Hip Pointer

United States data

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, 5]

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.

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.

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.

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.

Imaging studies used in the workup of hip pointer injuries include the following:

• Plain radiographs: Order radiographs if fracture or myositis ossificans is considered possible.[6]

• 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.

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.

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.[7] 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.

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.[8] 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). Athletes with a hip pointer injury typically recover in 1 to 3 weeks.[9]

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.

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

Class Summary

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.

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.

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.

Class Summary

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.

Acetaminophen and codeine (Tylenol #3)

Indicated for the treatment of mild to moderate pain.

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

Drug combination indicated for moderate to severe pain.

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

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.

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