Hip Clinical History

Hip pain is a common and disabling condition that affects patients of all ages. The differential diagnosis of hip pain is broad, presenting a diagnostic challenge. Patients often express that their hip pain is localized to one of three anatomic regions: the anterior hip and groin, the posterior hip and buttock, or the lateral hip. Anterior hip and groin pain is commonly associated with intra-articular pathology, such as osteoarthritis and hip labral tears. Posterior hip pain is associated with piriformis syndrome, sacroiliac joint dysfunction, lumbar radiculopathy, and less commonly ischiofemoral impingement and vascular claudication. Lateral hip pain occurs with greater trochanteric pain syndrome.

Clinical examination tests, although helpful, are not highly sensitive or specific for most diagnoses; however, a rational approach to the hip examination can be used. Radiography should be performed if acute fracture, dislocations, or stress fractures are suspected. Initial plain radiography of the hip should include an anteroposterior view of the pelvis and frog-leg lateral view of the symptomatic hip. Magnetic resonance imaging should be performed if the history and plain radiograph results are not diagnostic. Magnetic resonance imaging is valuable for the detection of occult traumatic fractures, stress fractures, and osteonecrosis of the femoral head. Magnetic resonance arthrography is the diagnostic test of choice for labral tears.

Hip pain is a common presentation in primary care and can affect patients of all ages. In one study, 14.3% of adults 60 years and older reported significant hip pain on most days over the previous six weeks.1  Hip pain often presents a diagnostic and therapeutic challenge. The differential diagnosis of hip pain (Table A) is broad, including both intra-articular and extra-articular pathology, and varies by age. A history and physical examination are essential to accurately diagnose the cause of hip pain.

Differential Diagnosis of Hip Pain

DIAGNOSIS PAIN CHARACTERISTICS HISTORY/RISK FACTORS EXAMINATION FINDINGS ADDITIONAL TESTING

Anterior thigh pain

Meralgia paresthetica

Paresthesia, hypesthesia

Obesity, pregnancy, tight pants or belt, conditions with increased intra-abdominal pressure

Anterior thigh hypesthesia, dysesthesia

None

Anterior groin pain

Athletic pubalgia (sports hernia)

Dull, diffuse pain radiating to inner thigh; pain with direct pressure, sneezing, sit-ups, kicking, Valsalva maneuver

Soccer, rugby, football, hockey players

No hernia, tenderness of the inguinal canal or pubic tubercle, adductor origin, pain with resisted sit-up or hip flexion

Radiography: No bony involvement

MRI: Can show tear or detachment of the rectus abdominis or adductor longus

Anterolateral hip and groin pain (C sign)

Femoral neck fracture/stress fracture

Deep, referred pain; pain with weight bearing

Females (especially with female athlete triad), endurance athletes, low aerobic fitness, steroid use, smokers

Painful ROM, pain on palpation of greater trochanter

Radiography: Cortical disruption

MRI: Early bony edema

Femoroacetabular impingement

Deep, referred pain; pain with standing after prolonged sitting

Pain with getting in and out of a car

FADIR and FABER tests are sensitive

Radiography: Cam or pincer deformity, acetabular retroversion, coxa profunda

Hip labral tear

Dull or sharp, referred pain; pain with weight bearing

Mechanical symptoms, such as catching or painful clicking; history of hip dislocation

Trendelenburg or antalgic gait, loss of internal rotation, positive FADIR and FABER tests

MRI: Can show a labral tear

Magnetic resonance arthrography: offers added sensitivity and specificity

Iliopsoas bursitis (internal snapping hip)

Deep, referred pain; intermittent catching, snapping, or popping

Ballet dancers, runners

Snap with FABER to extension, adduction, and internal rotation; reproduction of snapping with extension of hip from flexed position

Radiography: No bony involvement

MRI: Bursitis and edema of the iliotibial band

Ultrasonography: Tendinopathy, bursitis, fluid around tendon

Dynamic ultrasonography: Snapping of iliopsoas or iliotibial band over greater trochanter

