scan, and a bone marrow biopsy of her hip, all of which where negative.

      On a friend's recommendation, Dorothy came to see me. I listened to her recount her medical history and litany of testing, and I lightly put my hand on the outside of her hip. She screamed and jumped off the examining table. As I suspected, she had iliotibial band syndrome, a tightening of the band across the hip. With 10 minutes of stretching each day, she was running again in 10 days without pain.

      The fibrous band running down the outside of the thigh is called the iliotibial band. It provides lateral stability to the hip so that it can't move too far to the outside. In some people, particularly runners, the band overdevelops, tightens, and saws across the hip bone. Each time the runner flexes and bends the knee, the band rubs against bone, causing pain. Although this condition often causes knee pain, it may also cause pain over the point of the hip. (For more about iliotibial band syndrome, see Chapter 11.)

      A snapping pain in your hip is almost always due to the iliotibial band snapping back and forth over the point of the hip. As you stretch the band out, this pain will disappear. (See the stretching program in Chapter 1.)

HIP POINTER

A hip pointer is a blow to the rim of the pelvis that causes bleeding where the muscles attach. The treatment is to rest until the pain subsides, which usually takes one to two weeks. During that time, ice the rim of the pelvis intermittently.

      To prevent hip pointers, wear hip pads. Many recreational hockey and football players don't, and they suffer the consequences.




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