REIDER PART 2 30
190 Chapter 5_Pelvis, Hip, and Thigh
Figurę 5-49. Palpation of the piriformis fossa.
Hamstrings. Hamstring injurics are primarily strains that occur during eccentric contraction of the muscle. They may involve almost any portion of the muscles, from thcir origins on the ischial tuberosity to just above the knee. The majority seem to occur in the proximal thigh. As with the quadriceps, hamstring injuries should be care-fully palpated for defects or, rarely, complete disruption. Severe hamstring strains significantly restrict the passive straight-leg raising test and may produce a tripod sign, as described in the Manipulation section.
Medial Aspect
The adductor muscle group constitutes the primary mass of the medial thigh. The proximal portion of the adductor longus is the most distinctive component of the adductor group. Placing the lower limb in a figure-four position allows the examiner to easily palpate and often visualizc this muscle as it originates from the pubis (Fig. 5-50). The muscle mass just posterior to the adductor longus consists of the adductor brevis, gracilis, and adductor magnus muscles. Further distally, the muscles are not easily distinguished. Strains of the adductor group are often called groin pulls. Significant tears of the adductor longus can cause the muscle mass distal to the tear to bunch up in a prominence, which can be misconstrued as a soft tissue tumor if the history of trauma is not elicited.
■ MANIPULATION
Muscle Testing
Abductors
The gluteus medius muscle is the principal hip abductor, with the gluteus minimus and tensor fascia lata func-tioning as auxiliary abductors. Ali three are innervated by the superior gluteal nerve. Hip abduction strength is best tested with the patient lying on the opposite side with the hips and knees extended. The patient is asked to abduct the limb away from the examination table. The examiner then presses downward against the limb at about the level of the knee, instructing the patient to resist the exam-iners attempt to push the limb back down toward the table (Fig. 5-51). In a normal patient, it should be very difficult for the examincr to overcome the patients abductor muscle strength. Abductor weakness is a com-mon sequela of arthritis of the hip joint.
Adductors
Flip adduction strength is supplied by the adductors longus, brevis, and magnus, and the gracilis.
Innervation of these muscles is primarily via the obtura-tor nerve, although the sciatic nerve contributes to the innervation of the adductor magnus. Testing the hip adductors against gravity is awkward because the patient must lie on the hip being tested to do so. Therefore, the adductors are usually tested with the patient lying supine on the examination table with the hips and knees fully extended. The examiner then passively abducts the limb to be tested and instructs the patient to attempt to adduct the limb back to the midline as powerfully as possible
Figurę 5-50. Palpation of the adductor longus.
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