Legg-Calvé-Perthes disease

Deep, referred pain; pain with weight bearing

2 to 12 years of age, male predominance

Antalgic gait, limited ROM or stiffness

Radiography: Early small femoral epiphysis, sclerosis and flattening of the femoral head

Loose bodies and chondral lesions

Deep, referred pain; painful clicking

Mechanical symptoms, history of hip dislocation or low-energy trauma, history of Legg-Calvé-Perthes disease

Limited ROM, catching and grinding with provocative maneuvers, positive FADIR and FABER tests

Radiography: Can show ossified or osteochondral loose bodies

MRI: Can detect chondral and fibrous loose bodies

Osteoarthritis of the hip

Deep, aching pain and stiffness; pain with weight bearing

Older than 50 years, pain with activity that is relieved with rest

Internal rotation < 15 degrees, flexion < 115 degrees

Radiography: Presence of osteophytes at the acetabular joint margin, asymmetrical joint-space narrowing, subchondral sclerosis and cyst formation

Osteonecrosis of the hip

Deep, referred pain; pain with weight bearing

Adults: Lupus, sickle cell disease, human immunodeficiency virus infection, corticosteroid use, smoking, and alcohol use; insidious onset, but can be acute with history of trauma

Pain on ambulation, positive log roll test, gradual limitation of ROM

Radiography: Femoral head lucency and subchondral sclerosis, subchondral collapse (i.e., crescent sign), flattening of the femoral head

MRI: Bony edema, subchondral collapse

Slipped capital femoral epiphysis

Deep, referred pain; pain with weight bearing

11 to 14 years of age, overweight (80th to 100th percentile)

Antalgic gait with foot externally rotated on occasion, positive log roll and straight leg raise against resistance tests, pain with hip internal rotation relieved with external rotation

Radiography: Widened epiphysis early, slippage of femur under epiphysis later

Septic arthritis

Refusal to bear weight, pain with leg movement

Children: 3 to 8 years of age, fever, ill appearanceAdults: Older than 80 years, diabetes mellitus, rheumatoid arthritis, recent joint surgery, hip or knee prostheses

Guarding against any ROM; pain with passive ROM

Hip aspiration guided by fluoroscopy, computed tomography, or ultrasonography; Gram stain and culture of joint aspirate

MRI: Useful for differentiating septic arthritis from transient synovitis

Transient synovitis

Refusal to bear weight

Children: 3 to 8 years of age, sometimes fever and ill appearance

Pain with extremes of ROM

Lateral pain

External snapping hip*

Pain with direct pressure, radiation down lateral thigh, snapping or popping

All age groups, audible snap with ambulation

Positive Ober test, snap with Ober test, pain over greater trochanter

Radiography: No bony involvement

MRI: Bursitis and edema of the iliotibial band

Ultrasonography: Tendinopathy, bursitis, fluid around tendon

Greater trochanteric bursitis*

Pain with direct pressure, radiation down lateral thigh

Runners, middle-aged women

Pain over greater trochanter

Dynamic ultrasonography: Snapping of iliopsoas or iliotibial band over greater trochanter

Greater trochanteric pain syndrome

Pain with direct pressure, radiation down lateral thigh

Associated with knee osteoarthritis, increased body mass index, low back pain; female predominance

Proximal iliotibial band tenderness, Trendelenburg gait is sensitive and specific

Posterolateral pain

Gluteal muscle tear or avulsion*

Pain with direct pressure, radiation down lateral thigh and buttock

Middle-aged women

Weak hip abduction, pain with resisted external rotation, Trendelenburg gait is sensitive and specific

MRI: Gluteal muscle edema or tears

Iliac crest apophysis avulsion

Tenderness to direct palpation

History of direct trauma, skeletal immaturity (younger than 25 years)

Iliac crest tenderness and/or ecchymosis

Radiography: Apophysis widening, soft tissue swelling around iliac crest

Posterior pain

Hamstring muscle strain or avulsion

Buttock pain, pain with direct pressure

Eccentric muscle contraction while hip flexed and leg extendedSkeletal immaturity, eccentric muscle contraction (cutting, kicking, jumping)

