II. Epidemiology
-
Hip Osteoarthritis affects up to 10% of U.S. adults by age 45 years and a 25% lifetime risk
- Up to 5% of U.S. adults will have a hip replacement within their lifetime
III. Risk Factors: Groin Injury in Athletes
- Groin Injury accounts for 2-5% of Sports Injury
- Related to chronic, repetitive stress injury
- Higher risk sports for Groin Injury
- Soccer
- Hip and groin injuries represent roughly half of all injuries in non-elite adult soccer athletes
- CAM Deformity of the femoral neck or femoral head is commonly found in adult soccer players
- Ice hockey
- American Football
- Australian Football
- Fencing
- Handball
- Cross Country Skiing
- Hurdling
- High Jumping
- Soccer
- Other risk factors
- Increased competition level
- Decreased relative hip adduction strength (compared with abductors)
- Adductor Squeeze Test with decreased strength
- Hip internal rotation reduced
- Inadequare off-season training or sport specific conditioning
- Older age
- Low Vitamin D Levels
- Prior Groin Injury
IV. Precautions: Risk Factors for serious pathology
- Age over 65 years
- Pain on Hip Range of Motion (esp. painful hip flexion or hip rotation)
- Intrinsic hip pathology
- Septic Arthritis of the hip
- Inability to bear weight
- Hip Stress Fracture
- Hip Septic Arthritis
- Avascular Necrosis of the Hip
- Femoral lesion (e.g. malignancy)
- Unstable Slipped Capital Femoral Epiphysis (8-15 years old)
-
Abdominal Pain
- Abominal aortic aneurysm (may present with back pain if retroperitoneal bleeding)
- Appendicitis
- Renal Calculi
- Pelvic tumors
- Ectopic Pregnancy
- Pelvic Inflammatory Disease
- Abdominal Hernia or Inguinal Hernia
- History of malignancy (or Night Sweats, weight loss)
- Hip Trauma
- Alcohol Abuse
- Night pain, Constant pain, Weight loss
- Malignancy
-
Fever
- Septic Arthritis of the hip
- Malignancy
- Perirectal Abscess
- Appendicitis
- Chronic Corticosteroids, Chronic inflammatory conditions or Coagulopathy
- Avascular necrosis of the hip
- Cardiovascular Risk Factors (e.g. Diabetes Mellitus, Tobacco Abuse, Coronary Artery Disease, Carotid Stenosis)
V. Causes
VI. History
- Sporting activity
- Frequency, duration and intensity
- Injury mechanism
- Stopping, cutting or kicking
- Pain characteristics
- Location, timing, region, radiation, palliative and provocative
- Associated symptoms
- Swelling
- Ecchymosis
- Locking or catching (labral tear or other intraarticular cause)
- Popping or clicking (labral tear or other intraarticular cause)
- Instability
- Altered Sensation, Paresthesias or weakness (nerve entrapment)
- Past History
- Developmental Dysplasia of the Hip (Congenital Hip Dysplasia)
- Slipped Capital Femoral Epiphysis (SCFE)
- Sports participation (see high risk sports above)
- Family History of hip disorders
- Referred pain sources
VII. Exam
- See Hip Exam
- See Hip Anatomy
- Observe for groin Ecchymosis (avulsion, Muscle tear, abdominal wall Hematoma)
- Observe for bulge in the abdominal and inguinal region (Hernia)
- Also palpate the Superficial Inguinal Ring with valsalva or cough
- Examine in frog-leg position
- Palpate the lower Abdomen and pupic symphysis
- Palpate adductor insertions (pubic tubercle, medial inferior pubic ramus)
- Palpate abdominal Muscles
- Palpate anterior superior iliac spine (ASIS, sartorius and tensor fasciae latae insertion)
- Palpate anterior inferior iliac spine (AIIS, rectus femoris insertion)
- Palpate anterior hip
- Perform active range of motion and passive range of motion
- Specific Tests
- Hip Adduction Test
- Also includes Single Hip Adductor Test, Bilateral Hip Adductor Test
- FABER Test
- Flexion ABduction External Rotation
- Also known as Patrick's Test or Figure of Four Test
- FADIR Test
- Flexion ADduction Internal Rotation
