AUTHOR AND EDITOR INFORMATION

Section 1 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

INTRODUCTION

Section 2 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Background

A hip pointer is a contusion to the iliac crest, the surrounding soft tissue structures, or the greater trochanter of the femur. Typically, the injury is caused by a direct blow or fall. Hip pointer injuries occur most commonly in contact sports (eg, football, hockey), but they can also occur in noncontact sports (eg, volleyball) as a result of a fall onto the hip or side. Pain and tenderness in this region can limit an athlete's participation in sports.

Frequency

United States

No specific statistics for frequency of hip pointer injuries are available; however, hip injuries generally comprise 5-9% of high school athletic injuries.

Functional Anatomy

The anterior iliac crest region of the hip and the greater trochanter of the femur have a minimal amount of overlying fatty tissue or muscle and are more susceptible to contusion and injury than more protected regions of the body.

The iliac crest has multiple muscle origins and insertions, including the sartorius, the tensor fascia lata, the internal and external obliques, and a portion of the rectus femoris muscle.

CLINICAL

Section 3 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

History

Obtain a detailed history, including the mechanism of injury and the patient's description of his or her symptoms. A hip pointer is usually an acute injury, and the patient can typically recall a precipitating event, though some may present 24-48 hours after the initial injury.

• Hip pointer injuries are usually caused by a direct blow to the iliac crest or greater trochanter in contact sports such as football or hockey.
• A hip pointer may also be caused by a fall onto the hip in sports such as soccer or skiing.
• Typically, the patient presents with the sudden onset of hip pain in the iliac crest or greater trochanteric region after sustaining trauma.
• • The pain is localized and may be exacerbated with activities such as running, jumping, twisting, or bending.
  • The pain can limit range of motion (ROM) at the hip joint and/or rotation of the trunk if the abdominal musculature is involved.

Physical

Physical examination should include abdominal examination to exclude trauma to intra-abdominal organs. Examination should consist of visual inspection, palpation, passive and active ROM assessment, sensory testing, and gait analysis.

• Contusion or swelling may be evident upon visual inspection. The athlete usually reports increased pain with palpation of the affected iliac crest or greater trochanter. Limited ROM of the hip secondary to pain may also occur.
• Motor strength of the hip flexor and extensors should be intact. Strength of the hip abductors and external rotators may be limited by pain if the contusion includes the sartorius muscle and/or the iliotibial tract.
• Sensation should be intact to light touch, although this portion of the examination may be limited if the patient has severe pain.
• Initial gait analysis may also be limited secondary to pain, but it provides a baseline from which to evaluate recovery.

Causes

• The primary cause of hip pointers is a direct blow or fall onto the iliac crest or greater trochanter.
• Risk factors include participation in contact sports and wearing limited or no padding or protective equipment in the region.

DIFFERENTIALS

Section 4 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Other Problems to be Considered

Bursitis of the greater trochanter
Avulsion fracture of the iliac apophysis
Periostitis/myositis ossificans
Soft tissue tumors
Intra-abdominal injuries
Muscle strain injury (eg, external oblique tear, sports hernia)
Iliotibial band syndrome
Osteoid sarcoma
Pelvic or stress fracture

In children, also consider slipped capital femoral epiphysis (if groin pain exceeds hip pain), avascular necrosis of the hip, Legg-Calvé-Perthes disease, and transient synovitis.

WORKUP

Section 5 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Lab Studies

• Typically, laboratory studies are not useful in the diagnosis of hip pointers.

Imaging Studies

• Plain radiographs: Order radiographs if fracture or myositis ossificans is considered possible.
• CT scans: Consider CT scans if the patient has continued pain or if his or her pain exceeds that expected from examination findings. CT scans can help diagnose deep hematoma or internal injuries (eg, spleen).
• Bone scans: Order a bone scan to exclude a stress response or fracture if initial radiographic findings are normal and the symptoms do not resolve or improve.

Procedures

• If a significant hematoma is present, then aspiration can provide some pain relief and help prevent development of myositis ossificans or pressure and compression of local nerves (eg, lateral femoral cutaneous nerve).
• Injection of a local anesthetic (eg, lidocaine) may provide short-term pain relief.
• Compartment pressures can be measured if a thigh or gluteal compartment syndrome is considered possible.

TREATMENT

Section 6 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Acute Phase

Rehabilitation Program

Physical Therapy

Initial therapy consists of ice, anti-inflammatory and pain medication, compression, and relative rest of the affected hip until symptoms improve. Crutches can be used in the initial treatment phase if walking or bearing weight on the affected leg is painful.

As the pain decreases, ROM and active resistance exercises for the hip may be initiated. Patients may also begin strength and aerobic conditioning, as tolerated.

Medical Issues/Complications

• The formation of a hematoma, with increasing pain and possible cutaneous neurologic compromise, may be an early complication, usually arising within the first 24 hours.
• Additional complications can include development of myositis ossificans. Failure to diagnose a fracture or an intra-abdominal injury frequently leads to complications.

