II. Epidemiology

  1. Hip Osteoarthritis affects up to 10% of U.S. adults by age 45 years and a 25% lifetime risk
    1. Up to 5% of U.S. adults will have a hip replacement within their lifetime

III. Risk Factors: Groin Injury in Athletes

  1. Groin Injury accounts for 2-5% of Sports Injury
  2. Related to chronic, repetitive stress injury
  3. Higher risk sports for Groin Injury
    1. Soccer
      1. Hip and groin injuries represent roughly half of all injuries in non-elite adult soccer athletes
      2. CAM Deformity of the femoral neck or femoral head is commonly found in adult soccer players
    2. Ice hockey
    3. American Football
    4. Australian Football
    5. Fencing
    6. Handball
    7. Cross Country Skiing
    8. Hurdling
    9. High Jumping
  4. Other risk factors
    1. Increased competition level
    2. Decreased relative hip adduction strength (compared with abductors)
      1. Adductor Squeeze Test with decreased strength
      2. Hip internal rotation reduced
    3. Inadequare off-season training or sport specific conditioning
    4. Older age
    5. Low Vitamin D Levels
    6. Prior Groin Injury

IV. Precautions: Risk Factors for serious pathology

  1. Age over 65 years
  2. Pain on Hip Range of Motion (esp. painful hip flexion or hip rotation)
    1. Intrinsic hip pathology
    2. Septic Arthritis of the hip
  3. Inability to bear weight
    1. Hip Stress Fracture
    2. Hip Septic Arthritis
    3. Avascular Necrosis of the Hip
    4. Femoral lesion (e.g. malignancy)
    5. Unstable Slipped Capital Femoral Epiphysis (8-15 years old)
  4. Abdominal Pain
    1. Abominal aortic aneurysm (may present with back pain if retroperitoneal bleeding)
    2. Appendicitis
    3. Renal Calculi
    4. Pelvic tumors
    5. Ectopic Pregnancy
    6. Pelvic Inflammatory Disease
    7. Abdominal Hernia or Inguinal Hernia
  5. History of malignancy (or Night Sweats, weight loss)
  6. Hip Trauma
  7. Alcohol Abuse
  8. Night pain, Constant pain, Weight loss
    1. Malignancy
  9. Fever
    1. Septic Arthritis of the hip
    2. Malignancy
    3. Perirectal Abscess
    4. Appendicitis
  10. Chronic Corticosteroids, Chronic inflammatory conditions or Coagulopathy
    1. Avascular necrosis of the hip
  11. Cardiovascular Risk Factors (e.g. Diabetes Mellitus, Tobacco Abuse, Coronary Artery Disease, Carotid Stenosis)
    1. Aortoilliac Occlusive Disease

VI. History

  1. Sporting activity
    1. Frequency, duration and intensity
    2. Injury mechanism
      1. Stopping, cutting or kicking
  2. Pain characteristics
    1. Location, timing, region, radiation, palliative and provocative
  3. Associated symptoms
    1. Swelling
    2. Ecchymosis
    3. Locking or catching (labral tear or other intraarticular cause)
    4. Popping or clicking (labral tear or other intraarticular cause)
    5. Instability
    6. Altered Sensation, Paresthesias or weakness (nerve entrapment)
  4. Past History
    1. Developmental Dysplasia of the Hip (Congenital Hip Dysplasia)
    2. Slipped Capital Femoral Epiphysis (SCFE)
    3. Sports participation (see high risk sports above)
    4. Family History of hip disorders
  5. Referred pain sources
    1. Spine (radiculopathy)
    2. Abdomen and Pelvis
    3. Genitourinary tract
    4. Skin (e.g. Shingles)

