eMedicine Specialties > Sports Medicine > Hip

Hip Pointer

John M Martinez, MD, Medical Director, Primary Care Sports Medicine, Coastal Sports and Wellness Medical Center
Kenneth Honsik, MD, Consulting Staff, Department of Primary Care Sports Medicine, Kaiser Permanente

Updated: Mar 6, 2009

Introduction

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.^1,2,3 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.

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.

Related eMedicine topics:
Femoral Neck Stress and Insufficiency Fractures
Groin Injury
Hip Fracture
Hip Tendonitis and Bursitis

Frequency

United States

No specific statistics for the frequency of hip pointer injuries are available; however, hip injuries generally comprise 5-9% of high school athletic injuries.^1,2,3,4

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

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, although 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 in a person with a suspected hip pointer 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.

Differential Diagnoses

Other Problems to Be Considered

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

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

Workup

Laboratory 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.
• Computed tomography (CT) scans: Consider obtaining CT scans if the patient has continued pain or if his or her pain exceeds that expected from examination findings. CT scans can help clinicians to 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 from a hip pointer.
• Compartment pressures can be measured if a thigh or gluteal compartment syndrome is considered possible.

Treatment

Acute Phase

Rehabilitation Program

Physical Therapy

Initial therapy of a hip pointer injury consists of ice, anti-inflammatory and pain medication, compression, and relative rest of the affected hip until symptoms improve.⁵ 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 of a hip point, 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 in a patient with a hip pointer.
• 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 (padding that is 0.25-0.5-inch thick may alleviate pain and allow the athlete to return to play sooner).

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

The goals of pharmacotherapy in patients with hip point injuries are to reduce morbidity and to prevent complications.

Nonsteroidal Anti-inflammatory Drugs (NSAIDs)

NSAIDs have analgesic, anti-inflammatory, and antipyretic activities. The mechanism of action of these agents is not known, but NSAIDs 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.

Ibuprofen (Ibuprin, Motrin)

DOC for patients with mild to moderate pain. Inhibits inflammatory reactions and pain by decreasing prostaglandin synthesis.

Dosing

Adult

200-400 mg PO q4-6h while symptoms persist; not to exceed 3.2 g/d

Pediatric

<6 months: Not established

6 months to 12 years: 4-10 mg/kg/dose PO tid/qid

>12 years: Administer as in adults.

Interactions

Coadministration with aspirin increases the risk of inducing serious NSAID-related adverse effects; probenecid may increase the concentrations and, possibly, the toxicity of NSAIDs; may decrease the effect of hydralazine, captopril, and beta-blockers; may decrease the diuretic effects of furosemide and thiazides; may increase PT duration when taking anticoagulants (instruct patients to watch for signs of bleeding); may increase the risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently

Contraindications

Documented hypersensitivity; peptic ulcer disease, recent GI bleeding or perforation, renal insufficiency, or high risk of bleeding

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

Caution in patients with congestive heart failure, hypertension, and decreased renal and hepatic function; caution in the presence of coagulation abnormalities or during anticoagulant therapy

Naproxen (Aleve, Naprelan, Naprosyn, Anaprox)

For the relief of mild to moderate pain. Inhibits inflammatory reactions and pain by decreasing the activity of cyclooxygenase, which results in a decrease of prostaglandin synthesis.

Dosing

Adult

500 mg PO followed by 250 mg q6-8h; not to exceed 1.25 g/d

Pediatric

<2 years: Not established

>2 years: 2.5 mg/kg/dose PO; not to exceed 10 mg/kg/d

Interactions

Coadministration with aspirin increases the risk of inducing serious NSAID-related adverse effects; probenecid may increase the concentrations and, possibly, the toxicity of NSAIDs; may decrease the effect of hydralazine, captopril, and beta-blockers; may decrease the diuretic effects of furosemide and thiazides; may increase PT duration when taking anticoagulants (instruct patients to watch for signs of bleeding); may increase the risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently

Contraindications

Documented hypersensitivity; peptic ulcer disease; recent GI bleeding or perforation; renal insufficiency

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

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 the drug.

Ketoprofen (Oruvail, Orudis, Actron)

For the 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.

Dosing

Adult

25-50 mg PO q6-8h prn; not to exceed 300 mg/d

Pediatric

<3 months: Not established

3 months to 12 years: 0.1-1 mg/kg PO q6-8h

>12 years: Administer as in adults.

Interactions

Coadministration with aspirin increases the risk of inducing serious NSAID-related adverse effects; probenecid may increase the concentrations and, possibly, toxicity of NSAIDs; may decrease the effect of hydralazine, captopril, and beta-blockers; may decrease the diuretic effects of furosemide and thiazides; may increase PT duration when taking anticoagulants (instruct patients to watch for signs of bleeding); may increase the risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

Caution in patients with congestive heart failure, hypertension, and decreased renal and hepatic function; caution in the presence of coagulation abnormalities or during anticoagulant therapy

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.

Acetaminophen (Feverall, Tempra, Aspirin-Free Anacin, Tylenol)

DOC for pain in patients with documented hypersensitivity to aspirin or NSAIDs, those with upper GI disease, and those taking oral anticoagulants.

Dosing

Adult

325-650 mg PO q4-6h or 1000 mg tid/qid; not to exceed 4 g/d

Pediatric

<12 years: 10-15 mg/kg/dose PO q4-6h prn; not to exceed 2.6 g/d

>12 years: 325-650 mg PO q4h; not to exceed 5 doses/d

Interactions

Rifampin can reduce analgesic effects; coadministration with barbiturates, carbamazepine, hydantoins, or isoniazid may increase hepatotoxicity.

