Hip Pain in Children and Adolescents

Hip pain in the younger patient requires a very different diagnostic framework from adult hip pain. The open growth plate, rapid skeletal growth, and developing acetabular architecture mean that conditions such as slipped upper femoral epiphysis (SUFE) and Perthes disease must be excluded quickly and reliably before any physiotherapy-led management begins. The page organises the key conditions by age group and urgency, then describes the management principles that apply to each.

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Urgency Framework: Rule Out First

Before anything else, clinicians must screen for conditions that demand same-day referral or urgent imaging. Missing these leads to avascular necrosis, permanent deformity, or septic joint damage.

  • Septic arthritis: hot, swollen, febrile child who refuses to weight-bear or move the hip. Requires immediate hospital referral. The Kocher criteria (fever, non-weight-bearing, elevated ESR, elevated WBC) stratify risk. This is a surgical emergency.
  • Slipped upper femoral epiphysis (SUFE): typically an overweight adolescent (10–16 years) with groin, thigh, or referred knee pain and an externally rotated, shortened limb. Any clinical suspicion warrants same-day orthopaedic referral. Do not delay imaging to see if the child improves.
  • Perthes disease: typically a lean child (4–10 years, more common in boys) with limp, groin pain, and gradual loss of hip abduction and internal rotation. Less acutely dangerous than SUFE but still needs prompt orthopaedic involvement for staging and management planning.

Knowledge Check

A 14-year-old overweight boy presents with a 3-week history of left knee pain and a slight limp. He has no knee tenderness. Hip examination reveals pain and loss of internal rotation. What is the most likely diagnosis and immediate management priority?
Answer: Slipped upper femoral epiphysis (SUFE) — same-day orthopaedic referral
Referred knee pain in an overweight adolescent with reduced hip internal rotation is SUFE until proven otherwise. Same-day orthopaedic referral is required to prevent further slip and avascular necrosis.

Transient Synovitis: The Most Common Cause of Acute Hip Pain in Children

Transient (toxic) synovitis is the most common cause of acute hip pain in children aged 3–10 years and typically follows a viral illness. It presents with sudden-onset hip or groin pain and limp, often with mild restriction of hip movements (especially abduction and internal rotation), but the child is usually not systemically unwell and is afebrile or only mildly febrile.

The main clinical challenge is distinguishing transient synovitis from septic arthritis. The Kocher criteria provide a validated framework: fever, non-weight-bearing, elevated ESR (>40 mm/hr), and elevated WBC (>12,000/μL). A child with zero criteria has a very low probability of septic arthritis; those with two or more criteria warrant urgent blood tests and imaging.

  • Management: rest, anti-inflammatory analgesia, and reassurance. Most children recover fully within 1–2 weeks.
  • Follow-up: important because ~1–2% of cases are later diagnosed as early Perthes disease. A child who has not fully recovered in 2 weeks warrants re-examination and imaging.

Perthes Disease

Perthes disease (Legg–Calvé–Perthes) is avascular necrosis of the femoral head in childhood, most common in boys aged 4–10 years. The exact aetiology is unknown but involves disrupted blood supply to the epiphysis during a critical growth phase.

The condition passes through recognisable radiographic stages: initial/ischaemic (radiograph may be normal; MRI shows bone oedema), fragmentation (subchondral collapse), re-ossification, and remodelling/healing. Outcome depends on the degree of femoral head involvement at presentation (Herring lateral pillar classification), the child’s age, and the congruency of the hip joint during healing.

  • Clinical features: limp, groin or anterior thigh pain, progressive loss of abduction and internal rotation, leg-length discrepancy in later stages.
  • Physiotherapy role: maintaining joint range of motion, reducing loading during the fragmentation stage, and guiding sport participation decisions during healing. Physiotherapy does not replace orthopaedic management but supports it.
  • Key principle: the goal is a spherical, well-contained femoral head at skeletal maturity; containment strategies (orthoses, varus osteotomy) serve this goal.

Knowledge Check

In Perthes disease, which radiographic stage carries the greatest risk of femoral head deformity if the hip is not managed carefully?
Answer: Fragmentation stage
During fragmentation the femoral head is softened and most vulnerable to deformation under load. Containment strategies and load management are most critical during this phase.

