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Injuries About the Hip in the Adolescent Athlete
David Kovacevic, MD, Michael Mariscalco, MD, and Ryan C. Goodwin, MD
Abstract: Athletic injuries in or around the hip in the adolescent
athlete encompass possible causes such as a single, traumatic event
to those of repetitive microtrauma. The injuries may involve the
bone or the soft tissues, with former involving the epiphysis,
apophysis, metaphysis, or diaphysis, whereas the latter includes
muscles and tendons. With the improvements in surgical technique
and instrumentation for hip arthroscopy and the development of
magnetic resonance arthrography, clinicians have been able to
diagnose and treat labral tears, hip instability, snapping hip, loose
bodies, chondral injuries, and femoroacetabular impingement. The
clinician needs to consider acquired conditions that may have
coincidentally become apparent as a result of the adolescent’s
participation in an organized sports program. These include slipped
capital femoral epiphysis, Legg-Calve
´-Perthes disease, and patho-
logic lesions and fractures. This study reviews the more common
acute and chronic overuse injuries in or around the hip in the
adolescent athlete and discusses hip injury prevention in this active
patient population.
Key Words: hip injury, adolescent athlete, hip pain, labral tear,
snapping hip, sports injury
(Sports Med Arthrosc Rev 2011;19:64–74)
About 30 million children in the United States participate
in organized sports programs, with over one-third of
school-age children sustaining an injury that requires
evaluation and treatment by the medical community.
1
There are physical and physiological differences between
the adolescent athlete and adult athlete that may cause the
former to be more prone to sports injury. Adolescent
athletes may have a temporary decline in coordination and
musculoskeletal imbalance, as limb mass increases at a
faster rate compared with limb length.
2
In addition, as
muscle tendon growth lags behind bony growth, there is a
lack of flexibility, which may predispose to injury. This
increase in functional demand on the muscles can cause
increased stress on the tendons, musculotendinous junc-
tions, and apophyses. Adolescents have open growth plates,
and increased stress to the growth plate can lead to damage
to this area and possibly early physeal closure. Growing
cartilage is more susceptible to stress and may predispose
the adolescent to an overuse injury. All of these factors
place the adolescent athlete at risk during sporting activity
for injury. One study reported that sports-related injuries
account for about 2.6 million visits to the emergency room
made by children and young adults (aged 5 to 24 y),
whereas high-school athletic injuries have resulted in
500,000 physician visits, 30,000 hospitalizations, and a
total cost to the healthcare system of nearly $2 billion per
year.
3
The injury rate in organized high-school sports seems
to be the highest with football (41% to 46%) and wrestling/
gymnastics (40% to 46%), followed by basketball (31% to
37%).
4
Although athletic injuries to the adolescent hip have
been reported in the literature over the past 25 years,
5,6
this
anatomic area in this patient population is receiving
increased attention because of the advent of hip arthro-
scopy and the development of more advanced imaging of
this joint through magnetic resonance (MR) arthrogra-
phy.
7–10
The purpose of this study is to present an overview
of the more common acute and chronic overuse injuries in
or around the hip in the adolescent athlete and discuss basic
hip injury prevention strategies.
CLASSIFICATION OF HIP INJURIES
Injuries to the hip in the adolescent athlete can be
classified as involving the bony skeleton or the soft
tissues.
5,6
Skeletal injuries include avulsion fractures,
physeal fractures, fractures not involving the physis, stress
fractures, loose bodies and chondral lesions, pathologic
fractures, and hip dislocations. Soft tissue injuries include
those involving the labrum, the musculotendinous unit, the
apophyseal insertion sites, and contusions. The injury can
also be classified as acute traumatic, chronic overuse,
neurological, or acquired.
ACUTE TRAUMATIC SKELETAL INJURIES
Apophyseal Avulsion Fractures
In early adolescence, apophyseal strains are common.
Although more commonly seen at the knee (Osgood-
Schlatter disease), at the heel (Sever disease), and at the
elbow (Little League elbow), apophyseal strains at or around
the hip can present as either acute traumatic or repetitive
overuse injuries in the young athlete as well. The potential
sites for apophyseal injury include the ischium (hamstrings),
anterior superior iliac spine (sartorius),
11
anterior inferior
iliac spine (rectus), iliac crest (abdominal muscles),
12
lesser
trochanter (iliopsoas), or greater trochanter (abductors). A
recent case series reported on 203 avulsion fractures of the
pelvic apophyses in 198 adolescent athletes over a 22-year
period, and found that ischial tuberosity injuries make up
54% of all cases, anterior inferior iliac spine injuries were
responsible for 22% of total cases, and anterior superior iliac
spine accounted for 19% of all cases.
13
The mechanism of injury is either a sudden, violent
eccentric muscle contraction or excessive passive muscle
lengthening across an open apophysis. These avulsion
fractures are most common from the age at which the
secondary ossification center appears to the age at which it
Copyright r2011 by Lippincott Williams & Wilkins
From the Pediatric Orthopaedics and Scoliosis Surgery Service,
Cleveland Clinic Foundation, Cleveland, OH.
Conflict of Interest: None.
Reprints: Ryan C. Goodwin, MD, Attending Orthopaedic Surgeon,
Pediatric Orthopaedics and Scoliosis Surgery Service, Cleveland
Clinic Foundation, 9500 Euclid Ave., A-41, Cleveland, OH 44195
(e-mail: goodwir@ccf.org).
REVIEW ARTICLE
64 |www.sportsmedarthro.com Sports Med Arthrosc Rev Volume 19, Number 1, March 2011
fuses, because a violent contraction of a musculotendinous
unit causes the inherently weak apophysis to fail.
