A 15-year-old male came to clinic with a history of standing up in the night and having enough pain in his leg or hip when trying to walk that he had to sit down. He was able to eventually get up and walk to the restroom but said he was unsteady because he was worried the pain would increase. He went back to bed and was able to sleep. In the morning he was able to walk but said that his leg was fine as long as it wasn’t moved or held in specific positions. He had a history of mild intellectual disability and he wasn’t able to provide additional details. His father had not witnessed the episode, but said that the patient kept saying his leg hurt at times but then seemed to stop, during the morning, which prompted the appointment. Both agreed that he had no recent trauma or illnesses including fever, and no weakness, muscle pain, abdominal or radicular back pain and no syncope/vertigo. The past medical history was positive for a non-specific leg pain that resulted in a negative evaluation by a rheumatologist about 3 years previously.
The pertinent physical exam showed a pleasant male with normal vital signs. His weight was >99% for BMI. Abdomen and back examinations were normal. Leg, knee, ankle and foot examinations had normal sensation, and pulses were noted bilaterally. While usually pleasant during the exam, he had guarding of any palpation or movement of the right hip and groin area. His examination was inconsistent due to intense guarding with movement of the hip but it appeared that he did not have a hernia, nor specific pain on the ischial spine area with quadriceps flexion. The pain appeared located to the hip joint, but changes in pain intensity in different positions could not be ascertained. He would walk but this was more of a shuffling movement as he said he was worried walking would cause pain even though he was not having it with walking.
The clinician considered in his differential diagnosis a possible slipped capital femoral epiphysis, Legg-Calve-Perthes disease, fracture, septic arthritis and transient synovitis. He thought that a back problem, hernia or quadriceps avulsion fracture or muscular related problem were much less likely. An occult malignancy was also considered.
The laboratory evaluation showed a normal complete blood count and differential, complete metabolic profile, erythrocyte sedimentation rate and C-reactive protein. The radiologic evaluation showed no fractures but a mild cam abnormality of the femoral head that was consistent with femoracetabular impingement. The patient was referred to orthopaedics and given instructions for monitoring, along with a school excuse for no gym class and similar activities until he saw orthopaedics.
Discussion
Pain occurring in the hip, lower back or upper leg area can be difficult to pin down. The pain can be intermittent, occur only in certain positions or appear to move or radiate. It can be insidious. Patients, because of age, neurological differences or who are in pain or are very fearful of pain, may not be able to fully describe the problem and especially the exact location. They may actively resist examination even when they want to help the examiner. Therefore it can be difficult to narrow down the possible causes, and a broader evaluation is pursued to help lead the clinician to an answer.
Reviews of common causes of pain in the hip area can be found below:
- Leg pain
- Hip pain and limp
- Back pain
- Iliac avulsion fractures
- Benign acute childhood myositis
- Inguinal hernias
Learning Point
Femoroacetabular impingement (FAI) results when there is abnormal contact between the hip acetabulum and the femoral head. There are 3 major types:
- Pincer where “…there is increased acetabular depth results in acetabular overcoverage…” of the femoral head. The acetabulum appears to be pinching the femoral head from a cross-sectional viewpoint.
- Cam deformity occurs when the femoral head is aspherical and there is an abnormal angle between the femoral head-neck junction, which can occur because of abnormal bone formation.
- Both deformities which occurs in about 50-70% of patients.
Patients who have hip anatomic changes such as coxa vera (angle between head and shaft of femur is reduced), Legg-Calves-Perthes, osteonecrosis and slipped capital femoral epiphyses can lead to FAI. Athletes and former athletes are at risk for FAI and osteoarthritis. “This suggests that the morphological changes of FAI may be in a response to repetitive stress at the proximal femoral physis secondary to sporting activities during periods of skeletal growth.” Males are more likely to be affected than females. Male athletes in high impact sports such as basketball, hockey and jumping sports are at greater risk for cam deformities (1.9-8.0 times increased risk overall)
Patients may have insidious symptoms of groin or hip pain that is worsened by movements involving hip flexion. Patients may have overall decreased hip range of motion. Impingement movements can be attempted on physical examination and if positive will have increased pain with flexion, adduction and internal rotation.
As with anything there is a range of normal variation and depending on the population and specific criteria used, somewhere between 3-25% of the population may have FAI changes on radiograph yet be asymptomatic. It is also discussed that FAI may be an under-recognized entity where the patient is asymptomatic when young, but FAI may be an etiological factor for clinically significant early osteoarthritis some years later.
Treatment usually begins with physical therapy to understand what movements aggravate the problem and activity modification if necessary, along with strengthening of other muscles. Rest and anti-inflammatory medication can also help along with possible cortisol injections. Weight loss and supportive footwear can also potentially help. Surgical treatment can also be completed using either arthroscopic or open procedures.
Questions for Further Discussion
1. What causes pelvic pain?
2. What are common osseous tumors in adolescents?
3. What are the pros and cons of different types of radiological imaging hip or leg pain?
Related Cases
- Disease: Femoroacetabular Impingement | Hip Injuries and Disorders | Leg Injuries and Disorders
- Symptom/Presentation: Extremity Problems | Pain
- Specialty: Orthopaedic Surgery and Sports Medicine | Radiology / Nuclear Medicine / Radiation Oncology
- Age: Teenager
To view pediatric review articles on this topic from the past year check PubMed.
Evidence-based medicine information on this topic can be found at SearchingPediatrics.com and the Cochrane Database of Systematic Reviews. Information prescriptions for patients can be found at MedlinePlus for these topics: Hip Injuries and Disorders and Leg Injuries and Disorders.
To view current news articles on this topic check Google News.
To view images related to this topic check Google Images.
To view videos related to this topic check YouTube Videos.
Nepple JJ, Vigdorchik JM, Clohisy JC. What Is the Association Between Sports Participation and the Development of Proximal Femoral Cam Deformity? Am J Sports Med, 2015:43;2833-2840.
de Silva V, Swain M, Broderick C, McKay D. Does high level youth sports participation increase the risk of femoroacetabular impingement? A review of the current literature. Pediatr Rheumatol Online J. 2016;14(1):16.
Youngman TR, Johnson BL, Morris WZ, et.al. Soft Tissue Cam Impingement in Adolescents: MRI Reveals Impingement Lesions Underappreciated on Radiographs. Am J Sports Med, 2023:51;3749-3755.
Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa
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