Adolescent Hip Dysplasia and Other Causes of Hip Pain

Adolescent Hip Dysplasia and Other Causes of Hip Pain

by | Aug 6, 2021 | Hip Disorders

Content included below was presented at the 2021 Pediatric Orthopedic Education Symposium by pediatric orthopedic surgeon William Z. Morris, M.D.

You can watch the full lecture and download this summary.

In hip dysplasia, the acetabulum (or hip socket) is shallow and doesn’t adequately cover the femoral head. Developmental dysplasia of the hip (DDH) occurs in approximately 1% of newborn children, and it is associated with four risk factors:

  • Female
  • Firstborn
  • Feet first (breech)
  • Family history

Hip dysplasia is relatively more commonly diagnosed in skeletally mature adolescents, affecting around 3% to 5% of the asymptomatic population. Cross-sectional studies have shown that female sex and a family history of dysplasia remain risk factors in adolescents.

There has been growing attention to the treatment of hip dysplasia as there is an association between hip dysplasia and the development of early osteoarthritis. In 1939, Gunnar Wiberg first described hip dysplasia and objectively measured it using what is now called the lateral center edge angle, to describe how well the socket (acetabulum) covers the ball (femoral head). On an AP (anterior posterior) pelvis X-ray, the angle is created by a vertical line through the center of the femoral head and a line from the center of the femoral head to the lateral border of the acetabular fossa. A larger angle reflects greater hip coverage, and a smaller angle reflects less coverage, commonly seen in a dysplastic hip.

Wiberg followed patients with dysplasia for up to 30 years and found that all of the patients with hip dysplasia eventually developed osteoarthritis. The smaller their center edge angle was (reflecting greater hip dysplasia), the faster they developed osteoarthritis.

Development of Osteoarthritis in Dysplastic Hips
The development of early osteoarthritis is suspected to occur due to a couple mechanical reasons. The most important factor is that:

Pressure = Force / Unit Area
In the hip, pressure on the joint surfaces depends on the total surface area of the femoral head in contact with the socket. A well-covered femoral head distributes weight-bearing forces across a larger surface area, reducing the pressure on each unit of cartilage. In contrast, a dysplastic acetabulum offers less surface area which increases the pressure on the cartilage contributing to earlier hip degeneration. In addition to the smaller weightbearing surface, the acetabulum is also more obliquely oriented. Therefore, compressive forces are less and shearing forces are greatly increased. This increased shear force may also contribute to cartilage degeneration.

Symptoms of Adolescent Hip Dysplasia
There are many different causes of hip pain in an adolescent patient and combining clues from the history and physical exam is essential to determine the underlying problem. The location of a patient’s pain can help determine the underlying etiology. Intra-articular pain of the hip usually presents as anterior groin pain, often due to a cartilage injury, a tear in the labrum (the ring of cartilage at the periphery of the socket) or inflammation of one of the hip flexors called the Iliopsoas tendon. Lateral hip pain that locates over the greater trochanter (the bony prominence on the lateral aspect of the thigh) probably reflects trochanteric bursitis or inflammation of the bursa overlying that region. Pain or soreness after activity above the greater trochanter where hip abductors like the gluteus medius are located may signal hip abductor fatigue, which is common with hip dysplasia. Pain over the iliac crest where the abdominal musculature attaches could reflect some inflammation of that apophysis, of the anterior superior iliac spine (ASIS) where the sartorius attaches, or of the anterior inferior iliac spine (AIIS) where the rectus tendon attaches.

Additional Factors to Consider when Discussing Hip Joint Symptoms

  • Pain
    • Duration
    • Aggravating factors
      • Squatting, stairs, low chairs
    • Alleviating factors
  • Mechanical symptoms
    • Locking, popping, catching, snapping
  • Neurological symptoms (which may suggest spinal pathology)
    • Radiating pain, paresthesias

Physical Exam

  • Pain Assessment
    • Palpation can reproduce symptoms and help to localize the pain.
  • Strength Testing
  • Range of Motion
    • Limited internal rotation (IR) can indicate hip impingement or a more acute concern, slipped capital femoral epiphysis (SCFE)

Special Tests

Straight Leg Raise Test
A straight leg raise is a passive test that helps to distinguish between hip and spine pathology and is performed by flexing the hip with an extended knee in a supine position. If this maneuver reproduces the patient’s pain that radiates distally, the problem may be related to nerve compression in the spine rather than a problem in the hip.