Developmental Dysplasia of the Hip (DDH)

DDH encompasses a spectrum from mild acetabular dysplasia through subluxation to frank dislocation. It is more common in girls, in first-born children, in breech presentations, and with a positive family history. Neonatal screening (Ortolani and Barlow tests, plus ultrasound) aims to detect and treat DDH early; late-presenting or missed DDH is increasingly seen in older children and adolescents.

The older child or adolescent with DDH may present with activity-related groin or anterior hip pain, limited hip range of motion, or early labral pathology. They are also at much higher risk of femoroacetabular impingement (FAI) if the dysplastic socket has been surgically corrected with a periacetabular osteotomy (PAO) but the correction has created a cam or pincer morphology.

  • Physiotherapy role in DDH: pre- and post-operative rehabilitation, functional hip strengthening, gait retraining, and sport-specific return-to-activity programming.
  • Red flag: a young female with recurrent groin pain, instability symptoms, and labral pathology on MRI should prompt consideration of underlying dysplasia before a purely impingement-based treatment approach is adopted.

Apophyseal Avulsions in Active Adolescents

Rapid growth creates a mismatch between musculotendinous unit length and skeletal elongation, rendering apophyses vulnerable to avulsion injury during explosive activities. Around the hip and pelvis the most common sites are:

  • Anterior superior iliac spine (ASIS): sartorius or tensor fascia lata avulsion, typically with hip extension and knee flexion in sprinting.
  • Anterior inferior iliac spine (AIIS): rectus femoris avulsion, commonly in kicking sports.
  • Ischial tuberosity: hamstring origin avulsion, the most common and most significant — often a sudden ‘pop’ during explosive hip flexion with the knee extended.
  • Iliac crest: abdominal oblique avulsion, seen in rotational sports.
  • Lesser trochanter: iliopsoas avulsion, can mimic adductor strain.

Management is usually conservative for non- or minimally displaced avulsions: protected weight-bearing, pain-guided range of motion recovery, and a phased return to loading. Displaced ischial tuberosity avulsions (>2 cm) in high-level athletes may be considered for surgical fixation. A plain radiograph is usually sufficient for diagnosis; MRI adds value when the diagnosis is uncertain or to characterise fragment displacement.

Knowledge Check

A 15-year-old sprinter reports a sudden ‘pop’ at the back of the hip/buttock during a sprint start, with immediate inability to continue. Which apophyseal avulsion is most likely?
Answer: Ischial tuberosity (hamstring origin) avulsion
The ischial tuberosity is the most clinically significant site. Explosive hip flexion with a near-extended knee in sprinting loads the proximal hamstring origin acutely and is the classic mechanism.

Adolescent Overuse Presentations: Stress Reactions and Snapping Hip

Two additional presentations are worth highlighting in the adolescent population.

Femoral neck stress reaction and stress fracture occur in high-training-load adolescent runners and endurance athletes, particularly when relative energy deficiency (RED-S) or low bone density is present. Groin pain that is worse with impact activity and better with rest, progressive over weeks, without a clear trauma mechanism should prompt early imaging (plain X-ray and MRI). Tension-side femoral neck stress fractures are a surgical emergency; compression-side lesions may be managed conservatively with strict non-weight-bearing and multidisciplinary input.

Snapping hip syndrome (coxa saltans) is common in young dancers, gymnasts, and endurance athletes. The snap may be:

  • External (iliotibial band over the greater trochanter): lateral snapping, usually benign, responds to load management and ITB/hip abductor rehabilitation.
  • Internal (iliopsoas tendon over the iliopectineal eminence): anterior groin snapping, sometimes painful, responds to iliopsoas lengthening and functional strengthening.
  • Intra-articular: labral tear or loose body — the only type requiring further investigation.

Bottom Line

Hip pain in children and adolescents demands a structured, age-sensitive approach. Clinicians must first screen for urgent conditions — septic arthritis and SUFE in particular — before moving to the broader differential. The growth plate, open apophyses, and immature acetabular architecture create pathologies that are simply not seen in adult practice. Once serious pathology is excluded, the physiotherapy role is substantial: supporting containment in Perthes, rehabilitation after DDH surgery, guiding load management for apophyseal avulsions, and returning young athletes to sport safely after stress reactions and snapping hip.