Hip Pain in Children and Teens: Q&A with a Hip Specialist

Hip pain can be prevalent in children and teens who were born with a hip condition or disease, or could be the result of an injury at any age. Dr. Ernest Sink is the Chief of the Hip Preservation Service and a pediatric orthopedic surgeon specializing in hip surgery and treatment. Below are answers to common questions parents and patients ask about hip pain, along with background information on his specialty and what to expect at HSS.

What is the most common pediatric hip condition?

The most common pediatric patient is the adolescent and young adult with hip dysplasia, which occurs more frequently in females. We also evaluate hip impingement which is hip pain associated with a history of doing sports or activities that require major hip flexion. In sports activities like soccer, track and field or dancing, the hip can move beyond its normal constraints and cause some pain and sometimes injury to the hip.

Does hip dysplasia always require surgery?

Children with dysplasia don't always need surgery and our hope is that they won't have surgery. If hip dysplasia is found early on, either right after birth or in the perinatal period, then we can treat it effectively with bracing in most cases. If it's a mild case of dysplasia, we might just need to observe it to make sure that it improves. In adolescents and adults, the first treatment for mild dysplasia is usually extensive nonoperative treatment such as physical therapy.

What's the difference between dysplasia and developmental dysplasia?

Developmental dysplasia of the hip (DDH) is a general term for instability of the hip joint. It covers a large spectrum of disease ranging from dislocation, where the femoral head is not seated in the acetabulum to mild deformities of the femur or acetabulum, which is nearly impossible to diagnose until it becomes very painful at an older age.

Hip dysplasia is where the hip socket doesn't completely support the ball or femoral head. There is a large variation of the degree of hip dysplasia[SJ1] . It can either be so bad that the hip is dislocated at birth to the hip slightly moving out of the joint to where it's dysplastic, to mild deformities with no abnormal exam findings. Oftentimes, a patient like that won't show any signs until an older age.

Who is the typical pediatric patient who has hip pain?

Most patients that come here are experiencing hip pain, but there is a wide range of age groups for various pediatric hip conditions. We often see teenagers, young adults, as well as children under age 10 who complain of pain in the hip or groin that limits them from playing sports or doing their daily activities.  Another large group is babies and infants who were screened after birth by their pediatricians and diagnosed with a dislocated hip or hip dysplasia. Hip dysplasia is an abnormality of the ball and socket that may lead to arthritis later, sometimes in adolescence. 

When should a child or adolescent see a hip specialist?

Anybody with chronic hip pain that is limiting their activities on a daily basis should be evaluated by a physician or a surgeon that specializes in hip pain and disorders. Hip pain is not one of those normal things that people suffer from, like back pain or knee pain. If a child has hip pain most days, or pain that limits them from participating in sports, then they need a thorough evaluation of the hip, including x-rays or other imaging. Many of the problems that can lead to damaging arthritis can be subtle. What you learn as a hip specialist who evaluates hip conditions every day, is that some very subtle issues can lead to major problems later in life.

There are different criteria for children and teens of different ages. If a pediatrician examines a hip and feels that it's unstable after birth, then parents should come and see us. If there is a family history or a risk factor for hip dysplasia in a newborn, then we should evaluate that child, specifically if the exam and/or ultrasound testing is abnormal. As for older children with problems specific to pediatric orthopedics such as Perthes disease or slipped capital femoral epiphysis, which are deformities of the upper femur, they should be evaluated by a pediatric orthopedist or a hip specialist. Anyone of any age with chronic hip problems or hip pain of a duration of more than a few days, severe pain that does not immediately resolve, or pain that affects their quality of life, should see a specialist.

How do you work with referring physicians?

When a referring physician sends a patient to me, the first thing we guarantee is that the family gets a complete assessment of their child’s condition.  We make sure education is a key component of their visit.   Therefore when they leave the appointment or go back to the referring physician, they don't have a lot of questions because our visit was extensive.  We also make sure the referring physician understands completely what our  assessment was on that day in case there are additional questions or any treatment concerns. The referring physician can feel assured that their patient was taken care of and the patient understands their visit.

What is the difference between growing pains and hip pain?

Growing pains usually affects children under the age of ten. They tend to occur at night, with pain in the their legs, knees and hips, after the child runs and plays during the day. The next day, they get up and they run and do everything they want to do again without pain or limitations. They don't have any other associated symptoms such as fever or weakness, loss of appetite, etc. When children feel pain in one or both hips, in the groin area or even around the sides of the hips for days and it doesn't get better, they need to be evaluated.