Consultations

• Emergent consultation with an orthopedic surgeon is necessary if neurovascular compromise is considered possible.
• Consider consultation with an orthopedic surgeon for patients who have avulsion fractures or unresolved pain lasting longer than 2 weeks.

• Consult with a surgeon for patients with intra-abdominal injuries.

Other Treatment

Aspiration of a hematoma, if present, may provide some pain relief. Injection of a local anesthetic (eg, lidocaine, bupivacaine) may provide short-term pain control.

• No evidence supports or refutes the use of corticosteroid injections in hip pointer injuries.

• Corticosteroid injections may provide relief if greater trochanteric bursitis develops.

Recovery Phase

Rehabilitation Program

Physical Therapy

Rehabilitation programs should focus on returning the athlete back to his or her sport. Rehabilitation exercises should emphasize sport-specific strength and motions. Additional padding at the injury site may help limit recurrence or reinjury.

Maintenance Phase

Rehabilitation Program

Physical Therapy

The maintenance phase of the rehabilitation program should focus upon reducing the chance of reinjury. Additional padding or protection added to the hip may limit the risk of reinjury.

MEDICATION

Section 7 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

The goals of pharmacotherapy are to reduce morbidity and to prevent complications.

Drug Category: Nonsteroidal anti-inflammatory drugs

Have analgesic, anti-inflammatory, and antipyretic activities. Mechanism of action is not known but may inhibit cyclooxygenase activity and prostaglandin synthesis. Other mechanisms may also exist, including inhibition of leukotriene synthesis, lysosomal enzyme release, lipoxygenase activity, neutrophil aggregation, and various cell-membrane functions.

Drug Name	Naproxen (Aleve, Naprelan, Naprosyn, Anaprox)
Description	For relief of mild to moderate pain. Inhibits inflammatory reactions and pain by decreasing activity of cyclooxygenase, which results in a decrease of prostaglandin synthesis.
Adult Dose	500 mg PO followed by 250 mg q6-8h; not to exceed 1.25 g/d
Pediatric Dose	<2 years: Not established >2 years: 2.5 mg/kg/dose PO; not to exceed 10 mg/kg/d
Contraindications	Documented hypersensitivity; peptic ulcer disease; recent GI bleeding or perforation; renal insufficiency
Interactions	Coadministration with aspirin increases risk of inducing serious NSAID-related adverse effects; probenecid may increase concentrations and, possibly, toxicity of NSAIDs; may decrease effect of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; may increase PT when taking anticoagulants (instruct patients to watch for signs of bleeding); may increase risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently
Pregnancy	B - Usually safe but benefits must outweigh the risks.
Precautions	Category D in third trimester of pregnancy; acute renal insufficiency, interstitial nephritis, hyperkalemia, hyponatremia, and renal papillary necrosis may occur; patients with preexisting renal disease or compromised renal perfusion risk acute renal failure; leukopenia occurs rarely, is transient, and usually returns to normal during therapy; persistent leukopenia, granulocytopenia, or thrombocytopenia warrants further evaluation and may require discontinuation of drug

Drug Name	Ketoprofen (Oruvail, Orudis, Actron)
Description	For relief of mild to moderate pain and inflammation. Initially, small doses are indicated in small and elderly patients and in those with renal or liver disease. Doses >75 mg do not increase therapeutic effects. Administer high doses with caution, and closely observe for response.
Adult Dose	25-50 mg PO q6-8h prn; not to exceed 300 mg/d
Pediatric Dose	3 months to 12 years: 0.1-1 mg/kg PO q6-8h >12 years: Administer as in adults
Contraindications	Documented hypersensitivity
Interactions	Coadministration with aspirin increases risk of inducing serious NSAID-related adverse effects; probenecid may increase concentrations and, possibly, toxicity of NSAIDs; may decrease effect of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; may increase PT when taking anticoagulants (instruct patients to watch for signs of bleeding); may increase risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently
Pregnancy	B - Usually safe but benefits must outweigh the risks.
Precautions	Category D in third trimester of pregnancy; caution in congestive heart failure, hypertension, and decreased renal and hepatic function; caution in coagulation abnormalities or during anticoagulant therapy

Drug Category: Analgesics

Pain control is essential to quality patient care. Analgesics ensure patient comfort, promote pulmonary toilet, and have sedating properties, which are beneficial for patients who experience pain.

