Children have different injuries to adults. So a sudden onset, acute onset, traumatic injury around the hip or the groin could potentially be an injury to the immature growth plates. We talk about them not being split and matured.
SPEAKER_00:Hip pain in kids and adolescents can be quite a challenge in the clinic, particularly when it means ruling them out or pulling them back from sports. Today, we spoke to Dr. James Noak, who is a consultant in sports and exercise medicine. He's got over 10 years of experience working in elite sport, and he's passionate about non-surgical management for this population. We covered how hip pain in kids and adolescents should be viewed through a different lens as hip pain in adults, the acute and gradual onset type of hip pain, as well as having a lower threshold for imaging and thinking about some of those other diagnoses. I hope you enjoyed this episode. My name is Michael Roosk and this is PhysioExplained. Welcome James and thank you for joining us.
SPEAKER_01:Hi Mike, thanks for having me on.
SPEAKER_00:No problems. We're going to talk about hip pain, particularly in kids and adolescents. So we were discussing the phrase that it's not normal for kids to have hip pain, specifically the same as like an adult would. Could you tell us more about that?
SPEAKER_01:Yeah, sure. I think it's an important concept. Kids are very much, or adolescents we should call them, you know, very much different to adults, not least because they have different physiology to us, certainly. You know, they're not skeletally mature. They go through growth spurts. They have potentially vulnerable growth plates. So, you know, they're exposed to it. a different range of injuries and conditions, essentially. In adults, we see it all the time. Adults can have intermittent, grumbling, hip and groin pain that's transient, it's mild. And often we can't put a label on that necessarily. Or it might just be related to inevitable degenerative changes, osteoarthritis, as we get older. Whereas obviously kids haven't gone through that process. They've not been exposed to that. adolescents, whether sporty or inactive, if they have persistent or recurrent pain, that's a flag. It's important to be aware of that and be vigilant for that as clinicians to explore it a bit further, be mindful of exploring it a bit further and having a low threshold potentially for investigating and testing as you see fit.
SPEAKER_00:It's an interesting concept you're bringing up because it is so common to have an adult with hip pain. I think of a tradie who's got a sore hip or maybe a female runner and it's just normal and we're probably not alerted. We're not thinking MRI. We're not thinking red flags. We're probably not too concerned. We're probably just thinking a little bit of offloading. And this is slightly different for adolescents. What are you starting to think when an adolescent comes in with hip pain?
SPEAKER_01:I think it's also important to acknowledge that Well, in my experience, certainly, actually, kids and adolescent sporty kids are pretty tough and they're pretty robust. Sport's hugely important for them in terms of their life at school, interactions with their children, being sociable. It's a huge part of their life. So I think if a child is not enjoying their sport or shying away from their sport, they're not enjoying it, we have to be mindful that their pain is significant. there's probably something underlying, significant underlying structurally driving
SPEAKER_00:that. Oh, that's a great point that you're touching on there, that if they're straying away from sport, it's pretty unusual, so worth exploring. What you've got here as well, which I find interesting, is that are there other pressures on the adolescent to continue to play sport, or is there anything else going on in their lives? Could you unpack that a bit for us?
SPEAKER_01:Yeah, I think that's something you probably see quite quite frequently in clinic, you know, we have to consider parental pressure. A lot of these children are high achieving, playing multiple sports. There's this pressure for them to progress and be, essentially be ahead of other kids in their, you know, their training classes or their sports team. So it's not uncommon to see these adolescents overtraining, playing multiple sports each week, sometimes training twice a day, playing matches at weekends. So even though children are pretty resilient, eventually something's going to give. They're going to develop an injury potentially. So we need to be aware of those parental pressures and unpack those or explore those in clinic if it's possible, even if that means spending some time with the adolescents on their own, essentially.
SPEAKER_00:Yeah, that's really worth exploring it. I'm just visualizing the few adolescents that I would see. And there's a lot of high school pressure. There's a lot of studying pressure. And they're usually getting to a place where they're doing representative sport, where they might be training for a club and then training for the rep club. And then there might be even two games on the weekend instead of one. How do you approach that? I remember that's a really common conversation I was having and they were feeling like we'd have to let down one of the teams they play for. Do you see a lot of that?
SPEAKER_01:Yeah, that's a real challenge. It's quite a difficult conversation to have in the appointments with the parents there as well. So I think we're trying to understand what the child enjoys most. What's their priority? What do they get most out of? And sometimes we have to find a way, a strategy with the child and with the parents to reduce the amount of sports they're doing. Potentially have a discussion with coaches or the school, work out a way around that because a lot of these injuries are potentially overuse injuries. and we have to dial things back to allow them to recover and for tissues to heal essentially.