Contraindications

Documented hypersensitivity; known G6PD deficiency

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Hepatotoxicity possible in persons with chronic alcoholism after 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 exceeding the recommended maximum dose

Acetaminophen and codeine (Tylenol #3)

Indicated for the treatment of mild to moderate pain.

Dosing

Adult

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

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

>12 years: Administer as in adults.

Interactions

Toxicity of codeine increases with CNS depressants, tricyclic antidepressants, MAOIs, neuromuscular blockers, phenothiazines, and narcotic analgesics; rifampin can reduce the analgesic effects of acetaminophen; coadministration with barbiturates, carbamazepine, hydantoins, and isoniazid may increase the hepatotoxicity of acetaminophen

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Caution in opiate-dependent patients, because this substitution may result in acute opiate-withdrawal symptoms; caution in the presence of severe renal or hepatic dysfunction; hepatotoxicity with acetaminophen is 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 the recommended maximum dose

Hydrocodone and acetaminophen (Vicodin, Lorcet-HD, Lortab, Norcet)

Drug combination indicated for moderate to severe pain.

Dosing

Adult

1-2 tab or cap PO q4-6h prn

Pediatric

<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

Interactions

Coadministration with phenothiazines may decrease analgesic effects; toxicity increases with CNS depressants or tricyclic antidepressants

Contraindications

Documented hypersensitivity; high-altitude cerebral edema or elevated intracranial pressure

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

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 the presence of severe renal or hepatic dysfunction

Follow-up

Return to Play

Patients with hip pointer injuries may return to play once pain and swelling allow return to normal or near-normal function. Padding over the affected 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

The prognosis is usually very good, and the athlete with a hip pointer injury 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.

Miscellaneous

Medicolegal 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

1. Winfield C. Common hip injuries. In: Sallis RE, Massimino, eds. ACSM's Essentials of Sports Medicine. St. Louis, Mo: Mosby; 1991:440-1.

2. Ruane JJ, Rossi TA. When groin pain is more than "just a strain": navigating a broad differential. Phys Sportsmed. 1998;26(4):78-103. [Full Text].

3. Meyers WC, Ricciardi R, Busconi BD, et al. Groin pain in athletes. In: Ardent EA, ed. Orthopaedics Knowledge Update: Sports Medicine 2. Rosemont, Ill: American Academy of Orthopaedic Surgeons; 1999:281-9.

4. Borowski LA, Yard EE, Fields SK, Comstock RD. The epidemiology of US high school basketball injuries, 2005-2007. Am J Sports Med. Dec 2008;36(12):2328-35. [Medline].

5. Hubbard TJ, Denegar CR. Does cryotherapy improve outcomes with soft tissue injury?. J Athl Train. Sep 2004;39(3):278-9. [Medline]. [Full Text].

6. Adkins SB 3rd, Figler RA. Hip pain in athletes. Am Fam Physician. Apr 1 2000;61(7):2109-18. [Medline]. [Full Text].

7. Anderson K, Strickland SM, Warren R. Hip and groin injuries in athletes. Am J Sports Med. Jul-Aug 2001;29(4):521-33. [Medline].

8. DeLee JC, Farney WC. Incidence of injury in Texas high school football. Am J Sports Med. Sep-Oct 1992;20(5):575-80. [Medline].

9. Feeley BT, Powell JW, Muller MS, et al. Hip injuries and labral tears in the National Football League. Am J Sports Med. Nov 2008;36(11):2187-95. [Medline].

10. 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].

11. Schmitt KU, Nusser M, Boesiger P. [Hip injuries in professional and amateur soccer goalkeepers] [German]. Sportverletz Sportschaden. Sep 2008;22(3):159-63. [Medline].

Keywords

hip pointer, hip pain, hip injury, hip bruise, hip trauma, iliac crest contusion, groin injury, contact sports, football, hockey, soccer, skiing, volleyball, high school athletic injuries, anterior iliac crest region, greater trochanteric region, femur, sartorius, tensor fascia lata, obliques, rectus femoris muscle, range of motion, ROM, ROM exercises

Contributor Information and Disclosures

Author

John M Martinez, MD, Medical Director, Primary Care Sports Medicine, Coastal Sports and Wellness Medical Center
John M Martinez, MD is a member of the following medical societies: American Academy of Family Physicians, American College of Sports Medicine, and American Medical Society for Sports Medicine
Disclosure: Nothing to disclose.

Coauthor(s)

Kenneth Honsik, MD, Consulting Staff, Department of Primary Care Sports Medicine, Kaiser Permanente
Disclosure: Nothing to disclose.

Medical Editor

Leslie Milne, MD, Assistant Clinical Instructor, Department of Emergency Medicine, Harvard University School of Medicine
Leslie Milne, MD is a member of the following medical societies: American College of Sports Medicine
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Russell D White, MD, Professor of Medicine, Department of Community and Family Medicine, University of Missouri-Kansas City School of Medicine, Truman Medical Center Lakewood
Disclosure: Nothing to disclose.

CME Editor

Jon B Whitehurst, MD, Clinical Instructor of Surgery, University of Illinois College of Medicine; Partner and Executive Board Member, Rockford Orthopedic Associates; Orthopedic Chairman, Rockford Memorial Hospital
Jon B Whitehurst, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Society for Sports Medicine, and Arthroscopy Association of North America
Disclosure: Nothing to disclose.

Chief Editor

Sherwin SW Ho, MD, Associate Professor, Department of Surgery, Section of Orthopedic Surgery and Rehabilitation Medicine, University of Chicago
Sherwin SW Ho, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Society for Sports Medicine, and Arthroscopy Association of North America
Disclosure: Nothing to disclose.

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