Typically, the athlete gives a history of severe,
immediate, and well-localized pain. Many patients will
describe a “pop” along with the onset of discomfort. Many
are unable to ambulate comfortably due to the injury. On
examination, the pain may be further exaggerated with
passive stretch or resisted contraction of the muscle group
in question. Radiographs of the pelvis and orthogonal
views of the hip help to confirming the clinical diagnosis
and can be used to determine the magnitude of displace-
ment and the size of the avulsed fragment. It is imperative
that all patients with hip pain should also have a frog-leg
lateral view to rule out slipped capital femoral epiphysis.
14
Initial management of avulsion fractures will typically
be conservative, calling for rest, ice, and elevation, followed
by protected weight bearing with crutches until symptoms
resolve (Fig. 1). In contrast, surgical intervention is rare,
and it is indicated in those patients who have significant
displacement of the fracture fragment (>2 cm), nonunion,
chronic pain, or significant loss of function (Fig. 2).
5,9,15
Over the past 20 years, several case reports and clinical
reviews have advocated surgical repair in the acute setting
of ischial apophyseal avulsion fractures with greater than
2 cm of displacement.
16–19
Otherwise, the significantly
displaced fragment will go on to heal with a fibrous
nonunion, potentially giving rise to chronic buttock pain,
an ischial mass, decreased hamstring strength and endur-
ance, suboptimal athletic performance, or hamstring
syndrome (sciatic nerve impingement).
16,19,20
For those
with nondisplaced or minimally displaced avulsion frac-
tures, the following management plan is recommended:
After a short period of rest, physical therapy may begin
with gentle passive range of motion and stretching to
prevent stiffness, and strengthening exercises should com-
mence once pain is completely resolved.
21
Return to sport is
possible once the patient is pain free during activities
similar to those performed in the sport, and there is
radiographic evidence of bony healing. The time from
recovery to return to sport may take anywhere from 6
weeks to 6 months.
14
Hip Fractures (Physeal and Nonphyseal)
Femoral head and neck fractures are rare injuries in
children and usually result from high-energy trauma, such
as a motor vehicle accident or a fall from height, rather
than from organized sports participation. Delbet is credited
for developing the most used classification system for
pediatric fractures of the femoral head and neck based on
his work 100 years ago.
22
This classification describes 4
types of fracture based on the anatomic location of the
fracture line.
23
Type I fractures (transphyseal fractures) are the least
common, accounting for less than 10% of all hip fractures,
but have the highest morbidity of all hip fractures because
they carry the highest risk of osteonecrosis (38% to 100%)
and premature growth arrest.
5,24
Radiographs of the pelvis
and orthogonal views of the hip help to confirming the
clinical diagnosis, and a computed tomographic (CT) scan
may be helpful to define the presence of and direction of an
associated femoral head dislocation. Both irreducible
transphyseal fractures and transphyseal fractures with
femoral head dislocation require open reduction and
internal fixation using cannulated 6.5 mm screws in
adolescents.
25
Postoperatively, this patient population
should be managed with crutch ambulation, protected
weight bearing, and early motion.
FIGURE 1. Anterior inferior iliac spine (AIIS) avulsion fracture.
This anteroposterior right hip radiograph shows a displaced
avulsion fracture of the right AIIS apophysis. This adolescent
athlete did well with conservative therapy.
FIGURE 2. Ischial tuberosity avulsion fracture. A, This pelvis radiograph shows a displaced ischial tuberosity avulsion fracture in an
adolescent football player. B, This pelvis radiograph shows interval open reduction internal fixation using 2 cannulated 6.5-mm
diameter partially threaded cancellous screws.
Sports Med Arthrosc Rev Volume 19, Number 1, March 2011 Injuries About the Hip in the Adolescent Athlete
r2011 Lippincott Williams & Wilkins www.sportsmedarthro.com |65
Delbet type II fractures (transcervical) and type III
fractures (basocervical or cervicotrochanteric) are the most
common pediatric hip fractures (45% and 35%, respec-
tively). These fractures should be treated with anatomic
reduction and internal fixation using cannulated screws
without penetration of the growth plate if possible.
25
These
2 injuries differ primarily in their associated complication
rates, with type II fractures having approximately twice the
rate of osteonecrosis as type III fractures (28% to 42% vs.
18% to 25%).
5,24
There are few studies investigating the
role of capsular decompression to evacuate the fracture
hematoma after reducation and fixation of pediatric hip
fractures. A case series of 93 pediatric hip fractures
reported a significantly higher incidence of osteonecrosis
in those who were treated without hip decompression
(41%) than those treated with hip decompression in Delbet
type II and type III fractures.
26
Postoperatively these
patients are instructed to ambulate with crutches and
protected weight bearing.
Delbet type IV fractures (intertrochanteric) are extra-
capsular, account for only 12% of all pediatric hip
fractures, and have the most favorable prognosis of all
hip fractures in children. As the blood supply to the
proximal femur is preserved, the rate of osteonecrosis was
found to be 5% in a meta-analysis of 360 pediatric hip
fractures, and type I, II, and III fractures were 15, 6, and 4
times more likely, respectively, to result in osteonecrosis
compared with type IV fractures.
24
These fractures can be
treated with pediatric-sized blade plate fixation or screw
and side plate fixation.
27
Subtrochanteric Femur Fractures
Pediatric subtrochanteric femur fractures can be very
difficult to manage because the proximal femoral physis
may limit proximal fixation and the intramedullary canal
can be narrow proximally. These factors can prevent the
use of devices used to treat similar fractures in adults.