Trendelenburg Test
The hip abductors (e.g. gluteus medius) are typically weaker when patients come in with pain, so it can be targeted in physical therapy. The Trendelenburg sign is a quick physical examination used to assess for hip abductor weakness.
The patient stands on one leg (stance leg) and bends the other knee about 90°. Observe for evidence of hip abductor (i.e. gluteus medius) weakness which includes:

  • Pelvis drop contralateral to the stance leg.
  • Trunk lean/shift toward the stance leg.

Apprehension Test
Another test to further evaluate for dysplasia is the apprehension test:

  1. The patient lays in a lateral position
  2. Abduct the patient’s leg 30° away from midline
  3. Flex the patient’s knee 90°
  4. Gradually extend the hip

Patients who have an anterior uncovering of the socket from dysplasia will feel pain or a sensation of apprehension, which suggests that there may be some instability or dysplasia.

Femoroacetabular Impingement Test
Hip impingement should also be tested:

  1. Flex the hip to 90°
  2. Abduct the hip, bringing it towards midline
  3. Internally rotate the hip

This test attempts to reproduce hip impingement where the femoral head or neck collides against the socket. If this causes pain, there may be a cartilage injury such as a labral tear. An MRI is recommended to evaluate intra-articular soft tissues.

Slipped Capital Femoral Epiphysis – A condition not to be missed
Slipped capital femoral epiphysis (SCFE) is an adolescent disorder in which the growth plate is damaged and the femoral head epiphysis moves, or slips, with respect to the rest of the femur. Diagnosis in a timely manner is essential to prevent further injury to the hip.

Consider SCFE if these signs are present:

  • limp
  • walk with their foot externally rotated
  • have limited range of motion, especially with internal rotation

Obligate external rotation is nearly pathognomonic for slipped capital femoral epiphysis, so if the patient can’t flex their hip straight up without turning their leg into an externally rotated position to accommodate further flexion, an anterior-posterior and frog pelvis film is recommended to ensure slipped capital femoral epiphysis hasn’t been missed. Immediate non-weight bearing with a wheelchair and urgent referral to pediatric orthopedics or an emergency room is recommended for this condition.

Radiographic Evaluation
A radiographic evaluation is important for a definitive dysplasia diagnosis. The AP pelvis film is a workhorse tool for the evaluation of hip coverage. It is taken standing to allow assessment of the patient’s hip coverage in their functional position using the lateral center edge angle (LCEA). A hip with an LCEA less than 25° is considered dysplastic.
Imaging also allows an assessment of the inclination of the socket. By drawing a line between the medial and lateral edges of the roof of the socket and measuring the angle between that line and a horizontal line, physicians can determine the acetabular inclination. The more inclined the socket is, the more dysplastic.

Treatments
Treatment for dysplasia begins with nonoperative options, which include:

  • Physical therapy
  • Activity modifications
  • Non-steroidal anti-inflammatory drugs (NSAID)

When nonoperative treatments don’t work, and patients continue to have radiographic dysplasia and pain, including abductor fatigue pain above the greater trochanter or anterior intra-articular groin pain, they are treated surgically with a periacetabular osteotomy (PAO). This specialized procedure is done in patients who are approaching skeletal maturity or are already skeletally mature. Several cuts are made around the socket of the acetabulum to mobilize the socket. The socket is then reoriented to better cover the femoral head.

Outcomes
For patients with symptomatic hip dysplasia, the PAO has been shown to be successful in improving patients’ function, getting them back to their activities/sports, and preventing early hip replacement. In patients with hip pain and clinical or radiographic evidence of acetabular dysplasia, please consider a referral to Scottish Rite for Children for discussion of the condition and shared decision-making in the plan for management.