VII. Exam

  1. See Hip Exam
  2. See Hip Anatomy
  3. Observe for groin Ecchymosis (avulsion, Muscle tear, abdominal wall Hematoma)
  4. Observe for bulge in the abdominal and inguinal region (Hernia)
    1. Also palpate the Superficial Inguinal Ring with valsalva or cough
  5. Examine in frog-leg position
    1. Palpate the lower Abdomen and pupic symphysis
    2. Palpate adductor insertions (pubic tubercle, medial inferior pubic ramus)
    3. Palpate abdominal Muscles
    4. Palpate anterior superior iliac spine (ASIS, sartorius and tensor fasciae latae insertion)
    5. Palpate anterior inferior iliac spine (AIIS, rectus femoris insertion)
    6. Palpate anterior hip
  6. Perform active range of motion and passive range of motion
    1. See Hip Range of Motion
  7. Specific Tests
    1. Hip Adduction Test
      1. Also includes Single Hip Adductor Test, Bilateral Hip Adductor Test
    2. FABER Test
      1. Flexion ABduction External Rotation
      2. Also known as Patrick's Test or Figure of Four Test
    3. FADIR Test
      1. Flexion ADduction Internal Rotation
    4. Hip Scour Test (Hip Quadrant Test)
      1. Hip Flexed to 90 degrees and examiner applies axial load
      2. Internally rotate and externally rotate hip
  8. Other examination
    1. Perform an abdominal exam and back exam on all Hip Pain patients
    2. Evaluate Sensation and motor function
    3. Evaluate femoral and pedal pulses
    4. Gait Exam
      1. Antalgic Gait
      2. Trendelenburg Gait
  9. Findings most suggestive of hip intra-articular cause
    1. Pain on external and internal hip rotation
    2. Pain on hip axial loading (force applied at foot or knee towards hip)

IX. Imaging

  1. Hip XRay
    1. Obtain Anteroposterior View (AP View) and Frog-Leg Lateral View
    2. Indications
      1. First-line study in hip Pain Evaluation
      2. Evaluate for bony lesions (e.g. malignancy)
      3. Femoral Neck Stress Fracture
      4. Hip Avulsion Fracture
      5. Slipped Capital Femoral Epiphysis
      6. Avascular Necrosis of the Femoral Head
      7. Osteoarthritis
      8. Hip Joint lesions (e.g. pincer lesion, cam lesion)
      9. Osteitis Pubis
    3. Low yield for Osteoarthritis (36% Test Sensitivity)
      1. Kim (2015) BMJ 351:h5983 +PMID:26631296 [PubMed]
    4. Hip XRay may miss non-displaced Femoral Fractures
      1. Consider MRI or CT for negative XRay with higher index of suspicion
      2. Parker (1992) Arch Emerg Med 9(1): 23-7 [PubMed]
      3. Hakkarinen (2012) J Emerg Med 43(20: 303-7 +PMID:22459594 [PubMed]
  2. Hip MRI (or Hip CT if MRI unavailable) Indications
    1. Hip Pain with non-diagnostic XRay
    2. Muscle tears and Tendon Strains
    3. Avulsion Fractures
    4. Hip Avascular Necrosis
    5. Hip Labral Tear
    6. Hip cartilage defects
  3. Hip MRI with arthrography
    1. Indicated for suspected Hip Labral Tear (Test Sensitivity 90% contrasted with 36% for standard MRI)
  4. Hip Ultrasound
    1. Long axis view detects hip effusion and can direct hip needle aspiration if septic hip is suspected
    2. Also indicated in Functional Evaluation of hip
    3. Test Sensitivity approaches 80-85% for identifying hip effusion in children
      1. Vieira (2010) Ann Emerg Med 55(3): 284-9 +PMID:19695738 [PubMed]
  5. Bone Scan (Scintigraphy) Indications
    1. Stress Fracture
    2. Osteomyelitis
    3. Sacroiliitis
    4. Osteitis Pubis

X. Diagnostics

  1. Electromyography (EMG) or Nerve Conduction Study
    1. Consider for undifferentiated pain with suspected neuropathic origin
  2. Diagnostic Herniography
    1. Contrast injected within the peritoneum
    2. Patient performs Valsalva Maneuver
    3. Imaging demonstrates abnormal contour of contrast

XI. Management

  1. Treat specific conditions
    1. See Hip Pain Causes

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