Hip Injuries in Young Athletes
There are a variety of conditions that cause hip pain in athletes.
These include relatively common injuries such as:
- muscles strains
- hip pointers
- apophyseal injuries
- labral tears
- snapping hip syndrome
- stress fractures
- sports hernias
Other less common injuries include hip dislocations and subluxations, fractures and osteitis pubis.
Hip injuries can be very debilitating and a delay in diagnosis can make continued participation in sports frustrating and painful.
The hip is a ball and socket joint that allows a wide range of motion. The top of the thigh bone (femur) is in the shape of a ball that rotates within a cup-shaped portion of the pelvis (acetabulum). Strong ligaments secure the femoral head (ball) into the cup.
Several muscles attach the thigh bone to the hip and give the hip its range of motion. These include muscles that extend the hip (hamstrings and gluteus muscles), hip flexors (iliopsoas and quadriceps muscles), and those that bring the leg toward (adductors) and away from the body (abductors).
Muscle strains are one of the most common injuries that occur around the hip and pelvis. They occur when a muscle is stretched beyond a tolerable length causing it to tear. The most common location for a muscular strain to occur is where the muscle attaches to its tendon; they can also occur within the muscle belly themselves. The muscles most prone to strain are those that cross two joints. In the hip these include the hamstring muscles, the tensor fascia lata, the sartorius, and rectus femoris muscle.
Muscle strains frequently occur while the muscle is being eccentrically contracted. An eccentric contracture is one where the muscle is suddenly stretched while it is trying to shorten (contract).
Athletes with muscular strains will complain of pain that worsens with resisted contracture of the involved muscle. There may be associated swelling and occasionally bruising with severe strains. The area is usually tender to the touch. The initial treatment should include rest from painful motions, ice and compression to keep swelling down. Gentle range of motion exercises are begun once they are tolerated with minimal pain. Once full motion has been achieved, strengthening is begun. Athletes may return to sports when they are pain free and range of motion and strength have returned to normal.
Ways to prevent muscle strains include warming up prior to sports participation, stretching, and strengthening.
A hip pointer is a bruise to the iliac crest of the pelvis. The iliac crest is the superior border of the hip bone. Hip pointers occur from a direct blow to the iliac crest. Because of the superficial location of the iliac crest, it is very susceptible to impact injuries. Hip pointers frequently occur during football, but can occur in any sport where the iliac crest is at risk to direct impact.
Athletes with a hip pointer frequently complain of pain and occasionally develop swelling and bruising at the site of injury.
Initial treatment should focus on minimizing swelling and bleeding. This is done with ice and compression. Because hip pointers can be very painful, athletes occasionally require crutches during the first few days after the injury to assist with ambulation. Stretching and strengthening of adjacent muscles are added once pain has resolved. Athletes may return to sports once they have regained full strength and range of motion.
Use of appropriate padding over the iliac crest can help reduce the risk sustaining a hip pointer.
An apophysis is a prominence of a bone. These prominences serve as attachment sites for tendons. In the pelvis there are several of these, and some of the more common ones include the anterior superior iliac spine (the prominence felt at the front of both sides of the pelvis), the anterior inferior iliac spine, the ischial tuberosity, and the lesser trochanter (located on the proximal thigh bone). Repetitive pulling of the tendons at their attachment sites without adequate rest between activities can lead to inflammation and pain (apophysitis). Because of its strong attachment, the tendon can actually pull a small piece of bone (the apophysis) off the pelvis with a forceful contracture (apophyseal avulsion).
An athlete with an injury to an apophysis will have pain and occasional swelling and bruising at the injured apophysis. The pain is worsened with resisted contracture or stretching of the involved muscle.
Radiographs will reveal whether the apophysis was avulsed or just irritated. If a fragment of bone is pulled from the pelvis, it usually has not moved far from its original site and seldom requires surgical fixation. Treatment includes ice, rest, and protected weightbearing. Compression shorts can help pain and control swelling. Weight-bearing and range of motion exercises are begun once pain is controlled. A return to sports is allowed once full range of motion and strength have been restored.
The acetabular labrum is a small band of tissue located along the rim of the cup of the hip joint (acetabulum). The labrum looks and feels like a rubber band. It acts as a cushion as the ball of the hip (femoral head) comes into contact with the cup in extremes of motion.
The labrum can be torn by a twisting or slipping injury, or over time by repetitively compressing the labrum between the femoral head and cup. An athlete with a labral tear will usually complain of pain to the anterior groin. The pain is often worsened with certain motions, especially hip flexion. Sometimes a quick sharp pain or catching sensation can be felt with certain motions. As the condition worsens, pain can be felt with walking and sitting for long periods of time.
If a labral tear is suspected, physicians will usually order a special type of an MRI of the hip, called an MR arthrogram. Small labral tears can be treated with physical therapy, but larger tears usually require surgical treatment.
Athletes with snapping hip syndrome complain of a snapping sensation in the groin or at the side of the hip with hip motion. The snapping or popping is occasionally audible and associated with pain. Two varieties of snapping hip syndrome occur; the more common type is called external snapping hip syndrome. It is caused by the iliotibial band (a wide band of tissue that extends from the side of the hip to just below the knee) catching on a bony prominence on the side of hip (the greater trochanter) as the hip is flexed and extended. It frequently occurs in athletes who are involved in repetitive, physically demanding motions, such as dancers, runners and soccer players.
Internal snapping hip occurs when the tendon of the iliopsoas muscle (hip flexor) slides over the lesser trochanter (a bony prominence on the inner upper leg) or the pelvic brim (anterior inferior iliac spine).
Snapping hip syndrome is often caused by tight muscles and can be treated with rest from aggravating activities, appropriate stretching exercises, and occasionally anti-inflammatory medications. Surgery is rarely necessary.
Stress fractures of the proximal femur are more commonly seen in female athletes, but do occur in males. They are more common in sports that involve jumping and landing on hard surfaces, such as distance running, ballet, basketball and gymnasts. Stress fractures sometimes are asssociated with eating disorders and irregular menstruation. Athletes with stress fractures complain of hip pain that worsens with impact activities (running, jumping/landing). Because they are often not visible on regular radiographs, a special type of radiograph called a bone scan or an MRI can be used to detect stress fractures.
Initial treatment includes rest from impact activities and, if necessary, counseling with a dietician. Ways to prevent stress fractures include maintaining a well-balanced diet, avoiding sudden increases in activity, and strengthening core musculature.
A sports hernia is caused by a tear in the muscles of the lower abdomen where they attach to the pelvis. Sports hernias are more common in male than female athletes. Athletes with a sports hernia usually complain of pain in the lower abdomen or groin. The pain is worsened with coughing, sneezing, or quick motions in sports such as sprinting or side stepping.
Radiographs and occasionally an MRI may be used to rule out other conditions. Initial treatment consists of resting from aggravating activities, ice, anti-inflammatory medications, and physical therapy. Surgery is occasionally required when symptoms have failed to improve with extensive non-surgical treatment.
Article by Jeffrey M. Vaughn, D.O.
Phoenix Children's Hospital
This article was published in the January 2009 issue of Kids & Sports, the Valley's youth sports parenting resource.