Hip Pain: Causes, Diagnosis and Treatment

What causes hip pain?
For kids who are growing, it is common to experience aches and pains – even in their hips. It can be caused by their level of activity or inactivity– i.e. too little or too much. However, understanding the specifics of those complaints is important to make sure that the cause of the pain is not something more.

What are the signs and symptoms of hip problems? 

  • Pain in the hip, groin, thigh or knee with activity.
  • Reduced movement or range of motion of the hip.
  • Limping while walking. 
  • In toddlers, the child refuses to stand or walk on the affected leg.

When should I go to the doctor for hip pain? 

  • If your child’s pain is persistent or they are having issues walking or performing daily tasks, it is important for them to be seen by a pediatric orthpedic specialist.
  • If your child is febrile, looks ill and refuses to move the leg or walk, hip infection may be the reason and the child should be seen at an emergency room. 
What are hip disorders? 
Hip disorders can affect one or both hips and are sometimes apparent at birth or develop during childhood. Scottish Rite for Children treats thousands of patients with hip pain for the below hip disorders every year:
  • Developmental Hip Dysplasia
  • Adolescent Hip Dysplasia
  • Perthes Disease
  • Slipped Capital Femoral Epiphysis
  • Femoroacetabular Impingement
Other common hip conditions treated by our experts:
  • Transient synovitis of the hip
  • Sickle cell disease affecting the hip
  • Avascular necrosis of the hip
  • Bone dysplasias affecting the hip
  • Sports related injuries of the hip 
  • Avulsion injuries of muscles around the hip
  • Hip dislocation due to Downs syndrome
  • Hip subluxation and dislocation due to cerebral palsy
  • Hip dysplasia due to Charcot-Marie-Tooth disease
Our physicians in the Center for Excellence in Hip conduct groundbreaking research to determine the best treatment plan for each patient with a hip condition.

Areas of Treatment

What is hip dysplasia?

Hip dysplasia is a general term that refers to an abnormal relationship between the ball and socket of the hip joint or abnormal shape of the socket or the ball. Hip dysplasia causes inadequate coverage of the ball by the socket and increases the risk of arthritis later in life. In some cases, hip dysplasia represents a broad spectrum from a very mild shallow socket to a hip with a complete dislocation of the ball from the socket (i.e. the ball is completely outside of the socket).
The hip joint consists of:
  • Femoral head: the ball part of the femur 
  • Acetabulum: the socket of the pelvic bone 
Developmental dysplasia of the hip (DDH) is a condition where the “ball and socket” of the hip joint does not form properly in babies and young children. DDH can occur before birth, at birth, after birth or during early childhood. In most patients, the diagnosis of DDH is made during the first few months of life with neonatal and perinatal exams followed by a hip ultrasound. Sometimes, the signs of DDH are subtle and go unnoticed until walking age when limping is seen or adolescence (adolescent hip dysplasia) when hip pain occurs.

The cause of DDH is known in some and unknown in others. DDH is more common in babies who are born in breech presentation (feet first). There also seems to be a genetic hereditary component associated with DDH because children with a family history of the condition are more likely to have DDH than those without a family history of DDH. Swaddling of babies with legs straight and tightly wrapped also increases the risk.

The condition can be discovered by checking a baby’s hips and, if suspected, performing an ultrasound of the hip. Your baby’s doctor should look for:
  • Risk factors for DDH such as family history, breech, low uterine water level during pregnancy and uterine abnormality.
  • A hip click.
  • Limited hip movement.
  • A difference in leg lengths.
  • Increased skin folds on thighs.
  • When both hips are dislocated, the leg lengths, skin folds and hip movement are going to be the same, which makes the diagnosis difficult without getting an ultrasound or X-ray.
  • If the child walks, a waddling or swayed-back walking pattern.
The diagnosis of a dislocated or dislocatable hip in infants is often challenging as it is not painful and does not limit the physical development of the child, such as walking. It is important to identify developmental hip dysplasia as early as possible and to treat this condition to prevent hip problems later in life.