How do you identify a hip problem in a newborn?

There are certain risk factors for hip dysplasia in newborns, such as a family history of hip problems, a breech child, or any abnormal exam or findings, such as foot deformity. Children with risk factors are usually recommended to have an ultrasound at 4 to 6 weeks of age to make sure that the hip is normal or doesn't have dysplasia. They should be evaluated by a pediatrician or by a pediatric orthopedic surgeon to ensure they get appropriate evaluation and treatment.

What can be done nonsurgically for children experiencing chronic pain?

We have very specialized physical therapists who provide outstanding results. The therapy protocols that we have implemented and are developing for preoperative, postoperative patients and non-operative patients are second to none. We ensure that physical therapy is a key component in patient care. Regardless of surgery, we want athletes back to sports as quickly as possible. Oftentimes that requires very specific regimens to manage their muscles and their soft tissues after surgery to get them back to their activities as quickly as possible. For patients that don't need surgery or that don't want surgery, we have specific protocols that may improve pain and avoid surgery.

Why should pediatric patients with chronic hip pain come to HSS?

We offer what's best for the hip. Our goal is to preserve the hip joint and to understand why the hip is painful. We have created a center of excellence where people from all over the world can come and know that they will get an expert evaluation and a treatment tailored for their specific case. The fact that we have specialized non-operative surgeons, arthroscopic surgeons, open surgeons, total joint surgeons here in one place - not limited by only offering treatment that one surgeon knows how to perform – is a clear advantage. We make sure our pediatric patients are appropriately managed by the team member who is most expert in managing that specific treatment or condition.

The diagnostic ability to detect hip disease is getting better and better. The radiologists here at HSS are experts at picking up subtleties and provide constant feedback. We work together on a day-to-day basis to make sure that we are diagnosing the problem correctly. Through research, education, and teamwork we also have a goal of improving our treatment outcomes and advancing the knowledge of hip preservation over time.

What is your background and why did you come to HSS?

Hip disease and managing hip disease was a big part of my pediatric orthopedic fellowship in San Diego, as they have experts in pediatric and young adult hip disease. That initiated a groundwork of fascination with the hip joint. After a few years at Denver Children's, I realized I was passionate about treating hip problems and decided to go to Boston and then Switzerland with Professor Ganz, learning more about complex hip pathology and management. From there, it just took off. It became part of my practice and I committed to understand and to take care of hips for the rest of my career.

What brought me to HSS was the ability to work with Bryan Kelly, MD and the other surgeons and physicians in the hip preservation service to make the best hip center in the world, where people could come receive world-class evaluation and care. Teaming up with the other surgeons here at HSS gave me a platform to make an impact on pediatric hip conditions, from birth to young adulthood, and on preserving hip joints and preventing hip arthritis.

What kind of hip surgery do you specialize in?

I was asked to join the faculty at HSS because of my two areas of expertise. One is called the periacetabular osteotomy, which was developed in Bern, Switzerland. That is a procedure that allows us to redirect the acetabulum or socket and place it into a better position so the hip functions better. In hip dysplasia, the problem is often that the socket is not covering the ball, or femoral head, and the periacetabular osteotomy allows us to effectively reorient the hip socket to a better position and preserve the hip.

My second area of expertise is surgical dislocation of the hip. The hip joint is very deep inside the hip, which makes it difficult to access and treat problems. Surgical hip dislocation was also developed in Switzerland and allows us to disarticulate or take the two pieces of the hip apart safely to observe and fix the abnormalities that have led to pain to increase function and mobility for the patient. Many hip procedures can be performed arthroscopically, but some patients need this open procedure because of the limitations of an arthroscopic approach.

What role does research play in hip treatment and preservation?

Research is important to make sure we have the most effective treatment for patients specific to their problem. All our patients are placed into a registry so we can get feedback and study our current results of treatment. Members of the Hip Preservation Team meet weekly to discuss surgical and non-surgical treatment.  We extensively review complex patients, their diagnosis, and develop treatment recommendations.  We have  a large volume and diversity of patients and families seen at HSS.  That volume allows us to be better at picking up subtleties and what is the most effective treatment. Over the years with continued research, education and the combined experience of the Hip Preservation Service Team, more patients will be evaluated for their hip pain and receive the most advanced and effective treatment worldwide at HSS.

Authors

Image - Photo of Ernest L. Sink, MD
Ernest L. Sink, MD
Chief, Hip Preservation Service, Hospital for Special Surgery
Associate Attending Orthopedic Surgeon, Hospital for Special Surgery
 

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