Hip pain in sporty teens can be challenging. Active teens are at risk of hip pain due to many causes. The most common cause is hip apophysitis, a swelling of the growth plate (also known as a traction apophysis) at the tendons’ attachment to the pelvic bones. So who gets hip apophysitis, and what do we do about it?

What is traction apophysitis or growth plate injury? 

An apophysis is a growth plate that attaches the tendon to the bone. This apophysis differs from the larger growth plates in the long bones responsible for increased height.

A growth plate contains cartilage cells that are softer and more susceptible to injury than hard mature bone. If the muscle and tendon attached to the apophysis are tight or overused, the cartilage cells swell, causing apophysitis.

Generally, apophysitis affects different parts of the body at different ages. For example, apophysitis of the heel, also called Sever’s disease occurs in 10-year-olds; apophysitis of the knee, known as Osgood Schlatter’s disease, occurs in 12-14-year-olds, and apophysitis of the hip happens in 15-16-year-olds.

Common sites of hip apophysitis 

hip apophysitis

There are many apophyses in the hip and groin. The most commonly affected are:

  • Anterior inferior iliac spine (AIIS apophysitis) where the large quadriceps muscle attaches to the front of the hip
  • Iliac crest (Iliac apophysitis) where the abdominal muscles attach to the pelvis
  • Ischial tuberosity (ischial apophysitis) where the hamstring muscle connects to the sitting bone

Diagnosis of hip apophysitis 

teenagers playign football

In general, hip apophysitis occurs in active teens. Examples of sports where we see this condition include running, football, rugby, hockey, tennis, and dance.

Usually, teens report pain in the hip or groin during and after activity. In more severe cases, pain occurs at rest and also at night. Rest usually settles the pain, only to flare up again with a return to sport.

Often, there has been a sudden jump in training intensity or sessions. Also, a change in training drills or a new coach might be an important triggering factor.

Examination by a doctor is essential. Usually, we find tenderness at the apophysis and pain with muscle contraction attaching to the apophysis. Also, checking the hip joint and lumbar spine is vital to ensure pain is not coming from a different area.

In some cases, sudden muscle contraction can lead to the apophysis being pulled off the bone rather than swelling. This is also called an avulsion fracture. Generally, avulsion fractures present with sudden pain and an inability to return to activity. Usually, the teen is limping and unable to continue the sport. Often, this type of injury is misdiagnosed as a muscle strain.

Hip traction apophysitis imaging 

Often, we suggest a plain X-ray to show the changes of traction apophysitis and rule out an avulsion fracture or another cause. Generally, an X-ray reveals a fluffiness to the apophysis.

In cases where the diagnosis is unclear, and the X-ray is normal, then ultrasound or MRI is helpful. Also, MRI can rule out more serious causes.

Other causes of hip pain in active adolescents 

Slipped upper femoral epiphysis (SUFE) 

perthese disease on X-ray

SUFE os slipped upper femoral epiphysis is also associated with an injury to the growth plate. However, the growth plate is at the femoral neck rather than the pelvis. Generally, SUFE occurs in overweight young teens and sporty teens. Usually, teens present with severe pain in the hip. Often teens find it difficult to put weight on their legs and have a limp. Early diagnosis is essential as a SUFE can stop the blood supply to the head of the femur. Treatment is surgery, significantly if the slip has progressed.

Perthes disease 

Perthes disease is a condition disrupting the blood supply to the femoral head. Generally, it occurs in teens between the ages of 10 and 12 and is associated with pain in the hip and limping. Like SUFE, diagnosis is essential to prevent the death of the bone leading to early arthritis.

Other less common causes of hip pain in sporty teens include:

Hip apophysitis treatment

Overall, the most crucial part of successful treatment is to rest from the offending activity. Rest from sports, including school sports, is needed in mild cases. Sometimes, these talented teens play multiple sports; they may need to pick only one sport for a few months. In more severe cases, we suggest complete rest from other activities such as swimming, cycling, and even excessive walking. Sometimes, crutches for a short period (1-4 weeks) may be needed. Again, good communication with parents, coaches, and school is essential.

Other simple treatments include ibuprofen and regular ice for 10 minutes every 4-6 hours. Then, as the acute pain settles, you can get back to daily activities such as walking, cycling, and swimming.

Generally, we recommend stretching and strengthening the hip and pelvis, focusing on the muscles attached to the apophysis. Once flexibility and strength return to normal, sport-specific training can be started. For example, you can often start with jogging and then progress to sprinting, change of direction, and training.

When can I return to sport after hip apophysitis? 

It isn’t easy to know when you should return to sport. However, a return to sport should be driven by what you can do rather than a specific time frame. Everyone heals at different rates. If you return too soon, you have a high chance of the pain returning. To reduce the risk of a return to pain, we suggest you only return to sport once you have satisfied the following:

  • full range of motion of the hip
  • return of full strength
  • you can jog without pain
  • acceleration/deceleration is pain-free
  • change of direction and figure 8 sprints are pain-free
  • hopping and jumping are ok

Avulsion fracture hip in teenagers: how to treat 

avulsion fracture on x-ray

Avulsion fractures of the hip in teenagers occur when the apophysis separates from the bone. The apophysis is torn off the bone rather than tearing the tendon or muscle (which occurs in adults).

Usually, teens describe sudden sharp pain with an associated crack sound. Ususal triggering activities include sprinting or kicking. Often, they cannot continue with their sport.

X-rays will show a fragment of bone pulled from the pelvis.

How long does a hip avulsion fracture take to heal?

Generally, treatment is the same as apophysitis, except it often takes longer to return to sport – usually at least three months. Surgery is only recommended if the bone fragment is more than 3 cm away from the pelvic bone.

Final word from Sportdoctorlondon on hip traction apophysitis  

Think about hip apophysitis for an active teen with hip pain. But don’t forget other causes of hip pain in teenagers, including Perthes disease, slipped epiphysis, and labral tears.

Related condition: 

Dr. Masci is a specialist sport doctor in London. 

He specialises in muscle, tendon and joint injuries.