Painful Hips In Children

oPatientPlus articles are written by UK doctors and are based on research evidence, UK and European Guidelines. They are designed for health professionals to use, so you may find the language more technical than the condition leaflets.

Hip pain in children is always potentially serious and needs urgent assessment. The main immediate concern is to distinguish infection of the hip joint or pelvic bones from irritable hip. If examination shows a restriction of hip movement or there are X-ray abnormalities, many will have a serious disorder requiring long-term management.

Save time & improve your PDP on Patient.co.uk

  • Notes Add notes to any clinical page and create a reflective diary
  • Track Automatically track and log every page you have viewed
  • Print Print and export a summary to use in your appraisal
Click to find out more »
  • At any age:
  • Age 0-3 years:
    • Septic arthritis
    • Osteomyelitis
    • Developmental hip dysplasia
    • Infantile cox vera
    • Fracture or soft tissue injury (including non-accidental injury)
  • 3-10 years:
    • Transient synovitis or irritable hip
    • Septic arthritis
    • Osteomyelitis
    • Perthes’ disease
    • Fracture or soft tissue injury (stress fracture)
  • 10-15 years:
  • A hip problem is the most common cause of a limp in a child. Pain in the hip is often referred to the knee.
  • Apart from an isolated hip problem (see 'Individual conditions', below), other possible causes of a limp include haematological (eg, sickle cell anaemia), infection (eg, pyomyositis or discitis), metabolic disease (eg, rickets), acute lymphoblastic leukaemia, neuromuscular disease (eg,  cerebral palsy, muscular dystrophy), primary anatomical abnormalities (eg, limb length inequality) and juvenile idiopathic arthritis.
  • Intra-abdominal pathology and testicular torsion may occasionally present as a limp.
  • Meticulous examination of the hips is crucial. Restricted internal rotation is the most sensitive marker of hip pathology in children, followed by a lack of abduction. 
  • Loss of hip abduction can be difficult to assess because children often tilt their pelvis to give a false impression of hip abduction.
  • Because of the serious nature of many of the underlying causes and the importance of early diagnosis and treatment, urgent referral for specialist assessment is often required.

An initial diagnosis can usually be based on clinical presentation. Imaging is then used to confirm the diagnosis.[3] 

  • Plain X-ray of the hips (always do both for comparison - and include AP and lateral "frog leg" view).
  • Ultrasound - the best method of showing hip joint effusion, and may guide the needle if aspiration is appropriate.
  • MRI and bone scintigraphy may be useful but CT has a limited role because of the risks associated with ionising radiation.[4] 
  • Transient synovitis:
    • Summary:
      • This usually has acute onset.[3]
      • It is a self-limiting condition thought to be due to viral infection or an autoimmune process.
      • It is often preceded by a viral upper respiratory tract infection.
      • It is twice as common in boys.
    • Presentation:
      • Pain is usually not severe but may prevent weight-bearing on the affected leg.
      • Usually there is no pain at rest and passive movements are only painful at the extreme range of movement.
      • The child is usually well and the ESR is either normal or slightly raised.
    • Management:
      • Includes rest and analgesia, with mobilisation once the pain has settled.
      • Symptoms usually resolve within two weeks but may recur.
      • There is no evidence of any long-term complications.
  • Developmental dysplasia of the hip: see the separate article on Developmental Dysplasia of the Hip.
  • Septic arthritis: see the separate article on Septic Arthritis.
  • Perthes' disease: see the separate article on Perthes' Disease.
  • Slipped upper femoral epiphysis: see the separate article on Slipped Upper Femoral Epiphysis.

Further reading & references

  1. Perry DC, Bruce C; Evaluating the child who presents with an acute limp. BMJ. 2010 Aug 20;341:c4250. doi: 10.1136/bmj.c4250.
  2. Fabry G; Clinical practice: the hip from birth to adolescence. Eur J Pediatr. 2010 Feb;169(2):143-8. doi: 10.1007/s00431-009-1025-x.
  3. Gough-Palmer A, McHugh K; Investigating hip pain in a well child. BMJ. 2007 Jun 9;334(7605):1216-7.
  4. Jain N, Sah M, Chakraverty J, et al; Radiological approach to a child with hip pain. Clin Radiol. 2013 Aug 9. pii: S0009-9260(13)00346-2. doi: 10.1016/j.crad.2013.06.016.

Disclaimer: This article is for information only and should not be used for the diagnosis or treatment of medical conditions. EMIS has used all reasonable care in compiling the information but make no warranty as to its accuracy. Consult a doctor or other health care professional for diagnosis and treatment of medical conditions. For details see our conditions.

Original Author:
Dr Colin Tidy
Current Version:
Peer Reviewer:
Dr John Cox
Last Checked:
18/10/2013
Document ID:
2564 (v23)
© EMIS