SPEAKER_00:It's a really brave conversation and it's a good skill set for young health professionals to pick up early is to communicate with the parents well, the coaches well, maybe even the school a little bit and bring all those parties together. James, when that adolescent comes in with hip pain, we were talking about potentially the pathway of acute pain versus the gradual onset and what each one might indicate for you. So if it was a really acute onset of pain, what thoughts are you starting to have?
SPEAKER_01:Yeah, so like you mentioned earlier, children have different injuries to adults. So a sudden onset, acute onset, traumatic injury around the hip or the groin could potentially be an injury to the immature growth plates. We talk about them not being split and mature. So the apophysis, the non-fused growth plates around the pelvis, So a common injury we might see is avulsion of the rectus femoris origin at the AIIS. That's probably the most common of these injuries. So potentially an acute pop or tear with a powerful kick or a sprint. And we see some lesser common injuries around TFL and sartorius, again, at the iliac crest, at the lesser cancer of the hip flexor, issue of tuberosity as well, potentially causing boot or buttock pain. The key concept here, I think, is to appreciate that The growth plate, the apophysis is the weak point. It's the vulnerable, vulnerable point. So, you know, children who are skinny to the immature don't get, or very rarely get muscle or tendon injuries. They don't get muscle tears or tendonitis, tendinopathy. You know, we should be looking at the anchor points. That is the anchor at the growth plate and hang a low threshold potentially for investigating those. We also need to think potentially about the labral tear. So labral tears are not as common in children as they are in adults, but they can occur acutely as an acute onset trauma or gradually over time. And we also need to think about conditions that are very specific to adolescence as well. For example, SUFI, which is slipped upper femoral epiphysis, that can come on as an acute onset pain, typically in a 10 to 15-year-old age group. So we need to be thinking about those structural flags as well.
SPEAKER_00:And so when we're thinking acute, that's more coming from your history, is like, I didn't have much pain and then I played in this game and then it came on. You'd be thinking it could be one of those that you just mentioned. Yeah,
SPEAKER_01:very much so. And usually there's a well-defined mechanism, like we described it, a force, a powerful kick or a sudden sprint and a pop and an immediate disability around the hip or groin, essentially.
SPEAKER_00:Yeah. And most of those, would you be thinking imaging, and particularly at the point when they see you?
SPEAKER_01:Yes, and as Sean's answer, I think you have to have a low threshold for imaging. Even a simple X-ray is a useful tool in this context. Most clinicians have access to that. So an X-ray, a simple, well-taken X-ray, will show an apophysis, avulsion, avulsion fracture. And certainly in terms of the more important flags like Sufi or Perthes, we'll pick those up. And if we think about the more gradual onset pain causes as well, again, plain x-ray can be really useful in that. So, for example, looking at hip dysplasia, which is a very common but overlooked cause of grumbling hip and groin pelvic pain in younger patients. And certainly femoroacetabular impingement will easily identify a CAM or a pincer lesion potentially on an x-ray. And also, we need to think outside the sporting context. Is there an underlying red flag children do get? rarely, but they do get femoral acetabular tumors. They can get inflammatory arthropathies. Infection can occur in the hip. So we shouldn't be missing, you know, we should be thinking about having that in the back of our mind, especially in insidious onset pain and pain that may not be related to activity necessarily.
SPEAKER_00:And that's going to be the adolescent that comes in maybe talking about grumbling hip pain for two or three months?
SPEAKER_01:Yes, it could be. It could be quite variable. Kids who have dysplasia and FAI in particular will often have a background of discomfort, which fluctuates, comes up and down with activity, but then might get acute spikes of pain. Again, with FAI, they might describe sudden sharp shooting pain, groin pain episodes during activity, and then again, a slow increase in pain afterwards for a couple of days or so. And that can build up over a course of months. And we see that with, like I say, with Perthase disease, which is an AVN of the femoral head, so not to go missed, particularly in a five to 10-year-old age group. And dysplasia itself, again, the symptoms are often quite vague. So these children might have a pretty good range of movement, but describe quite diffuse pain around the groin, the lateral hip, and the buttock, as those muscles around the hip, almost like a hip cuff, they work hard to stabilise the hip, to offset the muscles the sort of low level instability in the hip joints. Because those symptoms are quite vague and come and go, often it's quite, it goes under the radar. These things can be missed until it becomes functionally limiting.