Hip laxity can be common in babies. This occurs when the tissues that surround the hip are more flexible. The pediatric orthopedic surgeon can test for hip laxity on exam. Hip laxity frequently resolves after the newborn period.

The signs and symptoms of DDH can vary depending on the age of the child and when one or both (i.e. bilateral) hips are affected. In general, DDH is not painful.
  • Hip feels loose, unstable or clicks/clunks on exam.
  • One leg appears shorter than the other.
  • There is limited range of motion of the hip (particularly noticeable when seaparating the legs to change a diaper).
  • The folds of the skin of the buttocks or thigh may appear uneven.
  • The affected leg may turn slightly outward.
  • Limping in walking age.
  • Waddling gait and swayed-back appearance.

DDH treatment depends on the child’s age, the results of the hip exam and the results of the ultrasound or X-ray. Observation may be all that is required, or more active treatment options may be recommended. These options may include the use of a Pavlik Harness or brace in children less than 6 months old or hip reduction and cast application under general anesthesia if the harness or brace treatments are unsuccessful or the child is greater than 6 months of age. Depending on the patient and the severity of the condition, your doctor will discuss all options if surgery is necessary.

Nonsurgical treatment methods for developmental dysplasia of the hip in children:
  • Observation: The doctor may want to watch the child’s hips closely if the hip exam shows a stable hip and mild dysplasia on the ultrasound. Frequently, this mild hip dysplasia will improve as the baby continues to develop and mature. The child must be watched closely so that treatment can be initiated if there is no improvement under observation.
  • Pavlik Harness: For babies less than 6 months of age, the doctor may recommend a soft, fabric brace called a Pavlik Harness. The Pavlik Harness keeps the hips in a “frog-leg” position, holding the ball of the thighbone in the hip socket. The harness is usually worn for 23 to 24 hours per day for four to eight weeks, followed by a period of weaning off the brace for another few weeks. For 95 percent of babies treated with a Pavlik Harness, no further treatment is ever needed.
Adolescent hip dysplasia, often seen in middle to high school-aged children, is a condition where the hip socket inadequately covers the ball. This concentrates the forces on the hip to a smaller area of the socket and can lead to hip/groin pain or even a limp. The condition can present at birth or in early childhood, and can persist through adolescence if the diagnosis is not treated or if the child’s symptoms go unnoticed.

  • Pain in the groin or in the front or side of the hip.
  • Decreased ability to participate in normal activities or sports due to increased pain in the hip. 
  • Hip joint catching or locking.
  • Limp while walking.
  • Difference in leg lengths. 

Your doctor can confirm the condition by taking an X-ray of the child’s hip. The X-ray will reveal a hip socket that does not completely “cover” the top of the ball part of the hip and is too shallow. This leads to pain because the force from walking and running is distributed over too small of an area and the hip becomes less stable.

A physical exam along with diagnostic imaging can be performed to diagnose hip dysplasa, such as:
  • X-ray – examines the ball and socket of the hip joint to detect abnormal shape or formation. 
  • Computed Tomography (CT) scan – detects more detailed and complex hip bone and joint issues.
  • Magnetic Resonance Imaging (MRI) – able to detect changes in articular cartilage, soft tissues around the hip joint or the underlying bone.  

Nonsurgical treatment options: 
  • Physical therapy to improve the strength of the muscles that stabilize the hip
  • Activity modifications 
Surgical treatment options:
If the condition remains painful and is not responding to nonoperative measures, surgery is an option. The goal of surgery is to alleviate pain and allow the child to return to an active lifestyle. The surgery involves reorienting the hip socket to improve the coverage of the ball. One such procedure is called the periacetabular osteotomy.

What is Legg-Calvé-Perthes Disease?

