Hip Pain

Aka: Hip Pain, Groin Pain, Groin Injury, Groin Injuries in Athletes

1. See Also
   1. Rheumatologic Conditions affecting the Hip
   2. Hip Exam
   3. Hip Anatomy
   4. Testicular Pain
2. Epidemiology: Groin Injury in Athletes
   1. Groin Injury accounts for 2-5% of sports injury
   2. Higher risk sports for Groin Injury
      1. Soccer (Incidence 5-7%)
      2. Ice hockey
      3. Fencing
      4. Handball
      5. Cross Country Skiing
      6. Hurdling
      7. High Jumping
3. Causes: Common pearls by location
   1. Groin Pain
      1. Consider Intra-articular Hip Pain
   2. Lateral Pain
      1. Trochanteric Bursitis
   3. Buttock Pain
      1. Referred pain from lumbosacral spine
      2. Sacroiliac joint
      3. Piriformis Syndrome (deep pain worse with sitting)
4. Causes: Anterior Hip Pain
   1. Spontaneous onset without trauma in elderly
      1. Consider inflammatory arthritis, infection
      2. Ask about systemic symptoms
      3. Start evaluation with CBC, ESR, RF
   2. Insidious onset in elderly
      1. Risks: age >65, ROM pain, cancer, trauma, Alcohol
      2. Start with Hip XRay
         1. Evaluate for Osteoarthritis
         2. Consider Avascular necrosis, tumor or Fracture
   3. Overuse or sports related anterior Hip Pain
      1. Clicking or Snapping Hip
         1. Tests: Thomas Test or Snapping Hip maneuver
         2. Common Diagnoses (See Snapping Hip)
            1. Iliopsoas Bursitis
            2. Labral tear
      2. Suspected Stress Fracture
         1. Obtain MRI
         2. Non-weight bearing
      3. Resisted muscle testing and local tenderness
         1. Consider hip flexor Muscle Strain
5. Causes: Lateral Hip Pain
   1. Overuse or sports related
      1. Consider Iliotibial Band Syndrome
   2. Tender over greater trochanter
      1. Greater Trochanteric Bursitis
   3. Tender at gluteus medius, hip abductor weakness/pain
      1. Gluteus medius muscle dysfunction
   4. Anterolateral thigh neuropathic pain
      1. Meralgia Paresthetica
6. Causes: Groin Pain or Hip Pain in athletes
   1. Idiopathic in 30% of cases
   2. Adductor Strain or Adductor Tendinitis (Groin Pull)
   3. Pubic Instability
   4. Osteitis Pubis
   5. Myositis Ossificans
   6. Sports Hernia
   7. Groin Disruption
   8. Iliopsoas Strain or Iliopsoas Bursitis
   9. Snapping Hip syndrome
   10. Femoral Neck Stress Fracture
   11. Pubic Ramus Stress Fracture
   12. Avulsion Fracture (Adolescent Athletes)
       1. Anterior Superior Iliac Spine Avulsion Fracture
          1. Rapid sartorius contraction in jumping sport
          2. Responds to non-operative conservative therapy
       2. Anterior Inferior Iliac Spine Avulsion Fracture
          1. Strong rectus femoris contraction in kicking sport
          2. Responds to non-operative conservative therapy
       3. Ischial Tuberosity Avulsion Fracture
          1. Rapid hamstring contraction in sprinting, hurdling
          2. Fragments >1-2 cm may require ORIF
   13. Nerve entrapment
       1. Genitofemoral nerve entrapment
       2. Lateral Femoral Cutaneous Nerve Entrapment
       3. Ilioinguinal Nerve Entrapment
       4. Obturator Nerve Entrapment
7. Causes: Hip Joint disorders with groin or Hip Pain by age
   1. Pediatric Causes (under age 10 years)
      1. See Pediatric Limp
      2. Legg-Calve-Perthes Disease
      3. Septic Joint
      4. Toxic Synovitis
   2. Adolescent causes
      1. Slipped Capital Femoral Epiphysis
      2. Hip Avulsion Fracture
   3. Adult causes (See causes below)
      1. Osteoarthritis of femoral head
      2. Avascular necrosis of the femoral head
      3. Acetabular labral tear
8. Causes: Musculoskeletal causes of groin or Hip Pain
   1. Bone Causes
      1. Hip Fracture
      2. Femoral head avascular necrosis
      3. Cancer (primary site or metastases)
   2. Joint Causes
      1. Hip Osteoarthritis
      2. Septic Arthritis
      3. Gouty Arthritis
      4. Osteoid Osteoma
      5. Osteitis Pubis
   3. Muscle or tendon Causes
      1. Iliotibial Band Syndrome
      2. Trochanteric Bursitis
      3. Iliopsoas Bursitis
      4. Piriformis Syndrome
      5. Myositis Ossificans
   4. Neurologic Causes
      1. Lumbar Disc Disease
      2. Lumbar Spinal Stenosis
      3. Coccygodynia
      4. Meralgia Paresthetica (see nerve entrapment above)
9. Causes: Non-musculoskeletal causes of groin or Hip Pain
   1. General
      1. Inguinal Hernia
      2. Inguinal Lymphadenopathy or lymphadenitis
      3. Lumbar Disc Disease with L1-2 radiculopathy
      4. Nephrolithiasis
      5. Abdominal Aortic Aneurysm
      6. Appendicitis
      7. Diverticulitis
      8. Inflammatory Bowel Disease
      9. Malignancy
   2. Women
      1. Ovarian Cyst
      2. Urinary Tract Infection
      3. Pelvic Inflammatory Disease
   3. Men
      1. Epididymitis
      2. Hydrocele
      3. Varicocele
      4. Prostatitis
      5. Testicular Cancer
10. References
    1. Fields (1997) Lecture: AAFP Sports Medicine, Dallas
    2. Ruane (1998) Physician SportsMed 26(4):78-103
    3. Brunner (2003) Am Fam Physician 67(3):537-42
    4. Fricker (1997) Br J Sports Med 31:97-101
    5. Lynch (1999) Sports Med 28:137-44
    6. Morelli (2001) Am Fam Physician 64(8):1405-14