SPEAKER_00:And James, I'm interested in management for some of those, particularly the gradual onset ones. And by the time they get to you as a consultant, Are you tending to pull them off sport altogether? Is there a timeframe that you're looking at or are you trying to keep them going, but just lower load? What does that tend to look like?
SPEAKER_01:It's a very good question. I think that's pretty much tailored to the condition in a way, but most of the time by the time the patient comes to see me, they're pretty irritable. They've not progressed or they've not changed quickly with physiotherapy input. So certainly I'll be, looking at relatively early imaging as part of that workup process. But yes, they'll often need to be offloaded for a period of time to get the tissues less irritable, make you more confident in using the hip, and then working out a structured, often a multidisciplinary plan with the physical therapy team to build up their strength and conditioning, improve their function, and work for us a graded return to sport. So very much the principle of most the way we approach multiple skeletal injuries. But there are some conditions whereby the imaging and further workup can send a patient down a different pathway. So, for example, I saw a patient, a 14-year-old academy footballer last year, who had had this vague, diffuse pain around the hip and the pelvis for a year or so, but was coping functionally, and then had one particular episode where he went to sprint and felt a pop pop in the groin. So by the time he was seeing me, a couple of weeks down the line, he was limping, he was struggling, had an antalgic gait. The physio who saw him wondered whether he might have an apophysial injury, an abulsion, or maybe a hip flexor tear, which is pretty unlikely in a patient group. Ultimately, he had a labral tear on an MRI scan that we organised. But the MRI also suggested there was an element of hip dysplasia. So that prompted further imaging, so an X-ray can show dysplasia. He had an X-ray. And then a further CT scan, which is the gold standard way to assess dysplasia. So then it became a bit more complex and we needed input from the hip surgeon to understand whether the hip dysplasia itself needed assessing or managing or treating, correcting. And then how do we approach dealing with the labral tear? We went down the conservative route. We gave it time to settle and offload and the labral tear pain settled. And actually over time, without any invasive intervention, we got him back to sport. the course of two or three months so even in children we don't you know surgical inputs you know isn't you know always on the table but if you're looking for if a patient has a labral tear i think it's also important to make sure that you know we we work out why have they had a label tear in the first place usually there's an underlying um structural or morphological issue which is the catalyst for the injury and typically that's either an fai an impingement type of pattern or or hip instability. So again, hip dysplasia, sorry. So that's why I think early imaging in these cases is quite important. It can make a big difference to the patient's long-term outcome.
SPEAKER_00:That's a really nice case to bring all this together. Was this patient trying conservative treatment or had he been going to physio as an example for a while?
SPEAKER_01:No,
SPEAKER_00:he'd been coping
SPEAKER_01:fairly well for some time and managing it. He'd been told to a certain degree by people around him that, His pain was probably potentially growing pains that he'll get better over time, but didn't. And this was an adolescent who was clearly overtraining, was being pushed very hard by his parents. He was even doing a lot of external strength and conditioning work, which was probably inappropriate for his age. So there was a tipping point, there was a failure point. And that's when he had the injury in football, I suspect. It got to a point where he wasn't able to cope with the load. And there was that tissue failure point, essentially.
SPEAKER_00:The risk reward ratio seems different here. Generally, in my narrow clinical experience as a physio, James, I'll see patients who are underloaded. Like I think about a back pain and they never really progressed their strength work to get them better and to handle the rigors of life. With adolescence and hip pain, it seems like the opposite that there might be grumbling symptoms. And what I see clinically is they'll be going and going and going with grumbling symptoms for a couple of months. And maybe even they're being given exercises like squatting and just get stronger. And then we tend to miss that thing versus an early MRI might not be helpful in a 40-year-old with back pain, but an early X-ray or CT would be worthwhile in this population group. That's what I tend to see clinically. Does that kind of ring a bell with you?
SPEAKER_01:Yeah, very much so. I think, again, being vigilant for these structural conditions, these significant underlying adolescent conditions is so important and early imaging will very much, can very much help us define that treatment approach.
SPEAKER_00:Yeah. James, this is bread and butter for you, but I found this extremely helpful, a review of those conditions, you know, the acute and probably more grumbling conditions and what they could be, as well as how The management is different and we should just have that. I like how you put the lower threshold for imaging or concern, particularly as my bias and many physios bias is to hammer away at the SNC stuff at the moment. So I've really appreciated this episode. Thank you so much for your time and giving us that really thorough review of adolescents with hip pain. Thanks very much, Mike. And thank you for having me on.