Perthes disease, also known as Legg-Calvé-Perthes disease, is a childhood hip disorder that primarily affects the ball part of the hip joint. This ball is called the femoral head which sits on top of the thigh bone called femur. The femoral head is normally round and fits inside the round socket of the pelvis, called the acetabulum.
In Perthes disease, the blood supply to the femoral head is disrupted and all or part of the femoral head dies from the lack of blood flow. This death of the bone is called “avascular necrosis” or “osteonecrosis” of the femoral head. The femoral head is weakened after the bone death and can become flattened due to weight and pressure placed on the bone during normal physical activity. Over a one to two-year period, the dead bone in the femoral head is slowly removed and replaced with new bone.
Legg-Calvé-Perthes disease occurs when part or all of the ball of the hip (femoral head) loses blood supply. Without adequate blood flow, the bone weakens and can collapse leading to deformity of the hip. The cause of Perthes disease is currently unknown. Perthes disease is not genetic or hereditary in most cases since less than five percent of children with the disease have a family history of the disorder. There are hip conditions that are inherited that can mimic Perthes disease, such as multiple epiphyseal dysplasia and other skeletal dysplasia.
  • Hip, knee, or thigh pain
  • Limping
  • Increased pain with activity and decreased pain with rest
  • Limited range of motion in the hip
  • Stiffness in the hip
Perthes disease is a diagnosis of exclusion, which means that because there are other conditions that can mimic Perthes disease, similar conditions must be ruled out by taking a careful medical history and doing a thorough physical examination. Physicians generally ask about family history of hip disorders, family history of early joint replacement, previous hip surgery, past use of steroid medication for asthma or other medical conditions, history of sickle cell disease, history of hip infection, clotting disorders and endocrine disorders. In children, a hip disorder can elicit knee or thigh pain thus careful examination is required to correctly localize the anatomic location of the problem.    

In addition to medical history and physical examination, X-rays of the hips are required to make the diagnosis of Perthes. In a small number of patients who come to the clinic shortly after the onset of symptoms, the X-rays may be normal if not enough time has passed for changes to occur. If the patient is still suspected of having Perthes disease, a perfusion MRI may be helpful to make the diagnosis, as it is more sensitive than conventional MRI.
Various treatment methods exist for Perthes disease, and the best treatment option depends on several factors, such as the age of the child at onset of the disease, the amount of femoral head involvement and the stage of the disease at diagnosis. Because of these factors, plus the child’s ability to comply with treatment instructions and a doctor’s findings during examination, treatment is individualized. No single treatment method will work for all patients, and no single treatment consistently prevents the development of femoral head deformity. 

The primary treatment goals are to alleviate pain and to prevent lasting deformity of the femoral head. Because it is easier to prevent or minimize femoral head deformity than to restore the round shape of the femoral head after it has flattened or collapsed, early institution of treatment is important for older patients (8+ years) who do not have good femoral head reshaping potential. Treatments that restore hip motion and help reshape the femoral head as best as possible are used when the child is diagnosed at a later stage of the disease. 

We would recommend a consultation with your physician to determine the activities that are safe and beneficial because the answer would depend on the stage of the disease, your child's symptoms, hip joint stiffness and your child's age.

In our experience, most patients are able to return to running and sports once the femoral head is in the late re-ossification or healed stage.

It is a disease because it adversely affects the cells in the femoral head and affects hip function and development.

Pain generally suggests that there is hip joint inflammation and your child may be doing too much activity that irritates the inflammation. The amount of pain experienced by a child with Perthes disease varies from patient to patient. Some patients complain of activity-related pain or night pain only. Your child may complain of groin, thigh or knee pain. They may have restricted movement and a mild to noticeable limp. You and your child’s doctor will discuss how to best manage pain.

Although the blood flow to a part or all of the femoral head is disrupted and stops the femoral head from growing, a return of blood flow and healing will occur over time since tissue around the affected femoral head is alive and is able to respond to the abnormal change. In many patients, especially those with early onset of the disease (before age 6), normal growth is restored as the new vessels enter the dead bone and start the healing process. In older patients, restoration of normal growth of the hip is not as predictable.

