Evaluation of Hip Pain in Children & Young Adults

1. Evaluation of Hip Pain in Children & Young Adults Marzena Slater, M.D. PGY 3 Emory Family Medicine

2. Objectives • To provide a background of hip anatomy • Provide an overview of hip pain evaluation • Discuss special testing used in the evaluation of hip pain • Summarize key history and physical findings that will aid in diagnosing common hip problems • Discuss common hip pathologies in athletes and children

3. Hip Anatomy- Bones • Ball & socket joint • Made up of 2 components: • Acetabulum (Pelvic component) • Femoral Head • Several areas more injury prone: • Young: Femoral head epiphysis, ASIS, femoral neck • Older: Arthritis, fx of femur or pelvis Reference 1

4. Hip Anatomy-Muscles • Flexion: • Iliopsoas- primary • Quadriceps • Rectus Femoris, Vastus lateralis/medialis/intermedius • Extension: • Gluteus Maximus- primary • Hamstring group • biceps femoris, semitendinosus, semimembrenosus • Abduction: • Gluteus Medius- primary • Gluteus Minimus- not palpable • Adduction: • 5 muscles • Gracilis, pectineus, adductor longus, adductor brevis, adductor magnus • Internal rotation • External rotation

5. Hip Anatomy- Sensory Nerves • Sensory: • Genitofemoral nerve (L1-L2)- prox. Anteriomedial thigh • Obturator nerve (L2-L4)- inferiomedial thigh • Lateral Femoral Cutaneous nerve (L2-L3)- Anteriolateral thigh • Posterior Femoral Cutaneous nerve (S1-S3)- posterior thigh Reference 2

6. Hip Anatomy- Motor Nerves

7. Hip Anatomy-Bursae • Prevent excessive friction of soft tissue over bony prominences during motion • Become inflammed w/ repetitive activity & trauma • Most commonly injured: • Trochanteric bursae • Ischial tuberosity bursae (fall on bottom) • Illiopsoas bursae (less common)

8. Hip Anatomy- Nonmusculoskeletal Structures • Always keep in mind referred pain from: • Male & female sexual organs • Intestinal tract • Urinary tract • Vascular structures • Suspect when no obvious musculoskeletal or bony origin to pain, or when Rx doesn’t produce expected result.

9. Evaluation of Hip pain

10. History

11. Physical Exam • Approach it systematically • Don’t ignore the “good hip”- it can give you a reference for what’s normal in your patient • Expose both hips and perform: • Inspection • Palpation • ROM: passive and active in all planes • Strength testing- isolate relevant muscle groups individually, if possible • Special tests as indicated

12. Inspection • Gait: • Can the affected leg bear weight • Observe for: • Antalgic (painful gait)—Decreased stance phase • Lurch (Trendelenburg)- laterally vs posteriorly • Flat foot- no push off • Wide – feet > 4 inches apart • Decreased step size • Observe patient transfer from laying -> sitting -> standing • Estimate height symmetry of iliac crests—if asymetric compare leg length

13. Inspection Trendelenburg gait (lateral) Height symmetry iliac crests Leg length measurement Reference 1

14. Palpation • Bony structures: • Iliac crest • ASIS • Greater trochanter • Ischial tuberosity • SI joint • Spine • Muscle groups: • Relevant to pt complaint (particularly at attachments to bone) Fig 3, 6 p 146 Posterior Superior Iliac Spine Coccyx Ischial Tuberosity Reference 2

15. Range of Motion • If patient is unable to perform fully any of the active testing, passive testing should be conducted: • If Passive ROM normal but active ROM restricted, muscle weakness is a likely cause of restriction. • If passive and active ROM affected, bony (intra-articular) or soft tissue (extra-articular) blockage most likely- ex. Hip arthritis

16. Range of Motion- Passive • Abduction- 45-50 degrees from midline • Adduction- 20-30 degrees • Flexion- 135 degrees • Extension- 30 degrees • Internal Rotation- 30-35 degrees • External Rotation-45-50 degrees Internal rotation External rotation Reference 2