Ischial tuberosity tenderness, ecchymosis, weakness to leg flexion, palpable gap in hamstring

Radiography: Avulsion or strain of hamstring attachment to ischium

Ischial apophysis avulsion

Buttock pain, pain with direct pressure

MRI: Hamstring edema and retraction

Ischiofemoral impingement

Buttock or back pain with posterior thigh radiation, sciatica symptoms

Groin and/or buttock pain that may radiate distally

None established

MRI: Soft tissue edema around quadratus femoris muscle

Piriformis syndrome

Buttock pain with posterior thigh radiation, sciatica symptoms

History of direct trauma to buttock or pain with sitting, weakness and numbness are rare compared with lumbar radicular symptoms

Positive log roll test, tenderness over the sciatic notch

MRI: Lumbar spine has no disk herniation, piriformis muscle atrophy or hypertrophy, edema surrounding the sciatic nerve

Sacroiliac joint dysfunction

Pain radiates to lumbar back, buttock, and groin

Female predominance, common in pregnancy, history of minor trauma

FABER test elicits posterior pain localized to the sacroiliac joint, sacroiliac joint line tenderness

Radiography: Possibly no findings, narrowing and sclerotic changes of the sacroiliac joint space

FABER = flexion, abduction, external rotation; FADIR = flexion, adduction, internal rotation; MRI = magnetic resonance imaging; ROM = range of motion.

*—Conditions associated with greater trochanteric pain syndrome.

Anatomy

The hip joint is a ball-and-socket synovial joint designed to allow multiaxial motion while transferring loads between the upper and lower body. The acetabular rim is lined by fibrocartilage (labrum), which adds depth and stability to the femoroacetabular joint. The articular surfaces are covered by hyaline cartilage that dissipates shear and compressive forces during load bearing and hip motion. The hip’s major innervating nerves originate in the lumbosacral region, which can make it difficult to distinguish between primary hip pain and radicular lumbar pain.

The hip joint’s wide range of motion is second only to that of the glenohumeral joint and is enabled by the large number of muscle groups that surround the hip. The flexor muscles include the iliopsoas, rectus femoris, pectineus, and sartorius muscles. The gluteus maximus and hamstring muscle groups allow for hip extension. Smaller muscles, such as gluteus medius and minimus, piriformis, obturator externus and internus, and quadratus femoris muscles, insert around the greater trochanter, allowing for abduction, adduction, and internal and external rotation.

In persons who are skeletally immature, there are several growth centers of the pelvis and femur where injuries can occur. Potential sites of apophyseal injury in the hip region include the ischium, anterior superior iliac spine, anterior inferior iliac spine, iliac crest, lesser trochanter, and greater trochanter. The apophysis of the superior iliac spine matures last and is susceptible to injury up to 25 years of age.2

Evaluation of Hip Pain

HISTORY

Age alone can narrow the differential diagnosis of hip pain. In prepubescent and adolescent patients, congenital malformations of the femoroacetabular joint, avulsion fractures, and apophyseal or epiphyseal injuries should be considered. In those who are skeletally mature, hip pain is often a result of musculotendinous strain, ligamentous sprain, contusion, or bursitis. In older adults, degenerative osteoarthritis and fractures should be considered first.

Patients with hip pain should be asked about antecedent trauma or inciting activity, factors that increase or decrease the pain, mechanism of injury, and time of onset. Questions related to hip function, such as the ease of getting in and out of a car, putting on shoes, running, walking, and going up and down stairs, can be helpful.3 Location of the pain is informative because hip pain often localizes to one of three basic anatomic regions: the anterior hip and groin, posterior hip and buttock, and lateral hip (eFigure A).

Figure A.

Localization of hip pain. (A) Posterior view. (B) Anterior view.

Taken from Am Fam Physician. 2014 Jan 1;89(1):27-34., https://www.aafp.org/afp/2014/0101/p27.html