Hip replacement is not a surgery for children. Only if a patient develops painful degenerative arthritis later in adulthood is the hip replacement surgery warranted. Even with a deformed femoral head, most patients can perform daily activities and sports activities once the hip has healed.

It is not curable because we don't know the cause. However, it is a self-healing disease, meaning the body is able to heal the bone in the femoral head that is affected. The healing process and the duration of the disease vary from patient to patient. The clinical outcome also varies, depending on the age of the patient, the extent of femoral head involvement and the amount of femoral head collapse.

What is Slipped Capital Femoral Epiphysis?

Slipped capital femoral epiphysis (SCFE) usually occurs during the teenage years when the thighbone is growing at a fast rate. Unlike normal pain in the hip, the condition causes the ball part of the child’s thighbone (capital epiphysis) to slip from the growth plate, causing the child to limp or feel hip, thigh or knee pain.
The cause is unknown, but the condition may be linked to several factors:
  • Weakness in the bone due to hormone abnormalities (i.e., low thyroid hormone)
  • Excessive weight
  • Family history of hip conditions
The child’s doctor can confirm SCFE through physical examination and by taking X-rays of the hip. Since the pain from this condition can be in the hip, thigh or knee area, careful examination is required to determine the true source of the pain. There are two types of SCFE: 
  • A slow slipping of the epiphysis which is called stable SCFE. In this type of SCFE, patient can still put some weight on the affected leg. 
  • A sudden slipping of the ball part of the hip called unstable SCFE, resulting in severe pain and inability to walk.
If your doctor suspects your child has SCFE, the child should stop walking and be placed in a wheelchair (not crutches) to help prevent further slipping or a sudden slip of the bone. A sudden slip or progression to an unstable slip (where your child cannot put weight on their leg) can cause the ball part of the hip to lose blood supply (avascular necrosis), resulting in long-term pain, limping or hip replacement surgery in early adulthood. Therefore, preventing weight bearing immediately after diagnosis is essential to protect the hip.

When SCFE is confirmed, the child will be admitted to the hospital and put on bed rest. One of two types of surgery is performed.
  • In Situ Pinning Surgery: This less-invasive surgery keeps the ball of the thighbone (capital femoral epiphysis) from slipping further and secures it in the current position (in situ). One or two screws are placed through the skin into the thighbone to hold the epiphysis to the top of the thighbone and prevent further slipping.
  • Open Reduction Surgery: This surgical procedure is used for some patients with unstable SCFE to align the bone within the hip socket and prevent loss of blood flow to the ball of the thighbone.

What Is Femoroacetabular Impingement? 

Femoroacetabular impingement (FAI) is a condition of abnormal contact between the ball (femoral head) and the socket (acetabulum) of the hip, causing pain and a decreased range of motion.

There are two types of FAI:
  • Cam impingement: primary problem is on the ball part of the hip. When the ball is aspherical (cam-shaped), flexing the hip can lead to early collision of the ball and the socket, leading the pain and cartilage or labrum injury.
  • Pincer impingement: primary problem is on the socket side. When the socket overcovers the ball, there is early collision between the ball and socket during hip range of motion, leading to pain and cartilage or labral injury. 
  • Depending on the severity, a child diagnosed with FAI can heal without surgical intervention. The type of treatment and what is recommended by the doctor impacts that timeline. 
FAI occurs in the ball and socket joint, when the ball of the hip impinges against the rim of the socket inside the hip joint. This can happen from the ball being slightly misshapen, the socket being too deep or a combination of both.
Your doctor can confirm FAI by analyzing your family’s medical history, performing a detailed physical exam and diagnostic testing (X-ray, MRI, CT scan). FAI can cause pain in the groin and on the outside, back or lower side of the hip or thigh.
  • Physical therapy with modified activities.
  • Rest.
  • Injection of numbing and/or anti-inflammatory medication inside the joint.
  • Hip surgery, if necessary, is sometimes needed to reshape the ball or socket to prevent impingement during hip range of motion. Hip surgery can also address injury to the cartilage of the hip that can occur with FAI.
Dr. Kim with patient in the clinic



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