17. Strength Testing Abduction Adduction Flexion Extension External Rotation Internal Rotation Reference 2

18. Provocative Tests • Ober Test • On side: Flex & abduct hip • Leg should then adduct. If stays in abduction ITB contracture • Piriformis Test • On side: adduct hip • Pain in hip/pelvis= tight piriformis (compressing sciatic nerve) • 90-90 straight leg raise • Flex hip & knee 90 deg, extend knee • >20 deg flexion after full knee extension= tight hamstrings Piriformis Test Reference 1 & 2

19. Provocative Tests • Log Roll • Supine, hip extended:IR/ER • Pain in hip c/w arthritis • Patrick (FABER) • Flex, Abduct, ER hip, then abduct more • + if pain or won’t abduct more: Hip or SI joint pathology • Meralgia • Apply pressure medial to ASIS • Reproduction to pain, burning, numbness= LCFN entrapment Log roll FABER ASIS

20. Diagnosis & Treatment of Hip Conditions

21. Prepubescent:Transient Synovitis • Most common cause of hip pain in children • Hx: • +/- Recent trauma or viral infection • Limp acute onset • Young child • PE: • Pain w/ any hip movement • Labs to consider: • CBC,CRP, ESR • Prognosis: • Self limited- improve in 2-3 days • Ddx: • Septic Arthritis • Juvenile Rheumatoid Arthritis The log-roll test may help determine the severity of hip irritation and aid in distinguishing between transient synovitis of the hip and septic arthritis. The diagnosis of transient synovitis is more likely if an arc of 30 degrees or more of hip rotation is possible without pain.

22. Pre-pubescent:Legg Calve Perthes disease • Inflammatory disease of unknown etiology- affects femoral head • Males > Female (5:1) • Ages affected: • 4-8 yo typically • HX: • Insidious onset (1-3 mo) of limp w/ hip or knee pain • PE: • Limited hip abduction, flexion & internal rotation • DX: • Juvenile Arthritis • Other inflammatory arthritis • Labs: • CBC, ESR- wnl • X-Rays: • Early- changes in epiphysis • Late- Flattening of femoral head • If neg & high suspicon- get MRI or bone scan • Rx: Maintain ROM, Ortho referal Figure 1 X-ray of a child's normal hipbone and a broken (fractured) hipbone from poor blood flow because of Legg-Calve-Perthes disease (LCPD). Figure 2 MRI of a child's normal hipbone with fat in the growth center and an abnormal hipbone where the fat has been lost because of LCPD

23. Adolescent:Slipped Capital Femoral Epiphysis (SCFE) • Failure of cartilaginous growth plates epiphysis slips on the femoral neck • Typical ages: 11-14yo • Etiology: • Multifactorial • Obesity • Male sex • If missed may lead to avacular necrosis of femoral head • HX: • Acute or chronic onset • Hip pain +/- refered to knee or medial thigh • PE: • Acute- Pain w/ limited internal rotation • Chronic- may have leg length discrepancy • Ddx: Muscle Strain, Avulsion fx • Xrays: • Early- widened epiphysis • Late- slippage of femur under epiphysis • RX: • Urgent Ortho referral • Non-weight bearing, surgical pinning

24. Young Adult:Femoral Neck Stress Fracture • Hx: • Persistent groin discomfort • Worst w/ activity • h/o endurance sports • Female athletic triad • PE: • Painful ROM • Pain on palpation of greater trochanter • Imaging: • Xray • Cortical defects in femoral neck • +/- MRI, CT, Bone scan • RX: • Inferior surface fx • no wt bearing 2-4 weeks • Superior surface • Ortho referral--- ORIF • Prognosis: • Can progress to unstable fractures and AVN if not rx appropriately