- Hip Scour Test (Hip Quadrant Test)
- Hip Flexed to 90 degrees and examiner applies axial load
- Internally rotate and externally rotate hip
- Hip Adduction Test
- Other examination
- Findings most suggestive of hip intra-articular cause
- Pain on external and internal hip rotation
- Pain on hip axial loading (force applied at foot or knee towards hip)
VIII. Differential Diagnosis
- See Hip Pain Causes
- See Rheumatologic Conditions affecting the Hip
- Exclude serious hip causes
- Exclude serious external Hip Pain Causes
- Peripheral Arterial Disease (Aortoilliac Occlusive Disease, Abdominal Aortic Aneurysm)
- Peritonitis (or other surgical Abdomen)
- Malignancy involving hip or Pelvis (bony metastases, Multiple Myeloma, Chondrosarcoma)
IX. Imaging
-
Hip XRay
- Obtain Anteroposterior View (AP View) and Frog-Leg Lateral View
- Indications
- First-line study in hip Pain Evaluation
- Evaluate for bony lesions (e.g. malignancy)
- Femoral Neck Stress Fracture
- Hip Avulsion Fracture
- Slipped Capital Femoral Epiphysis
- Avascular Necrosis of the Femoral Head
- Osteoarthritis
- Hip Joint lesions (e.g. pincer lesion, cam lesion)
- Osteitis Pubis
- Low yield for Osteoarthritis (36% Test Sensitivity)
-
Hip XRay may miss non-displaced Femoral Fractures
- Consider MRI or CT for negative XRay with higher index of suspicion
- Parker (1992) Arch Emerg Med 9(1): 23-7 [PubMed]
- Hakkarinen (2012) J Emerg Med 43(20: 303-7 +PMID:22459594 [PubMed]
- Hip MRI (or Hip CT if MRI unavailable) Indications
- Hip Pain with non-diagnostic XRay
- Muscle tears and Tendon Strains
- Avulsion Fractures
- Hip Avascular Necrosis
- Hip Labral Tear
- Hip cartilage defects
- Hip MRI with arthrography
- Indicated for suspected Hip Labral Tear (Test Sensitivity 90% contrasted with 36% for standard MRI)
-
Hip Ultrasound
- Long axis view detects hip effusion and can direct hip needle aspiration if septic hip is suspected
- Also indicated in Functional Evaluation of hip
- Test Sensitivity approaches 80-85% for identifying hip effusion in children
- Bone Scan (Scintigraphy) Indications
X. Diagnostics
-
Electromyography (EMG) or Nerve Conduction Study
- Consider for undifferentiated pain with suspected neuropathic origin
- Diagnostic Herniography
- Contrast injected within the peritoneum
- Patient performs Valsalva Maneuver
- Imaging demonstrates abnormal contour of contrast
XI. Management
- Treat specific conditions
- See Hip Pain Causes
XII. References
- Fields (1997) Lecture: AAFP Sports Medicine, Dallas
- Ruane (1998) Physician SportsMed 26(4):78-103
- Schleihauf (2019) Crit Dec Emerg Med 33(5): 19-28
- Shahideh (2013) Crit Dec Emerg Med 27(9):10-18
- Braly (2006) Clin Sports Med 199-210 [PubMed]
- Brunner (2003) Am Fam Physician 67(3):537-42 [PubMed]
- Chamberlain (2021) Am Fam Physician 103(2): 81-9 [PubMed]
- Fricker (1997) Br J Sports Med 31:97-101 [PubMed]
- Lynch (1999) Sports Med 28:137-44 [PubMed]
- Morelli (2001) Am Fam Physician 64(8):1405-14 [PubMed]
- Wilson (2014) Am Fam Physician 90(1): 27-34 [PubMed]
Images: Related links to external sites (from Bing)
Related Studies
Concepts | Sign or Symptom (T184) |
ICD10 | M25.559 , M25.55 |
SnomedCT | 49218002, 268065004, 156598006, 202473003, 156592007, 202486007 |
LNC | MTHU020861 |
English | Coxalgia, Arthralgia (hip), Hip arthralgia, hip joint pain, hip joint pain (symptom), hip pain, Pain in hip, Painful hips, Pain in unspecified hip, painful hip, hip arthralgia, hip pains, Pain;musculoskeletal;hip, Pain;hip, hip joints pain, hips pain, pain in hip, hip joint pains, arthralgia - hip, arthralgia - pelvis / hip / femur, arthralgia of hip (diagnosis), arthralgia of hip, Pain in joint - coxalgia, Hip painful, Hip pain, Arthralgia of hip, Hip joint pain, Hip pain (finding), coxalgia, hip; joint pain, hip; pain, joint, Hip Pain, musculoskeletal hip pain |
