When a young athlete visits their pediatrician or primary care provider (PCP) with hip pain, the proper course of treatment isn’t always clear. The damage caused by acute and traumatic hip injuries can often be determined in imaging, while overuse injuries may be more difficult to diagnose.
For significant injuries requiring surgical intervention, it’s always in the best interest of a young athlete to be immediately referred to a pediatric orthopedic surgeon. But for nagging hip pain that doesn’t have a discernible cause, the best course of action may not be evident.
What are some of the more common hip injuries you see in young athletes?
The hip is a complex joint, so we see multiple types of injuries, both outside and inside the joint. Some of the injuries outside the joint are more minor — muscle strains, tendinitis or bursitis. In Sports Medicine, we often see hip flexor tendinitis causing anterior hip pain, bursitis or IT band tendinitis causing lateral hip pain, as well as sacroiliac (SI) joint problems and piriformis problems causing posterior hip joint pain.
Then we have problems inside the joint that can cause hip pain; things like a labral tear. One typically tears the labrum in the front of the hip, usually from repetitive overuse. Labral tears are often associated with underlying anatomical issues, such as hip impingement or hip dysplasia.
Are there certain conditions that tend to be misdiagnosed or improperly treated more than others?
I see both ends of the spectrum. For me it’s more about finding that middle ground between what is causing them pain and what is structurally wrong.
A lot of patients are referred with labral tears, and this is where I’ll typically see some issues on both ends of the spectrum. On one end I see patients who have an MRI showing a labral tear, but their symptoms and their exam fit more with hip flexor tendinitis.
It’s becomes complex because there are athletes without any symptoms. For example, if you have MRIs from a group of athletes, possibly 100 dancers who have no hip pain, about 20 percent of them would have a labral tear. Just because you see that on MRI doesn’t mean that’s what is causing their symptoms or that it needs to be treated.
It’s really a careful process of matching the history with the physical exam and imaging to come up with the right diagnosis. I’ll see patients sent in for a labral tear but they actually have hip flexor tendinitis, which we can treat with therapy and injections. Over time, they get better and the labrum was sort of an incidental finding.
On the other hand we see patients who have had hip pain for years. They’ve been told it’s a hip strain, it’s not getting better, and they finally get an MRI and it shows a labral tear. So I see both ends of the spectrum. For me it’s more about finding that middle ground between what is causing them pain and what is structurally wrong.
What are some symptoms a young athlete might present with that you believe would warrant a referral to an orthopedic specialist?
I think if a young athlete is seeing the PCP first and they have hip pain, it’s important to figure out whether it’s acute traumatic hip pain — they had an injury and now they’re having hip pain — versus a repetitive pain with no specific injury. This is important in terms of making the diagnosis.
More common hip pain in young athletes is generally going to be a soft tissue injury, like a tendinitis or a muscle strain. If you get x-rays and it looks normal, those can typically be treated with an initial period of rest from sports, physical therapy, ice or anti-inflammatories. If you’ve done that and the hip pain isn’t going away or it’s getting worse, then I would recommend referral for further evaluation.
Primary care doctors often have a question of whether they should get an MRI and refer them or refer them without an MRI. I prefer to see them without the MRI because sometimes we simply don’t need it, and it obviates the issue of an MRI that shows a labral tear where there wasn’t a tear. Other times, we get different MRIs based on what we’re concerned about. So we may get an MRI arthrogram if we’re concerned about a labral tear, or a glycosaminoglycans (GAG) MRI if we’re more concerned about the articular cartilage.
Boston Children’s Hospital also does MRIs on a 3 Tesla (3T) machine, and the radiologists here have developed special sequences — for example radial sequences — which are very helpful and increase the accuracy in terms of diagnosis.
Have you noticed any hip injuries becoming more common for young athletes in recent years?
I think labral tears have really exploded; the exponential growth in the number of patients we see with labral tears is almost epidemic. I’ve done over 1,700 hip arthroscopies, and most of those are for patients with labral tears. I think that’s in part because kids are playing highly competitive sports at a younger and younger age while also focusing more on a single sport.
The underlying sports have changed and I think the demands have changed. So there are probably more labral tears happening, but we’re also diagnosing them more accurately. We’re diagnosing them with MRI, we have ways of treating them with arthroscopic surgery, and there’s increased awareness of labral tears, so people tend to look for it. I think that has led to an increase as well.
Are there any warning signs or indications of an impending hip injury that a PCP may notice in a young athlete during a regular check up?
If the patient is complaining of hip pain, it’s definitely worth examining the hip. If on exam they have a limited motion with pain — particularly with hip flexion and hip flexion internal rotation — then that is often a sign of something going on in the joint like a labral tear or impingement.
In addition, I think there are certain athlete groups to be aware of because we see repeated pathology. For example, in ice hockey players we see a lot of labral tears and impingement. In dancers we see a lot of labral tears and often dysplasia of the hip. Also in dancers, gymnasts and figure skaters there are a lot of repetitive overuse tendinitis types of conditions, like hip flexor tendinitis or trochanteric bursitis.
Over time, if there is underlying impingement, it can start to injure the smooth cartilage in the joint and that can lead to early arthritis in the hip. In general, the sooner we can get to patients, the less pathology there is and the better the outcomes of our treatments.
Learn more about the Child and Young Adult Hip Preservation Program
About our expert: Mininder Kocher, MD, MPH, is a pediatric orthopedic surgeon at Boston Children’s Hospital, associate director of the Sports Medicine Division and professor of Orthopedic Surgery at Harvard Medical School.