Drug Name	Acetaminophen and codeine (Tylenol #3)
Description	Indicated for the treatment of mild to moderate pain.
Adult Dose	30-60 mg/dose PO q4-6h or 1-2 tab q4h (based on codeine content); not to exceed 4 g/d of acetaminophen
Pediatric Dose	0.5-1 mg/kg/dose PO q4-6h (based on codeine content) <12 years: 10-15 mg/kg/dose PO (based on acetaminophen content); not to exceed 2.6 g/d of acetaminophen
Contraindications	Documented hypersensitivity
Interactions	Toxicity of codeine increases with CNS depressants, tricyclic antidepressants, MAOIs, neuromuscular blockers, phenothiazines, and narcotic analgesics; rifampin can reduce analgesic effects of acetaminophen; coadministration with barbiturates, carbamazepine, hydantoins, and isoniazid may increase hepatotoxicity of acetaminophen
Pregnancy	C - Safety for use during pregnancy has not been established.
Precautions	Caution in opiate-dependent patients, because this substitution may result in acute opiate-withdrawal symptoms; caution in severe renal or hepatic dysfunction; hepatotoxicity with acetaminophen possible in persons with chronic alcoholism following various dose levels; severe or recurrent pain or high or continued fever may indicate a serious illness; acetaminophen is contained in many OTC products and combined use with these products may result in cumulative acetaminophen doses and exceed recommended maximum dose

Drug Name	Hydrocodone and acetaminophen (Vicodin, Lorcet-HD, Lortab, Norcet)
Description	Drug combination indicated for moderate to severe pain.
Adult Dose	1-2 tab or cap PO q4-6h prn
Pediatric Dose	<12 years: 10-15 mg/kg/dose PO q4-6h prn (based on acetaminophen content); not to exceed 2.6 g/d acetaminophen >12 years: 750 mg PO q4h (based on acetaminophen content); not to exceed 10 mg hydrocodone bitartrate per dose or 5 doses/d
Contraindications	Documented hypersensitivity; high-altitude cerebral edema or elevated intracranial pressure
Interactions	Coadministration with phenothiazines may decrease analgesic effects; toxicity increases with CNS depressants or tricyclic antidepressants
Pregnancy	C - Safety for use during pregnancy has not been established.
Precautions	Tablets contain metabisulfite, which may cause hypersensitivity; caution in opiate-dependent patients, because this substitution may result in acute opiate-withdrawal symptoms; caution in severe renal or hepatic dysfunction

FOLLOW-UP

Section 8 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Return to Play

Patients may return to play once pain and swelling allow return to normal or near-normal function. Padding over the area may help protect the area from reinjury.

Complications

Complications include hematoma formation, which may lead to myositis ossificans and scar tissue formation. Additionally, inflammation and continued pain may result in chronic bursitis.

Prevention

Prevention of hip pointers may be difficult, but extra padding and protection over the iliac crest in football and hockey players may decrease the frequency and severity of injury.

Prognosis

Prognosis is usually very good, and the athlete can usually return to normal participation in 1-3 weeks, depending upon the extent of the injury.

Education

Education should include an explanation of the injury and advice on treatment, rehabilitation, and prevention of future hip pointer injuries.

For excellent patient education resources, visit eMedicine's Foot, Ankle, Knee, and Hip Center and Sports Injury Center. Also, see eMedicine's patient education article Repetitive Motion Injuries.

MISCELLANEOUS

Section 9 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Medical/Legal Pitfalls

• Medicolegal pitfalls include failure to diagnose a fracture or avulsion of the iliac crest and failure to diagnose an intra-abdominal injury (eg, splenic rupture, soft tissue tumor).
• Other pitfalls include improper or limited rehabilitation, which could result in scar tissue formation, myositis ossificans, and limited ROM.

REFERENCES

Section 10 of 10

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

• Adkins SB 3rd, Figler RA. Hip pain in athletes. Am Fam Physician. Apr 1 2000;61(7):2109-18. [Medline].
• Anderson K, Strickland SM, Warren R. Hip and groin injuries in athletes. Am J Sports Med. Jul-Aug 2001;29(4):521-33. [Medline].
• DeLee JC, Farney WC. Incidence of injury in Texas high school football. Am J Sports Med. Sep-Oct 1992;20(5):575-80. [Medline].
• Gomez E, DeLee JC, Farney WC. Incidence of injury in Texas girls' high school basketball. Am J Sports Med. Sep-Oct 1996;24(5):684-7. [Medline].
• Hubbard TJ, Denegar CR. Does cryotherapy improve outcomes with soft tissue injury?. J Athl Train. 9 2004;39(3):278-279. [Medline]. [Full Text].
• Meyers WC, Ricciardi R, Busconi BD, et al. Groin pain in athletes. In: Ardent EA, ed. Orthopadics Knowledge Update: Sports Medicine 2. Rosemont, Ill: American Academy of Orthopedic Surgeons; 1999:281-289.
• Ruane JJ, Rossi TA. When groin pain is more than "Just a strain": Navigating a broad differential. Phys Sports Med. 1998;26(4).
• Winfield C. Common hip injuries. In: Sallis RE, Massimino, eds. ACSM's Essentials of Sports Medicine. St. Louis, Mo: Mosby; 1991:440-441.

Article Last Updated: Dec 6, 2005