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Building Muscle in Young Athletes: Making Nutrition Count

Building Muscle in Young Athletes: Making Nutrition Count

by | Jul 30, 2021 | Sports Medicine

Young athletes in strength-based and power sports may desire to increase muscle mass for better performance or to help them as they start a new position on their team. “While there are many nutrition supplements available, it’s important to understand that these may not be safe for children and teens,” says Taylor Morrison, MS, RD, CSSD, LD. “A young athlete at the appropriate developmental stage should be able to achieve his or her goals with with food and beverages alone.”

 

Before setting any goals, it is also important to understand that young pre-pubertal athletes will not gain muscle mass like an adult because they do not yet have the level of hormones needed to support these gains. While he/she can still build muscle, the level of hormones required to support larger gains in muscle, like those often desired by young male athletes, are not present until after puberty.

When ready, here are important facts to know about how the young athlete’s nutrition can help build muscle for sport.

What builds muscle?

With the appropriate hormones present, these are necessary components for building muscle:

  1. Adequate calories: Getting enough calories or increasing daily calorie intake is essential to building muscle.
  2. Protein: Protein is the key nutrient for building muscle and should be included in all meals and some snacks.
  3. Carbohydrates: Carbohydrates are the main source of energy for working muscles and the brain. They should be present in all meals and snacks to provide energy and allow protein to build desired muscle mass.
  4. Resistance training: Exercises like lifting, pushing and pulling an outside force create necessary changes within the muscle that result in longer, stronger and bigger muscles.

Easy ways to increase calories

  • Increase the number of meals or snacks eaten per day. Most young athletes need a minimum of 3 meals and 2 snacks per day.
  • Add spreads to sandwiches and wraps such as avocado, hummus, pesto and mayonnaise.
  • Choose heartier or thicker slices of bread.
  • Include oatmeal or fresh smoothies with breakfast or snacks and add items such as milk, yogurt, peanut butter, almond butter, honey, fruit, flax or chia seeds.
  • Choose nutrient-dense cereals such as: granola, Raisin Bran®, shredded wheats and Grape-Nuts®.

Ideas for increasing protein at meals and snacks

  • Add an egg or Greek yogurt to breakfast.
  • Choose granola bars with whole grains, nuts or seeds.
  • Include a string cheese with a snack.
  • Add a glass of milk or chocolate milk to meals or snacks.
  • Include beans, nuts and seeds in salads.

Carbs to include with meals & snacks

  • Whole-grain bagels or English muffins.
  • Fresh or dried fruits.
  • Starchy vegetables like white potatoes, sweet potatoes, peas, corn, winter squash.
  • Rice, pasta, quinoa, couscous, etc.
  • Milk or yogurt (also great sources of protein and calcium).
  • Whole-grain crackers, cereals, granola bars.

Keys to Success:

  • Be realistic: Young, pre-pubertal athletes will not gain muscle mass like an adult.
  • Work on body composition changes during the off-season. Trying to make big changes during the season could lead to decreased performance or injury.
  • Plan for gradual muscle gain. Include a well-balanced diet and a developmentally appropriate strengthening program.
  • Remember, the overall goal is optimal performance. Measure improvements in performance (jumping height, running distance, etc.), not a number on the scale.
  • Focus on real food: Rely on healthy, high-calorie and nutrient-rich foods instead of supplements and protein powders.
  • Get enough sleep and manage stress. This is often forgotten for achieving body composition or weight goals, but it is very important.

If unsure where to start, it’s always a good idea to work with a certified sports dietitian who can help you create a plan, recommend products and support you as you work towards your goals.

Not sure if your athlete is ready to build muscle? Read “Building Muscle in Young Athletes: Getting Started”

Visit our sports nutrition page to learn more about nutrition and fueling the young athlete.

What Does a Day of Muscle Building Meals & Snacks Look Like?
Specific foods and portion sizes will vary based on an athlete’s size, age, sport and training demands.