Dutch | pijnlijke heupen, pijn in heup, coxalgia, heup; gewrichtspijn, heup; pijn, gewricht |
French | Coxalgie, Hanches douloureuses, Douleur dans la hanche |
German | schmerzhafte Hueften, Schmerz in der Huefte, Koxalgie |
Italian | Coxalgia, Anche doloranti, Dolore all'anca |
Portuguese | Dor na anca, Ancas dolorosas, Coxalgia |
Spanish | Coxalgia, Caderas dolorosas, Dolor en cadera, coxalgia (hallazgo), coxalgia, dolor de cadera |
Japanese | 股関節痛, コカンセツツウ |
Czech | Bolest v kyčli, Bolestivé kyčle, Koxalgie |
Hungarian | Fájdalmas csípők, Fájdalom a csípőízületben, Coxalgia |
Ontology: Inguinal pain (C0239783)
Concepts | Sign or Symptom (T184) |
SnomedCT | 207217001, 102570003, 271856002 |
English | PAIN GROIN, [D]Groin pain, Groin Pain, [D]Groin pain (context-dependent category), Inguinodynia, groin pain (symptom), groin pain, inguinal pain, Pain groin, groin pains, Pain;groin, inguinodynia, [D]Groin pain (situation), Groin pain (finding), Inguinal region painful, Groin pain, Inguinal pain, Inguinal pain (finding), groin; pain, pain; groin |
Italian | Dolore inguinale |
Dutch | pijn in de lies, lies; pijn, pijn; lies, liespijn |
French | Douleur à l'aine, DOULEUR INGUINALE, Douleur inguinale |
German | Schmerz in der Leiste, Leistenschmerzen |
Spanish | Dolor de ingle, [D]dolor en la ingle (categoría dependiente del contexto), [D]dolor en la ingle, [D]dolor inguinal, [D]dolor en la ingle (situación), dolor en la ingle, dolor inguinal (hallazgo), dolor inguinal, inguinodinia (hallazgo), inguinodinia, Dolor inguinal |
Japanese | 鼡径部痛, ソケイブツウ |
Portuguese | DOR NA VIRILHA, Dor inguinal |
Czech | Bolest třísla |
Hungarian | Lágyék fájdalom, Lágyéktáji fájdalom |
Ontology: Injury of groin (C0272438)
Concepts | Injury or Poisoning (T037) |
ICD10 | S30-S39 |
SnomedCT | 11805005 |
English | injuries to the groin, groin injuries, groin injury, injury of lower extremity groin, Injury of groin (diagnosis), Injury of groin, Groin injury, Injury of groin (disorder), groin; injury, injury; groin, injury; iliac region |
Dutch | letsel; lies, letsel; regio iliaca, lies; letsel |
Spanish | injuria de la ingle, injuria inguinal, lesión traumática de la ingle (trastorno), lesión traumática de la ingle |
Ontology: Hip Injuries (C0281865)
Definition (MSH) | General or unspecified injuries involving the hip. |
Definition (CSP) | damage inflicted on the hip as the direct or indirect result of an external force, with or without disruption of structural continuity. |
Concepts | Injury or Poisoning (T037) |
MSH | D025981 |
SnomedCT | 125600009 |
French | Lésion de la hanche, Blessures de la hanche, Traumatismes de la hanche, Lésions traumatiques de la hanche |
German | Hueftverletzung, Hüftverletzungen |
Italian | Traumatismo dell'anca, Lesioni dell'anca |
Portuguese | Lesão traumática da anca, Lesões no Quadril, Lesões do Quadril |
Spanish | Herida en la cadera, injuria de la región de la cadera, lesión traumática de la región de la cadera (trastorno), lesión traumática de la región de la cadera, Lesiones de la Cadera |
Swedish | Höftskador |
English | INJ HIP, HIP INJ, injury of hip, injury of hip (diagnosis), hip injury, Hip Injuries [Disease/Finding], hip injuries, Hip Injuries, Injuries, Hip, Hip injury, Injury of hip region (disorder), Injury of hip region, hip; injury, injury; hip |
Japanese | コカンセツソンショウ, 股関節損傷 |
Czech | kyčel - poranění, Poranění kyčle |
Finnish | Lonkkavammat |
Russian | BEDRA POVREZHDENIIA, БЕДРА ПОВРЕЖДЕНИЯ |
Croatian | Not Translated[Hip Injuries] |
Polish | Urazy biodra |
Hungarian | Csípősérülés |
Norwegian | Hofteskader, Skader i hofte |
Dutch | heup; letsel, letsel; heup, Letsel, heup, heupletsel |