Similar to other fractures of the proximal femur, these
fractures are seen with high-energy trauma and rarely occur
in athletics. Full-length radiographs of the injured femur
will show the fracture with the proximal fragment typically
in flexion, abduction, and external rotation, as the
iliopsoas, hip abductors, and external rotators remain
attached to the proximal fragment. The deforming muscle
forces acting on the proximal segment need to be
neutralized at the time of reduction and immobilization.
Treatment in adolescents who are near skeletal maturity
calls for internal fixation using a fixed-angle device, such as
a dynamic hip screw or bridge plating with or without
locked screws.
28–30
Alternatively, intramedullary rod fixa-
tion can be considered for subtrochanteric femur fractures
with no extension into the piriformis fossa or no severe
bowing or deformity of the femur.
31
Hip Dislocation
As with hip fractures, pediatric hip dislocations are not
common, as only 5% of all traumatic hip dislocations occur
in patients younger than 14 years of age. Hip dislocations
are more common in boys, almost exclusively unilateral,
and must be treated as a true emergency. The mechanism of
injury for hip dislocation is classified as low energy in about
64% of patients.
32
Hip dislocations have been frequently
reported to occur as a result of sports injuries or falls from
relatively low heights.
32,33
The patients will typically present with posterior
dislocation, as they account for 90% to 95% of all
dislocations.
32–34
The patient’s involved lower extremity
will be flexed, adducted, and internally rotated. In
anteriorly dislocated hips, the injured extremity is extended,
abducted, and externally rotated. It is imperative to
document the neurovascular examination before reduction,
as the sciatic nerve can be involved, and careful evaluation
of the ipsilateral knee is important, as the mechanism of
injury can often involve blunt trauma to the knee. The
diagnosis can usually be made based on history and
physical examination findings. The radiographs, which
include a view of the pelvis and orthogonal views of the
involved hip, confirm the diagnosis. When the diagnosis is
in question or if there is a possibility of an ipsilateral pelvic
injury, CT scan can be useful to evaluate the bony
structures of the pelvis and the presence or absence of
fracture fragments within the hip joint.
The dislocated hip requires emergent treatment and
preferably reduction should be performed within first 6
hours from the time of injury to minimize the risk of
osteonecrosis. The incidence of osteonecrosis is about 5%
to 15% of patients, but increases by as much as 20 fold if
the time from injury to reduction is greater than 6
hours.
32,35
Closed reduction can initially be performed in
the emergency room using analgesia and sedation, but if
unsuccessful after 1 attempt, the patient needs to be taken
to the operative suite under general anesthesia for
reattempted closed reduction with an image intensifier.
Open reduction is indicated when closed reduction fails
after 2 or 3 attempts or when there is soft tissue or bony
fragments interposed between the femoral head and
acetabulum. The surgical approach to the hip should be
on the side of the dislocation; a posterior approach for
posterior dislocations and an anterior approach for
anterior dislocations should be used. The acetabulum
should be cleared of debris, any osteochondral fractures
should be identified and fixed if large enough for screw
fixation, and then attention should be directed to repairing
the capsular tear once the hip is reduced. Options for
fixation of osteochondral fractures include headless screws
sunk to the subchondral bone or headed screws in a
nonarticular portion of the proximal femur that lag the
fragment down to the head. Postoperatively, patients are
instructed not to bear weight for 3 weeks followed by
another 3 weeks of protected weight bearing. Then the
adolescent may be transitioned to progressive weight
bearing with restricted activities for a total of 6 weeks.
The athlete can return to sport only when full strength,
motion, and agility are achieved.
Historically, the major complication of hip dislocation
is osteonecrosis of the femoral head (ONFH), and the
incidence of osteonecrosis in children after an isolated hip
dislocation is 5% to 15%.
32,33,36,37
When a traumatic hip
dislocation is associated with femoral epiphysiolysis, the
risk increases to nearly 100%.
36,38,39
The single most
important factor that will decrease the likelihood of
progression to osteonecrosis is time from onset of injury
to concentric reduction. Being able to reduce the hip
dislocation within 6 hours after presentation will signifi-
cantly decrease the incidence of osteonecrosis.
32
A patient
who has delayed reduction should undergo MR imaging
(MRI) at least 3 to 6 months post injury to assess for early
signs of osteonecrosis,
40
whereas it may be reasonable to
obtain MRI scans at 6 weeks after traumatic hip dislocation
Kovacevic et al Sports Med Arthrosc Rev Volume 19, Number 1, March 2011
66 |www.sportsmedarthro.com r2011 Lippincott Williams & Wilkins
to evaluate for abnormal signal changes in the bone
marrow for the early detection of ONFH.
41
This prospec-
tive study proposed a treatment algorithm that included an
initial MRI scan at 6 weeks after injury. If the scan shows a
normal marrow signal, no further imaging is necessary at
later time points, unless the adolescent athlete has
complaints of hip pain or groin pain. Conversely, if the
initial scan shows an abnormal marrow signal in the
femoral head, a repeated MRI scan should be obtained 3
months after injury. If the changes observed initially persist
or worsen, the diagnosis of ONFH can be made, and
surgical intervention should be considered. If the second
scan shows considerable improvement in signal changes or
normal marrow signal, the initial changes are considered
transient and probably do not indicate ONFH. Ultimately,
the clinical situation and MRI findings dictate whether
activity restriction should be continued or lifted and
whether surgical intervention should be entertained.
Other complications include possible sciatic and
superior gluteal nerve injury, although rare, as about 5%
of children with hip dislocation will have neurological
findings. Observation of nerve recovery is recommended
after hip reduction, and nerve exploration is not warranted
unless open reduction is performed for other reasons.