Here is a great example. 

Paralympian Tanner Wright Is Tokyo-Bound

Paralympian Tanner Wright Is Tokyo-Bound

by | Jul 23, 2021 | Spotlight

Years of hard work and determination have Tanner’s lifelong dream in his sight – the 2020 Tokyo Olympics. Born to stand out, Tanner has with a condition that caused his left arm to never fully develop. He first came to Scottish Rite for Children as a baby and has received world-class care from our team of hand experts.

Never letting anything hold him back, he is now a member of the U.S. Paralympic Men’s Track and Field Team and will represent Team USA as he competes in Tokyo.

Through the years, he has left his mark at Scottish Rite. Originally a camper at Hands Down Camp, he then chose to give back and became a top-notch hand camp counselor. “Tanner is a great role model at camp and encourages the kids to exceed their own expectations of themselves, strive to get out of their comfort zone and accomplish things they never thought possible,” says Occupational Hand Therapist Amy Lake, O.T.R., C.H.T.

 

“We are so proud of Tanner we are excited to cheer him on as he chases his track and field dreams!”

Recovery Strategies for Young Gymnasts

Recovery Strategies for Young Gymnasts

by | Jul 22, 2021 | Sports Medicine

Gymnasts have training needs that differ from many other athletes.

The demands on gymnasts typically involve many hours of high-intensity skills training. Not addressing recovery with the same commitment can leave them less prepared for another workout and at an increased risk for injury. Gymnasts and other athletes have to balance training sufficiently with appropriate rest and recovery techniques. Investing valuable time and money into recovery strategies requires thoughtful consideration.

Recovery principles include reducing edema (swelling), improving blood flow, restoring damaged muscle cells, reducing soreness and returning the athlete to a state for optimal training. These are achieved using a combination of these modalities:

  • Compression
  • Massage
  • Cold

Common strategies include:

  • Massage sessions or tools – Generalized massage can be beneficial to circulate the blood and prevent stiffness post-workout. Localized massage, foam rollers or manual therapy can address specific areas of pain or release tense muscles to reduce postural malalignment.
  • Contrast hot/cold pools – Water offers a dual approach to recovery. The immersion provides compression and alternating between warm and cold environments adds the benefits offered by cold therapy. At Scottish Rite, we have HydroWorx® hot and cold plunge pools for our patients.

  • Epsom salt baths – Easy to implement at home, adding Epsom salt (a naturally occurring mineral compound) to a bath offers a combination of the benefits of compression from immersion as well as possible benefits from the absorption of magnesium, which may help to reduce muscle soreness.
  • Combination cold and compression – After an injury or training, RICE (Rest Ice Compress Elevate) is a traditional approach to reduce swelling. Our team uses a GameReady® device which provides both cold and compression.  The device circulates very cold water around the joint or limb while simultaneously mimicking the muscle pumping actions that circulate blood and prevent swelling.
  • Dynamic compression device – Improving on a therapeutic concept of sequential compression to improve blood flow in the legs, companies like Normatec offer a sleeve that applies a wave of pressure to mimic muscle action.
  • Active recovery – Lower intensity exercise after higher intensity exercise may help reduce stiffness, optimize gains made during training and use muscle activation to create the compressive forces to improve blood flow. Examples include:
    • Dynamic (active) or static stretching
    • Swimming
    • Yoga
    • Pilates
    • Cycling

  • Nutrition – Properly timed and pre- and post-workout fueling help optimize the athlete’s recovery:
    • Anti-inflammatory foods that have shown promise in treating muscle soreness: watermelon, cherry juice, pineapple and ginger.
    • Recovery snacks need these three key components:
      • Carbohydrates
      • Protein
      • Fluid

Professional athletes, world-class gymnasts and exercise enthusiasts have appreciated the value of recovery. Young athletes should learn recovery principles and learn to “listen” to how their bodies respond to exercise and modalities to optimize recovery and prepare for the next workout.

Learn more about pediatric sports medicine. 

