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]