Hip Pain

See Also

Epidemiology

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

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
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
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

Precautions
Risk Factors for serious pathology

Age over 65 years
Pain on Hip Range of Motion (esp. painful hip flexion or hip rotation)
1. Intrinsic hip pathology
2. Septic Arthritis of the hip
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)
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
History of malignancy (or Night Sweats, weight loss)
Hip Trauma
Alcohol Abuse
Night pain, Constant pain, Weight loss
1. Malignancy
Fever
1. Septic Arthritis of the hip
2. Malignancy
3. Perirectal Abscess
4. Appendicitis
Chronic Corticosteroids, Chronic inflammatory conditions or Coagulopathy
1. Avascular necrosis of the hip
Cardiovascular Risk Factors (e.g. Diabetes Mellitus, Tobacco Abuse, Coronary Artery Disease, Carotid Stenosis)
1. Aortoilliac Occlusive Disease

Causes

History

Sporting activity
1. Frequency, duration and intensity
2. Injury mechanism
  1. Stopping, cutting or kicking
Pain characteristics
1. Location, timing, region, radiation, palliative and provocative
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)
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
Referred pain sources
1. Spine (radiculopathy)
2. Abdomen and Pelvis
3. Genitourinary tract
4. Skin (e.g. Shingles)

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)
1. Also palpate the Superficial Inguinal Ring with valsalva or cough
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
Perform active range of motion and passive range of motion
1. See Hip Range of Motion
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
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
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)

Differential Diagnosis

See Hip Pain Causes
See Rheumatologic Conditions affecting the Hip
Exclude serious hip causes
1. Septic Arthritis of the Hip
2. Hip Fracture or Hip Stress Fracture
3. Hip Avascular Necrosis
4. Slipped Capital Femoral Epiphysis (SCFE, peri-Puberty)
Exclude serious external Hip Pain Causes
1. Peripheral Arterial Disease (Aortoilliac Occlusive Disease, Abdominal Aortic Aneurysm)
2. Peritonitis (or other surgical Abdomen)
3. Malignancy involving hip or Pelvis (bony metastases, Multiple Myeloma, Chondrosarcoma)

Imaging

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]
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
Hip MRI with arthrography
1. Indicated for suspected Hip Labral Tear (Test Sensitivity 90% contrasted with 36% for standard MRI)
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]
Bone Scan (Scintigraphy) Indications

Diagnostics

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

Management

Treat specific conditions
1. See Hip Pain Causes

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]