With the advances of hip arthroscopy and increased
use in the pediatric population, surgeons are finding value
with using this technology in patients who continue to have
disabling hip pain after traumatic hip dislocation. A recent
retrospective case series study of 14 athletes, who sustained
a traumatic hip dislocation, was done to investigate the
intra-articular hip joint pathologies found at the time of hip
arthroscopy.
42
Five of the 14 athletes were adolescents,
whose mean time to relocation was 2.8 hours and average
time from injury to arthroscopy was 123 days (range, 45 to
218 d). All 5 patients had labral tears and chondral defects,
4 had femoroacetabular impingement (FAI), 3 had
acetabular rim fractures, 1 had a capsular tear, and 1 had
adhesions. The chondral defects were addressed with
microfracture and those with cam or mixed lesions of the
femoral head-neck junction had an osteoplasty to restore
the appropriate head-neck offset to prevent impingement.
The acetabular rim fractures were small fragments less than
1 cm wide and were excised without compromising stability.
In addition to labral or chondral injuries after a traumatic
hip dislocation, the treating surgeon should be aware of
ligamentum teres tears as a cause of persistent hip pain.
43
These reports show the value of hip arthroscopy to address
persistent hip pain after traumatic hip dislocation, and to
identify and treat intra-articular hip pathology in the
adolescent athlete.
ACUTE SOFT TISSUE INJURIES
Acetabular Labral Tear
With the increased use of hip arthroscopy, acetabular
labral tears are being recognized as a cause of hip pain in
athletes.
44
Labral tears may occur during sporting activity
when the athlete sustains a hip injury from traumatic
twisting or planting and cutting. The patient may complain
of hip or groin pain and appreciate the sensation of
catching or locking with hip range of motion. On physical
examination, internal and external rotation maneuvers may
reproduce the pain, and the adolescent will experience pain
with hip flexion to 90 degrees, adduction, and internal
rotation—a highly sensitive, yet nonspecific, maneuver for
intra-articular hip pathology.
45
Radiographic imaging of
the pelvis and involved hip may show an undiagnosed hip
deformity, such as mild developmental dysplasia of the hip,
slipped capital femoral epiphysis (SCFE), Perthes disease,
or FAI, but MR arthrography is the appropriate imaging
modality to diagnose acetabular labral tears (Fig. 3).
45,46
In a review of 7 patients with labral tears, 6 of the
patients were adolescents, of which 3 presented with an
acute presentation of groin pain during sporting activity,
whereas the remaining 3 adolescents noted a gradual onset
of symptoms.
47
All 6 patients were diagnosed arthroscopi-
cally for having acetabular labral tears, and all did well with
conservative management by a period of nonweight
bearing. More recently, a long-term follow-up on hip
arthroscopy in 15 athletes, of which 4 were adolescents,
showed a return to sport at the earlier level before injury in
3 of 4 patients and a significant improvement in their
modified Harris hip at 10 years after surgical debridement
of any chondral or labral lesions compared with their
preoperative score (98 at final follow-up vs. 49 preopera-
tively).
48
In a retrospective review of 54 hip arthroscopies in
42 patients with a mean age of 15.2 years and at least 1 year
of follow-up, pain was the chief complaint in 48 hips and
catching or locking in 6 hips.
9
All patients reported
diminished hip function with a preoperative modified
FIGURE 3. Bilateral acetabular labral lesions. This T2-weighted gadolinium-enhanced coronal magnetic resonance imaging of the
bilateral hips shows contrast tracking into the anterosuperior labrum bilaterally, shown here by the white arrows.
Sports Med Arthrosc Rev Volume 19, Number 1, March 2011 Injuries About the Hip in the Adolescent Athlete
r2011 Lippincott Williams & Wilkins www.sportsmedarthro.com |67
Harris hip score of 53.1. Surgical indications for 30 of 54
hip arthroscopies were an isolated acetabular labral tear
that required debridement. Revision procedures were
performed in 3 patients who had recurrent labral tears;
however, those patients with isolated labral tears had a
significant improvement in their modified Harris hip score
(preoperative 57.6 vs. postoperative 89.2).
9
Overall, all 42
patients had a significant improvement in their modified
Harris hip score after hip arthroscopy (preoperative 53.1 vs.
postoperative 82.9). From these early reports it can be
concluded that hip arthroscopy can be safely used to
examine the acetabular labrum and treat any tears that may
be present (Fig. 4).
CHRONIC OVERUSE INJURIES
Femoroacetabular Impingement
Hip impingement has garnered much attention, as
surgeons have been able to safely dislocate the adult hip
surgically, without the risk of osteonecrosis, to treat
FAI.
49,50
The association of FAI, acetabular labral tears,
and articular cartilage lesions has made this clinical entity a
focus of intense research and interest.
46,50–52
More recently,
hip arthroscopy has become popular as a less invasive
means to address the pathology associated with FAI, which
is now being recognized as a cause of hip pain in
adolescents.
53
Patients will typically present with complaints of
anterior groin pain or anterolateral hip pain that is made
worse with sporting activity.
53,54
Those with a labral tear
will often cup the anterolateral hip with the thumb and
forefinger in the shape of a “C.”
