What is the best course of action for a teenage athlete experiencing hip pain while playing sports?

Hip Pain in Teenage Athletes: Diagnostic and Management Approach

For a teenage athlete with hip pain during sports, immediately exclude slipped capital femoral epiphysis (SCFE), stress fractures, tumors, and infections before considering other diagnoses, then proceed with a structured evaluation for femoroacetabular impingement (FAI) syndrome or acetabular dysplasia. 1, 2

Immediate Red Flag Exclusion (First Priority)

You must rule out these serious pathologies before anything else:

• SCFE: Look for external rotation deformity, antalgic gait, and pain that may present as medial thigh or knee pain rather than hip pain 1, 2
• Stress fractures and tumors: Insidious onset, night pain, constitutional symptoms (fever, weight loss), and inability to bear weight 1, 2
• Infection: Fever, inability to bear weight, acute onset 1
• Perthes disease: Must be excluded in this age group 1

Critical pitfall: Hip pathology frequently presents as knee pain in adolescents—never dismiss knee pain without evaluating the hip 2

Age-Specific Diagnostic Approach

Early Adolescence (10-15 years)

• SCFE is the primary concern and can be easily missed because it often presents as thigh or knee pain 2
• Obtain AP pelvis and frog-leg lateral radiographs immediately if any suspicion exists 2

Late Adolescence (15+ years, transitioning to young adult)

• FAI syndrome becomes the predominant diagnosis 2, 3
• Acetabular dysplasia is the second most common cause 1, 2

Structured Physical Examination

Perform these specific maneuvers:

• FADIR test (flexion-adduction-internal rotation): A negative test helps rule out intra-articular hip pathology, though sensitivity is limited 1, 2, 4
• Mandatory lumbar spine screening: Always examine the lumbar spine as referred pain from spine pathology commonly mimics hip pain 1, 2, 3
• Assess for limited hip internal rotation and flexion: Common findings in FAI syndrome 3

Critical pitfall: Lumbar spine pathology presents as sharp lancinating pain radiating down the leg, often improved by position change—this can easily be mistaken for hip pathology 2, 3

Imaging Protocol

Initial Imaging

• AP pelvis and lateral femoral head-neck radiographs (Dunn, frog-leg, or cross-table views) to evaluate for SCFE, fractures, FAI morphology (cam/pincer), and dysplasia 2, 3, 4

Advanced Imaging (if initial radiographs are negative)

• MRI or MR arthrography to assess labral tears, chondral damage, and ligamentum teres pathology 3, 4

Critical pitfall: Incidental imaging findings (FAI morphology, labral tears) are extremely common in asymptomatic adolescent athletes—clinical correlation is mandatory 1, 2, 3

Most Likely Diagnoses After Red Flags Excluded

FAI Syndrome (Most Common in Late Adolescence)

• Groin pain is the hallmark symptom, worsened by hip flexion, adduction, and internal rotation 1, 3
• Pain may radiate to back, buttock, or thigh 1, 3
• Caused by cam morphology (femoral head-neck junction abnormality), pincer morphology (acetabular overcoverage), or mixed patterns 3

Acetabular Dysplasia

• Misalignment between femoral head and acetabulum causing instability and rim overload 1, 2
• Presents with groin pain during activities 1

Treatment Algorithm

Conservative Management (First-Line)

Initiate a 3-6 month trial of the following for FAI syndrome or dysplasia: 1, 3

• Exercise-based physiotherapy for at least 3 months duration 1
• Activity modification to avoid provocative positions 3
• NSAIDs for pain control 3

The exercise program must be sport-specific and progressively loaded, initially focusing on strength and basic athletic movements, then gradually introducing high-level tasks including running, twisting, and turning 1

Surgical Referral Indications

• Failed conservative management after 3-6 months with persistent symptoms 3
• MRI-confirmed labral or chondral damage with ongoing functional limitation 3

Return to Sport Considerations

• Quantify patient expectations regarding return to sport level and performance before initiating treatment 1
• Sport-specific activities must be assessed before clearing for return to play 1
• Psychological readiness should be evaluated alongside physical function 1
• Distinguish between return to participation (lower level), return to sport (same sport, lower performance), and return to performance (preinjury level) 1

Critical pitfall: Half of patients have overly optimistic expectations about return to sport after treatment—discuss realistic outcomes early 1