History

  • Age
  • Acute or chronic pain (C-sign)
  • Duration/Frequency
  • Sport/Mechanism
  • Pop/Tear
  • Swelling (Rapid?)
  • ROM deficit
  • Instability
  • Weight-bearing immediately
  • Location of pain
  • Mechanical symptoms
  • Attempted treatment (RICE?)
  • Hx of Perthes or SCFE?

Physical Exam

Inspection

  • Joint Effusion, ecchymosis
  • Skin integrity- abrasion/laceration etc
  • Alignment – (anteversion, retroversion, leg length discrepancy)
  • Gait/ability to bear weight (Walking, running, squatting, etc)
  • Positioning (How is patient sitting?)

ROM

  • Extension/Flexion, IR/ER, ADD/ABD

Palpation

  • Hip Flexors (Iliopsoas, Rectus Femoris and Sartorius)
  • Iliac Crest
  • ASIS, AIIS
  • Greater Trochanter
  • Iliotibial Band
  • Abductors (Gluteus Medius and Minimus)

Special Maneuvers

  • Impingement Test
  • MMT
  • Log Roll Test
  • Ober’s Test

Neurological exam

  • L1-L4 nerve roots
  • Femoral Nerve
  • Obturator Nerve
  • Saphenous Nerve

Adjacent Joints

  • Never neglect a hip assessment with reported knee pain or thigh pain.

Imaging

Radiographs Indications

  • Deformity, acute effusion, not weight bearing, instability, tender physis, chronic pain not improving, suspected leg length discrepancy
  • AP, Lateral, Dunn Lateral

MRI Indications

  • Radiographs fail to clarify the problem (consider with effusion)
  • To confirm your clinical suspicion (To answer a specific clinical question -Is there a labral tear?)
  • Pain failing conservative care
  • Planning for surgery

MRI’s should be ordered with arthrogram

Differential Diagnosis by Anatomic Location

Diffuse/Global Pain

  • Fracture, acute trauma, SCFE (10-14 years old), Synovitis

Anterior Hip Pain

  • Hip Flexor Strain
  • Apophysitis
  • FAI
  • Perthes (< 8 years old)

Lateral Ankle Pain

  • IT Band Syndrome
  • Hip Abductor Strain
  • Trochanteric Bursitis
  • TFL tightness
  • Snapping Hip

Groin Pain

  • Possible Labral Tear
  • Sports Hernia
  • Perthes (<8 years old)

Posterior Hip Pain

  • Extra-Articular condition
  • Ischial Bursitis
  • SI Joint
  • Piriformis Tendinitis

Management

R-Rest
I-Ice
C-Compression
E-Elevation

  • Pain Control
  • Crutches
  • Rehabilitation (Core/hip strengthening) avoid FADIR
  • Dry Needling

When to Refer

  • Failure to improve with conservative care
  • Instability
  • Potential surgical conditions (suspected FAI, Labrum tear)
  • Physis Injury
  • Parental Concern
  • Return to play concerns