54
On physical examination
they have decreased hip flexion and limited internal
rotation. They will have a positive impingement test and
recreation of their pain; while the patient is in supine
position the hip is internally rotated, as it is passive flexed
to 90 degrees and adducted. Radiographic imaging should
include an AP of the pelvis and orthogonal views of the
affected hip. The presence of a bony prominence on the
anterolateral head-neck junction, termed a cam lesion,
would suggest reduced offset and decreased clearance of the
femoral neck. Pincer impingement anatomy is suggested by
acetabular overcoverage and retroversion. Retroversion
can be diagnosed radiographically by the presence of
crossing-over of the anterior and posterior walls of the
acetabulum.
55
Additional imaging would include an MR
arthrogram to evaluate the labrum and cartilage for any
tears, lesions, or loose bodies.
56
Goals of conservative treatment include improving hip
muscle flexibility, strength, and posture.
54
Those patients
with refractory pain should be referred for a hip arthro-
scopy consultation. FAI is addressed surgically by remov-
ing the bony cam or pincer lesions while correcting femoral
offset and restoring bony alignment (Fig. 5). Encouraging
results have been reported after arthroscopic treatment of
FAI. In a study of 158 patients who underwent hip
arthroscopy, patients reported that 50% of their pain
resolved by 3 months, 75% by 5 months, and 95% by 1
year.
52
More recently, a short-term clinical outcomes study
in patients with FAI reported a better postoperative
outcome in patients with preserved joint space and repair
of labral pathology rather than debridement.
21
These
encouraging results show the potentially important role of
hip arthroscopy in the treatment of FAI in both the adult
and adolescent populations.
Loose Bodies and Chondral Lesions
Loose bodies of the hip may occur from traumatic
injury
42
or as sequelae of hip disorders, such as Perthes
disease, spondyloepiphyseal dysplasia, osteonecrosis, or
synovial chondromatosis. Patients presenting with Perthes
disease may complain of pain and mechanical symptoms
such as catching or locking. There may be an unstable
osteochondral fragment in the femoral head after the
healing phase, especially in patients with a flattened,
aspherical head. Radiographic imaging and MRI scan
may show a free osteochondral lesion. In a prospective
study of 38 hip arthroscopies in 35 patients with 2-year
follow-up, the investigators found that those patients
FIGURE 4. Arthroscopic identification of a labral tear. This
arthroscopic image shows the acetabulum (A), femoral head
(B), and labral tear (C) near the chondrolabral junction.
FIGURE 5. Hip arthroscopy to address cam impingement. This
arthroscopic image shows the acetabulum (A), surface of the
femoral neck after osteoplasty of a cam lesion (B), and labrum (C).
Kovacevic et al Sports Med Arthrosc Rev Volume 19, Number 1, March 2011
68 |www.sportsmedarthro.com r2011 Lippincott Williams & Wilkins
undergoing arthroscopy for a diagnosis of loose body,
labral lesion, or synovitis had an improvement in their
modified Harris hip score at final follow-up by either 34
points, 27 points, or 26 points, respectively, compared with
a median preoperative score of 57.
44
It seems that
arthroscopic removal of loose bodies has yielded adequate
results with minimal morbidity in patients presenting with
continued hip pain after traumatic injury (Fig. 6).
42,57
As
for chondral lesions of the hip, it has been established that
hip arthroscopy can be used to successfully treat these
injuries.
58
The extent of cartilage injury dictates whether
one should employ chondroplasty or microfracture. Chon-
droplasty is performed in cases in which there is a partial-
thickness tear of the articular cartilage,
58
whereas full-
thickness cartilage defects are addressed with microfrac-
ture
58,59
and have been associated with an average
percentage fill of 91% of the acetabular chondral lesions
at second look and 8 of 9 patients had grade 1 or 2 repair
product.
59
Stress Fractures of the Femoral Neck
Stress fractures are commonly seen in young people
enlisted in the armed forces
60
or those participating in track
and field
14
with a reported incidence as high as 31%
61
and
21%
62
among the groups, respectively. Similarly to track
and field athletes, annual incidence rates of up to 20% have
been reported in young female athletes.
63
This overuse
injury is the result of repetitive microtrauma, and stress
fractures develop when the extent of microdamage exceeds
that of the remodeling process. Although the tibia is
typically affected by chronic overuse, the femur accounts
for about 5% to 7% of all stress fractures.
64
Stress fractures of the femoral neck are of particular
importance because if they go unrecognized, untreated, or
inappropriately managed, they can have the devastating
consequence of an acute, displaced femoral neck fracture—
an orthopedic emergency.
65,66
The clinician should have a
high index of suspicion for this injury in adolescent
endurance athletes, especially female athletes, and young
military recruits. Femoral neck stress fractures have been
reported more commonly in female athletes and are
associated with the classic “female athlete triad” of
amenorrhea, eating disorders, and premature osteoporo-
sis.
67–69
The adolescent athlete will present with complaints of
persistent groin discomfort that is made worse with activity.
The patient will often provide a history of a recent
significant increase in activity, such as running. On physical
examination, there may or may not be pain elicited with hip
range of motion. Stress fracture should be considered if the
patient is unable to straight leg raise against resistance, a
positive Trendelenberg test, the presence of a gluteus
medius limp with gait testing, or pain/inability to hop on
1 foot. Initial radiographs may be negative, but if clinical
suspicion is high for a stress fracture, more sensitive
radiographic imaging may be required. MRI scan may be
the most useful diagnostic imaging modality to help
confirming the diagnosis and localize the location of the
fracture. It will show an edema pattern extending to the
cortex on either the inferomedial side or the superolateral
side of the femoral neck.
