PRACTICE RECOMMENDATIONS
• When you suspect an infectious cause of hip pain, immediately order laboratory studies, blood cultures, and hip radiographs to rule out septic arthritis. A
• When you suspect avascular necrosis of the femoral head, instruct the patient to remain non-weight bearing and provide a referral to an orthopedist. A
• Stabilization with in situ pinning is the gold standard treatment for slipped capital femoral epiphysis, whether the slip is stable or unstable. A
Strength of recommendation (SOR)
A Good-quality patient-oriented evidence
B Inconsistent or limited-quality patient-oriented evidence
C Consensus, usual practice, opinion, disease-oriented evidence, case series
CASE Sean L, a 12-year-old middle school student in the 90th percentile for weight, limps into your office and reports that it hurts to put his full weight down on his right leg. The pain just started, Sean says, but he began limping a day or 2 earlier. Sean plays on his school’s football team, and he wants to know what you can give him to relieve the pain so he won’t have to miss any games. What can you tell him?
Family physicians are increasingly likely to see children and adolescents with hip pain, the combined result of greater sports participation and a surge in childhood obesity. Diagnosing pediatric hip pain can be a daunting task, not only because of the complexity of the hip joint, but because of the need to consider bone, joint, tendon, muscle, bursa, and referred pain in the differential diagnosis.
But it doesn’t have to be. Being familiar with the major causes of pediatric hip pain, the diagnostic tests and maneuvers that are part of a comprehensive work-up, and the conditions that require rapid referral to an orthopedist makes it possible to adopt a straightforward approach. We’ve developed this review with that goal in mind.
Assess pain and movement with these maneuvers and tests
Begin with a pain history, determining the location of the hip pain—anterior, lateral, or posterior. Ask the patient to describe the pain and its quality: Is it diffuse, localized, or radiating? Identify any aggravating or relieving factors, and question the patient (or parents) about the onset, reproducibility, and timing of the pain, including the presence or absence of nighttime pain.
Find out, too, whether the pain is causing a limp; what effect, if any, the pain has had on the patient’s ability to bear weight; and to what extent the patient’s activity level has been affected. Then move on to the physical examination.
Begin with the patient standing up. Observe his or her gait, posture, and alignment. Check for Trendelenburg’s sign, in which the ipsilateral hip drops when the patient raises the unaffected leg. Its presence indicates a weakness of the opposite hip abductor.
With the patient in a supine position, inspect the hip for swelling, erythema, and warmth. Palpate the affected area, but keep in mind that palpation may not always reveal much because of the depth of the hip joint. If the patient is overweight, palpation of the muscles, tendons, or bones may be particularly difficult.
Test active and passive range of motion (ROM) and muscle strength of the hip in all directions. (Patients who are unable to tolerate lying down can undergo most of the ROM and strength tests in a seated position.) Check for a discrepancy in leg length, not only by visual inspection, but by measuring from the anterior superior iliac spine (ASIS) to the lateral malleoli.
Perform more focused maneuvers, as needed. If lumbar radiculopathy is a possibility, for example, do a straight leg raise, lifting the leg on the affected side in full extension with the ankle dorsiflexed, and repeat with the leg on the unaffected side. The test is positive if radiating pain down the affected leg and buttock is reproduced at ≤60° of leg elevation (or leg extension if the patient is seated). Conduct Ober’s test (FIGURE 1) to check for iliotibial band syndrome.
Follow with a system review, asking about recent conditions, including fever and infection, trauma, and constitutional, abdominal, and genitourinary symptoms. Perform an abdominal exam, and, if indicated, a pelvic or hernia exam. Check reflexes and sensation, as warranted, and examine the spine and knee.
CASE Sean is a healthy boy with no known medical problems. He has not been ill recently, and has not had any unexplained weight loss. His vital signs are normal, and he does not appear ill. He walks with a limp.
On examination, Sean has no palpable area of tenderness, swelling, or ecchymosis. His right hip has limited and painful internal rotation and, when flexed, it falls out to the side in external rotation.