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We are headed to the orthopedic surgeon's office this afternoon with our 18-year-old son. He's been having hip pain bad enough to make him limp. He's always been very active, involved in sports, and no couch potato. But he's looking more and more like Grandpa everyday. What could possibly be causing this kind of problem?

Orthopedic surgeons see all kinds of injuries in the athletic population. One of the less common but very challenging areas of injury to evaluate is the hip. Hip pain can be coming from the hip itself, of course. But it could also originate in the spine or knee. The medical diagnosis is based on an understanding of what happened, how it happened, clinical presentation (signs and symptoms), and the results of specific tests. It's really a differential diagnosis meaning the physician sorts through all the possible problems that could be present. Using the information collected so far, the doctor rules out those that don't fit the description. Then further tests are done until the final diagnosis is made. Some of the most common choices in the differential diagnosis include: hip pointer, greater trochanter bursitis, iliotibial band syndrome, snapping hip syndrome, tendon tears, and meralgia paresthetica. Let's take a closer look at each of these conditions. Athletes who collide with others or who take the force of a helmeted head into the lateral hip can end up with a hip pointer. This injury or contusion is visible as blood under the skin leaves a large bruise. It is treated with a leave it alone approach. Ice, rest, and compression help the body complete its natural course of healing. Bursitis is best treated by finding out what is causing the friction in the first place and dealing with that problem. It could be tight, inflexible muscles, tendons, or fascia. Stretching, strengthening, and manual therapy under the supervision of a physical therapist may be advised. Or it could be a postural or alignment problem such as a leg length difference, unsupported flat feet, or even broken down running shoes. Sometimes a tendon (e.g., the iliotibial band along the outside of the leg) snaps over the bone underneath. This condition is called iliotibial (IT) band syndrome or snapping hip syndrome. The IT band can be so tight that movement causes a pop that can be seen and heard. The athlete is taught how to avoid those movements and how to stretch the involved soft tissues. In chronic cases that don't respond to physical therapy, surgery to release or lengthen the tight tissue may be needed. That brings us to lateral hip pain caused by tendon tears. The tendons involved most often are from the buttock muscles (gluteus medius and gluteus minimus). Because of the way these muscles attach to the greater trochanter (part of the femur or thigh bone), tendinitis of the gluteal muscles can look just like bursitis or iliotibial band syndrome. And finally, meralgia paresthetica must be considered whenever there is numbness along the front and side of the thigh. Meralgia paresthetica is caused by entrapment of the lateral femoral cutaneous nerve. This nerve can get pinched or compressed by tight clothing, after surgery to remove bone from the pelvic crest, a large belly associated with obesity, or in association with diabetes. There are some more serious types of problems that can affect the hip. Bone fractures, infections, and tumors head the list and are part of the differential diagnosis. Fortunately, these are rare and not easily overlooked when present. Once the physician diagnoses the problem, then an injury-specific treatment plan can be determined and carried out. With the exception of the more serious problems, most of these hip conditions are considered self-limiting meaning they will eventually go away in time. Treatment is first with conservative (nonoperative) approaches. The most common plan of care is for oral anti-inflammatory drugs, rest, and physical therapy. The therapist will work on correcting postural issues or malalignment, stretching and/or strengthening, and modification of aggravating activities or movements. Of course, fractures, infections, and tumors are dealt with in a different way. Treatment is also injury-specific but may include surgery, immobilization, antibiotics, and so on. You are on the right track to see an orthopedic surgeon and get a diagnosis. The rest will fall into place from there.

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