Devas
70
has classified stress fractures of the femoral
neck into 2 types based on the fracture pattern (distraction
type vs. compression type). The first fracture type is a
transverse fracture involving the superior portion of the
neck. More common in adults, Devas termed this a
distraction fracture, as it involves the tension side of the
femoral neck and may become displaced. Before displace-
ment occurs, management calls for internal fixation with
percutaneous cannulated screws placed up the femoral neck
without violating the proximal femoral physis. If displace-
ment occurs, the fracture should be treated as a transcervi-
cal fracture, and immediate internal fixation should be
undertaken.
71
Weight bearing should be restricted in these
patients postoperatively.
66
The second type is a compres-
sion stress fracture in the inferomedial neck and it is more
commonly seen in children. These fractures rarely become
displaced but a mild varus deformity may result. Treatment
is usually nonsurgical with protected weight bearing and
activity restriction until there is radiographic evidence of
healing.
71,72
Return to play should be allowed only after
there is complete fracture healing noted on clinical
examination and radiographic imaging and completion of
a rehabilitation program.
66
It is imperative that the
clinician investigates possible causes for the stress fracture,
such as bone density problems or vitamin deficiency, by
obtaining a dual energy x-ray absorptiometry scan and a
serum vitamin D level.
Coxa Saltans (Snapping Hip Syndrome)
Snapping hip is characterized by an audible snap or
pop that occurs when the hip is brought through a range of
motion. It is typically exacerbated by sporting activity and
may be associated with pain. Three causes of snapping hip
have been described: external (lateral), internal (medial),
and intra-articular, with the external type being the most
common.
73,74
The external type (iliotibial band syndrome)
is caused by snapping of either the posterior border of the
iliotibial band or the anterior border of the gluteus
maximus muscle over the greater trochanter when the hip
is flexed from an extended position.
75
The internal type
(iliopsoas tendon) is most commonly associated with
painful displacement of the iliopsoas tendon over the
iliopectineal eminence or over the femoral head.
76
The
intra-articular type is a clicking sensation caused by a loose
body in the joint, such as a bony fragment, a torn labrum, a
chondral flap, or synovial plica.
51,77
FIGURE 6. Intra-articular loose bodies. This arthroscopy image
shows the acetabulum (A), femoral head (B), and loose body (C).
Treatment included arthroscopic removal of the loose body.
Sports Med Arthrosc Rev Volume 19, Number 1, March 2011 Injuries About the Hip in the Adolescent Athlete
r2011 Lippincott Williams & Wilkins www.sportsmedarthro.com |69
The history and physical examination usually lead the
clinician to the cause and location of the snapping hip.
Patients with iliotibial band syndrome will describe a
snapping sensation and discomfort localized over the
greater trochanter. The snapping and discomfort may be
reproduced by hip flexion and extension with internal
rotation. Patients with internal snapping hip syndrome will
localize the snapping sensation to the groin and anterior hip
with hip flexion and an adduction-abduction maneuver.
Initial management includes physical therapy to
improve hip abduction and external rotation strength and
flexibility for internal snapping hip and iliotibial band
stretching for external snapping hip, in addition to a trial of
anti-inflammatory medication. In cases in which conserva-
tive management does not relieve symptoms, surgical
treatment may be considered. Open surgical interventions
have traditionally been required to lengthen either the
iliotibial band
78,79
or iliopsoas tendon,
76,80
or excise the
intra-articular abnormality.
74
Although the prevalence of
snapping hip has been reported to be nearly 50% in a
subpopulation of adolescent ballet dancers, there have been
very few reports on treatment in the adolescent athlete.
81
One recent study reported their experience with fractional
lengthening of the iliopsoas tendon at the musculotendi-
nous junction in adolescent athletes with persistent
symptomatic internal hip snapping.
76
They reported that
surgical correction was effective, as all 9 patients (11 hips)
were able to return to their preoperative level of activity
while preserving hip flexion strength.
More recently, advances in hip arthroscopy has
improved the surgeon’s ability to treat external and internal
snapping hip by releasing the iliotibial band and iliopsoas
tendon, respectively,
82–85
and address intra-articular sources
of hip clicking.
86
Ilizaliturri et al
83
reportedontheir
prospective case series in 10 patients (11 hips) treated for
external snapping hip syndrome by endoscopic iliotibial band
release. Early outcomes, 2 years after surgery, showed 1 of 10
patients with nonpainful snapping, whereas remaining
patients had no complaints and returned to their preinjury
level of activity. This same group has reported similar success
in the short-term for treatment of internal snapping hip
syndrome by either endoscopic iliopsoas tendon release at the
lesser trochanter
82,84
or endoscopic transcapsular psoas
release from the peripheral compartment.
82
It was noted that
67% of patients were found to have concomitant intra-
articular lesions that were addressed during surgery.
84
Yamamoto et al
86
retrospectively reviewed 30 patients (32
hips) that underwent arthroscopic surgery to treat intra-
articular causes of snapping hip. Arthroscopy confirmed that
snapping was caused by acetabular labral tears in 27 of 32 hip
joints, intra-articular loose bodies in 2 joints, incompatibility
between the labrum and deformed femoral head in 2 joints,
and synovial chondromatosis in 1 joint. These case series
highlights the usefulness of hip arthroscopy and endoscopy
for diagnosis and treatment of external, internal, and intra-
articular type snapping hip.
NEUROLOGICAL CONDITIONS
Meralgia Paresthetica (Bernhardt-Roth
Syndrome)
Meralgia paresthetica is an entrapment syndrome
causing numbness, tingling, a burning sensation, or pain
in the distribution of the lateral femoral cutaneous nerve.
This sensory nerve originates from the second and third
lumbar nerve roots and may also have rare contributions
from the first lumbar nerve root.