25. Young adult:Avulsion Fracture • Hx: • Sudden violent muscle contraction • May hear or feel a “pop” • PE: • Pain on passive stretch & active contraction of involved muscle • Pain on palpation of involved apophysis • Imaging: • Xrays • CT or MRI if Xray neg & dx in question • RX: • >2cm displacement—Ortho referral • <2 cm displacement—PT, progressive ROM/strengthening Reference 5

26. Young Adult:Osteoid Osteoma • Hx • Vague hip pain • Present at night • Worst w/ activity • PE: • Restricted ROM • Quad atrophy • Imaging: • Xrays • +/- MRI, CT if sx persist & Xray neg • Rx: • ASA, NSAIDs • Surgical removal if medical rx fails Reference 6

27. Young Adult:Myositis Ossificans • Hx: • Contusion w/ hematoma 2-4 weeks earlier • PE: • Pain on palpation • +/- Firm mass palpable • Imaging: • Xray or USD • Calcified intramuscular hematoma • RX: • Ice/NSAIDS • Surgical resection if conservative Rx fails > 1 year Reference 7

28. Young/Older Adult:Iliotibial Band Syndrome • Hx: • Lateral hip, thigh or knee pain • Snapping as illiotibial band passes over greater trochanter • PE: • Positive Ober’s test • Rx: • Modification of activity, footwear • Stretching program • Ice • Massage • NSAIDS Reference 8

29. Older Adult:Trochanteric Bursitis • Hx: • Pain over greater trochanter • Pain during transition from standing to lying down • PE: • Pain on palpation of greater trochanter • Imaging: • Negative for bony involvement • Rx: • Ice • NSAIDS • Stretching • Protection from direct trauma • *Steroid injection

30. Older Adult:Avascular Necrosis Femoral Head • Hx: • Dull ache or throbbing pain in groin, lateral hip or buttock • Hx of : • prolonged steroid use • prior fx • SCFE • PE: • Pain on ambulation, abduction, internal & external rotation • Imaging: • Xrays- late changes • MRI- early changes • Rx: • Protected weight bearing exercises • Total hip replacement

31. Older Adult:Piriformis Syndrome • Hx: • Dull posterior pain • May radiate down leg- mimics radicular sx • Hx of track competition or prolonged sitting • PE: • Pain on : • active external rotation • passive internal rotation of hip • Palpation of sciatic notch • DX: • EMG studies- may help • MRI- lumbar, if suspect nerve root compression • RX: • Stretching, NSAIDs, Rest, correction of offending activity Reference 1 & 2

32. Older Adult:Meralgia Parasthetica • Hx: • Pain or parasthesia of anterior or lateral groin & thigh • PE: • Abnormal distribution of lateral femoral cutaneous nerve on sensory exam • Apply pressure medial to ASIS • Reproduction to pain, burning, numbness= LCFN entrapment • Dx: • Mostly clinical • EMG- may be helpful • RX: • Avoid external compression of nerve (clothing, equipment, pannus)

33. Older Adult:Iliopsoas (Illiopectineal) Bursitis • Hx: • Pain or snapping in medial groin or thigh area • PE: • Pain w/ active & passive flexion/extension of hip • DX: • Clinical- imaging neg • But avulsion fx in Ddx • RX: • Illiopsoas stretching • Steroid injection (done under USD guidance)

34. References • Adkins, S.B. & Figler, R.A; Hip Pain in Athletes.American Family Physcian. April 1, 2000. http://www.aafp.org/afp/20000401/2109.html • Hoppenfield, M. Physical Examination of the Spine and Extremities. New Jersey:Prentice Hall 1976. • O’Kane, J.W; Anterior Hip Pain. American Family Physician. October, 15 1999. http://www.aafp.org/afp/991015ap/1687.html • Thompson, J.C. Netter’s Concise Atlas of Orthopedic Anatomy. Philadelphia:Elselvier Inc 2002 • www.learningradiology.com/.../cow286lg.jpg • uwmsk.org • www.hughston.com/hha/b.xray.gif • www.floota.com