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Hip Pain
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Hip Pain
, Groin Pain, Groin Injury, Groin Injuries in Athletes, Sports-Related Groin Injury
See Also
Hip Pain Causes
Rheumatologic Conditions affecting the Hip
Hip Rotation Evaluation in Children
Hip Exam
Hip Anatomy
Testicular Pain
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
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
Foot
ball
Australian
Foot
ball
Fencing
Handball
Cross Country Skiing
Hurdling
High Jumping
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
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
Corticosteroid
s, Chronic inflammatory conditions or
Coagulopathy
Avascular necrosis of the hip
Cardiovascular Risk Factor
s (e.g.
Diabetes Mellitus
,
Tobacco Abuse
,
Coronary Artery Disease
,
Carotid Stenosis
)
Aortoilliac Occlusive Disease
Causes
See
Hip Pain Causes
See
Rheumatologic Conditions affecting the Hip
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,
Paresthesia
s 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
Spine (radiculopathy)
Abdomen
and
Pelvis
Genitourinary tract
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
)
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
See
Hip 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
Other examination
Perform an abdominal exam and back exam on all Hip Pain patients
Evaluate sensation and motor function
Evaluate femoral and pedal pulses
Gait
Exam
Antalgic Gait
Trendelenburg Gait
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)
Differential Diagnosis
See
Hip Pain Causes
See
Rheumatologic Conditions affecting the Hip
Exclude serious hip causes
Septic Arthritis
of the Hip
Hip Fracture
or
Hip Stress Fracture
Hip Avascular Necrosis
Slipped Capital Femoral Epiphysis
(
SCFE
, peri-
Puberty
)
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
)
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
)
Kim (2015) BMJ 351:h5983 +PMID:26631296 [PubMed]
Hip XRay
may miss non-displaced
Femoral Fracture
s
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 Strain
s
Avulsion
Fracture
s
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
Vieira (2010) Ann Emerg Med 55(3): 284-9 +PMID:19695738 [PubMed]
Bone Scan (Scintigraphy) Indications
Stress Fracture
Osteomyelitis
Sacroiliitis
Osteitis Pubis
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
Management
Treat specific conditions
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]
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