5
It leaves the lumbar
plexus and normally appears at the lateral border of the
psoas, just proximal to the iliac crest; then courses laterally
over the iliacus where it is covered by the iliac fascia, and
approaches the lateral portion of the inguinal ligament
posterior to the deep circumflex artery. The nerve usually
traverses beneath the inguinal ligament just inferior and
medial to the anterior superior iliac spine. It then exits
anteriorly through the fascia lata several centimeters distal
to the inguinal ligament before dividing into its anterior
and posterior branches, supplying the skin overlying the
anterolateral aspect of the thigh (Fig. 7).
5,87
There have been few reports of meralgia paresthetica
in children until a case series documented this entrapment
syndrome nearly 16 years ago.
87
The investigators identified
20 patients who presented with severe pain and marked
restriction of sporting activities due to meralgia paresthe-
tica, with 10 of those patients having bilateral involvement.
The average age at onset of symptoms was 10 years and the
average duration of the symptoms before the patient was
seen was 24 months. Six patients (7 lesions) had an
associated injury or a possible predisposition to this
entrapment syndrome, as 5 patients had a previous pelvic
osteotomy and 2 patients sustained a pelvic crush injury
with associated fractures. The pain could be reproduced by
palpation of the nerve and trial injection of local anesthetic
produced transient relief of symptoms. Twenty-one lesions
in 13 patients were eventually treated with successful open
decompression of the lateral femoral cutaneous nerve for
chronic, debilitating pain after failing conservative treat-
ment. Early outcomes, up to 2 years after surgery, showed
90% of the patients returned to sport with occasional pain
or no pain with vigorous activity. This was the first case
series to increase the awareness of chronic meralgia
paresthetica in the adolescent.
FIGURE 7. The course of the lateral femoral cutaneous nerve.
This illustrative schematic traces the course of the lateral femoral
cutaneous nerve proximally, as it originates from the second and
third lumbar nerve roots and then passes deep to the inguinal
ligament (A). Intraoperatively, the lateral femoral cutaneous
nerve can be found traveling between the split in the inguinal
ligament (B). The inguinal region has been circled. Reprinted
with permission from Edelson and Stevens.
87
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70 |www.sportsmedarthro.com r2011 Lippincott Williams & Wilkins
More recently, there have been a few case reports
linking anterior superior iliac spine avulsion with acute-
onset meralgia paresthetica in adolescents due to hematoma
and edema irritating the nerve.
88,89
Management of this
entrapment syndrome differed, as one group elected to
decompress the nerve and fix the avulsed fragment to the
iliac crest with a lag screw because the nerve was susceptible
to injury from the displaced bony fragment.
88
In contrast,
the other group chose to conservatively treat their patient
with narcotic analgesia, limited activity, and crutch
ambulation.
89
Both groups of patients did well as their
pain resolved and they were able to return to sport, but
initially it may be reasonable to consider conservative
treatment of this condition rather than subjecting the
patient to the risk of general anesthesia and surgery.
Iliacus Hematoma Syndrome
The iliacus hematoma syndrome, which is associated
with hemophilia,
90
anticoagulation therapy,
91
cardiac
catheterization,
92
and abdominopelvic surgery,
93
is a
compression neuropathy of the femoral nerve resulting
from hemorrhage in the iliac fossa. It has been reported
rarely in patients without coagulopathy and can occur in
adolescents due to trauma.
94–96
The patient initially presents with a severe pain in the
groin and inguinal areas and they typically keep their hip
flexed, abducted, and externally rotated to keep tension off
the iliopsoas muscle. Manifestations of femoral nerve
compression will develop, including sensory changes over
the anterior thigh and anteromedial leg and weakness of the
quadriceps muscles. The thigh weakness may be severe
enough that the patient will have difficulty ambulating due
to giving way of the knee. On physical examination, a mass
or swelling may be detectable in the iliac fossa and
ecchymosis is not uncommon in the acute period. There
will be weakness or even complete paralysis of the
quadriceps muscle with atrophy in the subacute and chronic
setting. There may be decreased or absent knee jerk reflex
and sensory loss over the anteromedial aspect of the thigh
and medial aspect of the lower leg. CT scan can be used to
confirm the location and size of the lesion, but an MRI scan
will allow for better soft tissue differentiation. Management
in younger patients, particularly those with athletic injuries,
is more likely to involve surgery,
95,97
if there is progression
of femoral nerve symptoms and the MRI scan shows a
collection of blood impinging on the femoral nerve.
96
Excellent results and full neurological recovery have been
reported in those patients undergoing surgery for hemato-
ma evacuation.
95,97
ACQUIRED CONDITIONS
Slipped Capital Femoral Epiphysis
SCFE occurs secondary to biomechanical and bio-
chemical weakening of the proximal femoral physis. The
displacement occurs through the physis, whereby, the
metaphysis moves in an anterosuperior direction in relation
to the capital femoral epiphysis, which remains in the
acetabulum. The condition occurs mainly in obese African-
American boys between 10 and 16 years of age. It is often
associated with the pubertal growth spurt, but may be due
to trauma, inflammatory conditions, and endocrine dis-
orders. Bilateral involvement occurs up to 60% of the
time.
98
When it occurs, controlaeral slipped epiphy-
sis typically presents within 18 months of the initial slipped
epiphysis.
99
A stable slip is such that a patient can bear
weight with or without crutches, whereas in an unstable slip
patients are unable to bear weight because of pain. Patients
typically present with activity related hip, thigh, or knee
pain. The average duration of symptoms before presenta-
tion is 5 months for stable slips. Physical examination
shows obligatory external rotation of the affected side.