Building Muscle in Young Athletes: Getting Started

Building Muscle in Young Athletes: Getting Started

by | Jul 21, 2021 | Sports Medicine

Young athletes may express an interest in building muscle or “lean body mass” for a variety of reasons. Body composition includes water, bone, fat, muscle and other tissues such as organs and vessels. The elements that are most affected by diet and exercise are fat and muscle. Pediatric sports medicine physician Jacob C. Jones, M.D., RMSK, says, “there are many benefits to increasing lean body mass, and for athletes, the growth of muscles often translates to improved strength and performance.”

Why might a child or teen want to increase lean body mass?

Motivation can come from inside the individual (intrinsic) or from an outside (extrinsic) demand or expectation. Intrinsic motivation is often called “drive” and can be a healthy approach to making positive changes in one’s life. These may include a desire to compete at a higher level, to be stronger, or to improve other areas of performance. Extrinsic motivation often comes from a parent, coach or peer that causes an athlete to set a bar or goal according to their expectations. These may include positive or negative pressures to meet a goal based on their own performance or in comparison to a standard or a teammate.

How can a parent know when a motivation or behavior is concerning?

When the motivation does not align with positive health goals or is based on an irrational comparison or expectation, there is a concern for the athlete’s safety. When an athlete has set a lean body mass target that is unhealthy, a parent may notice behaviors such as restrictive eating or over-exercising. Learning healthy strategies and setting appropriate goals can help to avoid these approaches. Consulting the pediatrician or primary care doctor can help reset goals and assess the need for additional help.

How can a young athlete increase lean body mass?

The strength of a muscle is defined by the amount of force it can resist. Muscle strength is measured when pushing, lifting or pulling an object or the athlete’s own body. More resistance must be applied progressively to increase the size (hypertrophy), length and strength of the muscle with exercise. With consideration of safety and proper fueling and recovery, resistance training leads to an increase in body mass.

What is a good first step in building lean body mass?

For some, resistance training has a narrow definition and requires lifting weights. Yes, lifting weights with proper technique can improve strength. However, equipment is not necessary to improve strength for most children. Activities that use gravity and body weight are an excellent starting point. These include doing ‘crab walks,’ ‘bear crawls,’ and ‘kangaroo hops.’ These activities properly focus on coordination, developing core strength and learning proper form before adding weight.

How can a parent help guide safe choices with resistance training?

  • Discourage comparison with like (or unlike) individuals. Keep the athlete focused on his or her goals and healthy strategies.
  • Provide access to a trained coach. Look for someone with a background and experience in nutrition and resistance training for children.
  • Promote training changes throughout the year. Strength and conditioning programs should vary based on sport season demand (pre- and post-season),
  • Facilitate rest in- and out-of-season. Year-round training, overuse and overtraining have been shown to increase the risk of injury. Regular rest is important.
  • Learn how nutrition plays a role in building muscle mass. Fueling for training and recovery can make exercise more effective.

What are safe measures of success for resistance training?

Using the scale or the amount of weight on a bar as the only measures of success can lead to poor and unsafe choices. Goals like these must be balanced with others that are more likely to directly translate to success on the field. These might include performance measures like endurance, jump height or other sport-specific skills.

Tips for setting appropriate goals –

  • ​Choose goals that are challenging but still achievable.
  • Consider the demands of the sport and position as well as the current weight and body type of the athlete.
  • Ask for help from the:
    • team coach to suggest goals based on the athlete’s performance, sport and season.
    • strength and conditioning coach to set progressive resistance and repetition goals based on the athlete and his or her capabilities.
    • primary care doctor or pediatrician to establish appropriate body composition goals and to discuss nutritional needs based on family and patient history.

How can a parent support a young athlete to safely increase lean body mass?

  • Encourage open conversations about goals and progress.
  • Ask what is driving the desire for change.
  • Confirm appropriate instruction and supervision is in place.
  • Discuss plans and progress with a sports dietitian, a strength and conditioning coach and a primary care doctor.
  • Monitor for signs of overtraining or worrisome behaviors that increase the risk of injury.