Anteroposterior and cross-table lateral radiographs should
be used to confirm the diagnosis (Fig. 8). If a slip is
suspected but not shown on plain radiographs, an MRI
may be ordered which would show edema surrounding the
physis. There is no role for nonoperative treatment once the
diagnosis has been made. Treatment, therefore, involves in
situ pinning with a single screw crossing the physis. This
results in physeal closure over the subsequent 9 months.
Complications include osteonecrosis, chondrolysis, and
degenerative joint disease.
Legg-Calve
´-Perthes Disease
Legg-Calve
´-Perthes disease is secondary to osteone-
crosis of the proximal femoral epiphysis. Numerous
vascular causes have been proposed but the exact etiology
is largely unknown. It is more common in male individuals
than female individuals, and occurs typically earlier in life
than SCFE, with an average age of 7 years. Bilateral
involvement occurs up to 15% of the time, although is
almost never simultaneous. Symptoms include hip and
ipsilateral knee pain, effusion, decreased ROM, and limp.
Anteroposterior and lateral radiographs are used for
diagnosis. The condition progresses through multiple
stages: initial, fragmentation, reossification, and reossified.
The Catterall
100
and Herring
101
classifications are 2 of the
more popular classification systems and help establish a
prognosis based on location and total amount of femoral
head involvement. Prognosis is based on the age at
diagnosis and amount of femoral head involvement, with
age less than 9 years, and less than 50% femoral head
involvement being positive prognostic factors.
101
The main
goal of treatment involves containment of the head within
the acetabulum. Containment can be accomplished by
traction, tendon releases, abduction bracing, or femoral
varus derotational osteotomy.
Owing to the abnormal morphology of the proximal
femur, adolescent athletes with a history of Legg-Calve
´-
Perthes disease may present later in life with FAI. A recent
prospective consecutive series reported the results of
arthroscopically assisted treatment of cam deformities and
FIGURE 8. Bilateral slipped capital femoral epiphysis. This frog-
leg pelvis radiograph shows bilateral slipped capital femoral
epiphyses in an adolescent athlete, with the left side representing
a more severe slip.
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r2011 Lippincott Williams & Wilkins www.sportsmedarthro.com |71
labral tears in 13 young adults (14 hips) with a history of
pediatric hip disease.
102
Early clinical follow-up after
surgery showed an improvement in the mean postoperative
Western Ontario and McMaster Universities Arthritis
Index scores by an average of 9.6 points, restoration of
hip geometry in 13 of 14 hips, no complications including
femoral neck fracture or osteonecrosis, and no evidence of
radiologic progression of osteoarthritis. The authors con-
cluded that hip arthroscopy is a safe treatment method for
patients with a history of SCFE, Perthes, and develop-
mental dysplasia of the hip.
Pathologic Fractures and Lesions
Although uncommon, both benign and malignant
tumors of the hip may occasionally be found when
evaluating the skeletally immature athlete presenting with
hip pain. Recently, Ruggieri et al
103
reviewed 752 pelvic and
hip lesions in children less than 14 years old over a 40-year
period. The most common benign lesions were simple bone
cysts and osteoid osteoma. Ewing and osteosarcoma were
the most common malignant tumors. Radiographs should
be obtained in all cases to assess lesion location, size, and
possible pathologic fracture. If further characterization is
needed or concern for a malignant lesion exists, CT or MRI
can be extremely useful. Some benign lesions heal
spontaneously, and therefore, may be observed every 6 to
12 months with serial radiographs. Others require surgical
intervention. Simple bone cysts, for example, have been
shown to respond more favorably to intralesional injection
of corticosteroid as opposed to bone marrow aspirate
injection.
104
Radiofrequency ablation is usually the treat-
ment of choice for osteoid osteoma. When concerned for a
malignant lesion, biopsy is often necessary to confirm the
diagnosis and establish an appropriate treatment plan.
Specific treatment is based on the pathologic diagnosis, but
includes chemotherapy, wide resection, and possible pelvic
reconstruction.
HIP INJURY PREVENTION IN ADOLESCENT
ATHLETE
The prevention of adolescent hip and lower extremity
injuries is important for players, parents, and coaches alike.
In addition to type and frequency of sport, core stability
and strength has been recently looked at as a significant
factor in reducing such injuries. Athletes rely on the
lumbopelvic-hip musculature to provide a stable base by
which all other functional movements are carried out.
Therefore, appropriate training and conditioning of these
muscles is essential. Leetun et al
105
tested a total of 140
male and female intercollegiate basketball and track
athletes to determine whether there was a correlation
between lower extremity injury and lumbopelvic core
strength. Their findings showed definite sex differences with
male athletes having greater hip abduction, external
rotation, and quadratus lumborum strength measures.
Those athletes who sustained an injury were significantly
weaker in hip abduction and external rotation strength.
After logistic regression, hip external rotation strength was
the only true predictor of injury status over the course of 1
season. In a similar study, Nadler et al
106
looked at a cohort
of 210 National Collegiate Athletic Association Division I
athletes to assess the relationship between hip abduction
and extension strength on previous lower extremity injury
and/or low back pain. Among female athletes who reported
previous injuries, a significant difference in side-to-side
symmetry of maximum hip extension strength was ob-
served. There was no strength asymmetry among male
athletes regardless of previous injury status. These studies
show the importance of developing, strengthening, and
maintaining the core and lower extremity muscle groups to
decrease the likelihood and severity of hip injury in the
adolescent athlete. We believe there is benefit in designing
and performing clinical research studies in the future to
develop novel strategies for hip injury prevention in the
adolescent athletes.
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