Learning Objectives:
At the conclusion of this activity, participants will be able to:
- Discuss common diagnoses for hip pain in patients presenting to a primary care office or clinic.
- Understand basic pathoanatomy of common acute and chronic injuries about the hip.
- Describe a thorough physical exam of the hip utilizing inspection, palpation and provocative testing to confirm diagnoses.
- Understand the appropriate course of action for a patient, whether it be initiating a course of non-operative treatment, or immediate referral to a specialist.
In order to obtain AMA PRA Category 1 Credit™, participants are required to adhere to the following:
- Review the learning objectives at the beginning of the CME article. If these objectives match your individual learning needs, read the article carefully. The estimated time to complete the educational activity is one hour.
- After reflecting on the contents of the article, demonstrate your understanding by answering the post-test questions in the online form at wwd.mdadvantageonline.com/cme/spring-2021. These questions have been designed to provide a useful link between the CME article and your everyday practice. The entire online form must be completed, including the evaluation section. The post-test cannot be processed if any sections are incomplete. If you are unable to complete the online form, please contact Alysiana Bagwell at 888-355-5551 or ABagwell@mdanj.com.
- If a passing score of 80% or more is achieved, a CME certificate awarding AMA PRA Category 1 Credit™ will be immediately available to download. Individuals who fail to attain a passing score will be offered the opportunity to reread the article and submit a new post-test.
- All post-tests must be submitted between May 5, 2021, and May 4, 2022. Submissions received after May 4, 2022, will not be processed.
Author: William H. Rossy, MD, Princeton Orthopaedic Associates, PA
Article Content Last Updated: This content was updated as of April 30, 2021.
Accreditation Statement: HRET is accredited by the Medical Society of New Jersey to provide continuing medical education for physicians. This enduring article has been planned and implemented in accordance with the accreditation requirements and policies of the Medical Society of New Jersey (MSNJ) and Health Research Education and Trust of New Jersey (HRET) in joint providership with MDAdvantage Insurance Company. HRET is accredited by the Medical Society of New Jersey to provide continuing medical education for physicians.
AMA Credit Designation Statement: HRET designates this enduring activity for 1.0 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
Disclosure: The content of this activity does not relate to any product of a commercial interest as defined by the ACCME; therefore, there are no relevant financial relationships to disclose. No commercial funding has been accepted for the activity. This article was peer reviewed in accordance with the MDAdvisor Guidelines for Peer Review.
Musculoskeletal complaints are common ailments suffered by patients of all ages. A recent national survey found the most frequent diagnoses in primary care clinics are often ones associated with musculoskeletal pain.¹ Large portions of these patients seek care from their primary care physicians (PCP).
As public health advocates continue to promote physical activity to optimize health and minimize the risk of obesity and other ailments such as diabetes, one can expect the number of musculoskeletal injuries to continue to rise. Although a recent National Health Statistics report found that many patient complaints reported at the PCP level were from acute injuries,2 it should not be neglected that chronic ailments, such as arthritis and tendinopathies, are also commonly seen.
The goal of this article is to further familiarize PCPs with commonly encountered musculoskeletal complaints of the hip, as this is a frequently injured joint in sports and recreational activities.2-4 At the conclusion of this article, the reader will have an improved fundamental understanding of the anatomy of the hip joint, how patients typically present with injuries (both acute and chronic), how to thoroughly examine the injured area and document findings, as well as how to proceed after a diagnosis is made.
The Hip: The Basics
The hip is a structurally complex joint that is a common cause of pain. The hip joint has been shown to be difficult to evaluate as it is buried deep below multiple layers of fascia and muscle and cannot be directly palpated. The spectrum of differential diagnoses of hip pain ranges from acute injuries in the young, active athlete to chronic injuries and pain in the aging population.
As illustrated in Figure 1, the hip is a ball-and-socket joint. The articulating surfaces of the hip joint are comprised of the acetabulum and the femoral head, both of which are covered with hyaline cartilage.
The labrum is a cartilaginous ring that sits around the acetabulum to further deepen the joint, increasing its stability. It has also been shown to be crucial in maintaining the suction seal of the hip, thereby ensuring that synovial joint fluid remains in the joint to optimize joint mechanics.5
Multiple muscles of the pelvis and hip add support to the joint (see Figures 2 and 3).
Figure 1. The Hip Joint
Figure 2. Anterior Thigh Muscles
Figure 3. Posterior Thigh Muscles
Common Hip Ailments
All of the structures just mentioned must be considered when evaluating a patient with hip pain in order secure an accurate diagnosis and initiate appropriate treatment. Common causes of hip pain to be considered include femoroacetabular impingement, labral tears, greater trochanteric pain syndrome, tendon avulsion/tears, and arthritis.
Femoroacetabular Impingement
Femoroacetabular impingement (FAI) is a relatively recent diagnosis that has been accepted as a common cause of hip pain in the young/middle aged patient.6,7 FAI is characterized as abnormal contact of the femoral head-neck junction and the acetabular rim.7,8 When FAI is present, as the hip flexes forward and rotates, the front of the ball can make contact with the socket causing the impingement. Over time, this has been shown to lead to labral tears and damage to adjacent cartilage. This can lead to pain, dysfunction and a predisposition to arthritis in the future.9
There are two types of FAI. A cam lesion occurs when the deformity is present on the femur at the femoral head-neck junction. Pathology can also exist on the acetabular side. In this instance, there is over-coverage of the ball by the socket. This is called a pincer deformity. Very often, patients present with a combination of both pathologies. A common complaint described by these patients is deep groin pain with increased activities and increasing pain with rotation of the hip.
Labral Tear
Labral tears can cause significant groin pain and dysfunction. They can occur from acute injuries that involve a quick change in direction or a traumatic fall. Additionally, they can occur without any direct injury and present as more of a chronic complaint, likely secondary to a concomitant diagnosis of FAI.
Labral tears cause groin pain, similar to FAI. They can also be associated with a clicking sound in the hip or a sensation that something is getting caught in the hip. In the setting of large labral tears, a patient may even experience a loss of normal motion due to the tear causing a mechanical block. The pain that a patient reports from a labral tear is commonly described as a sharp, pinching type pain.
Greater Trochanteric Pain Syndrome (GTPS)
Greater trochanteric pain syndrome is a term used to describe pain localized to the region surrounding the greater trochanter of the proximal femur. It typically encompasses greater trochanteric bursitis, gluteus medius tears or tendinopathy, and snapping hip syndrome. The most common cause of lateral sided hip pain is greater trochanteric bursitis; however, as advanced imaging of the hip improves, the diagnosis of gluteus medius tears and/or tendinopathy have been increasing.10,11
In GTPS, the patient typically complains of increased lateral sided hip pain with running or other strenuous activities. Since the gluteus medius is the main hip abductor, if this muscle/tendon unit is torn, the patient may also exhibit an altered gait (i.e., Trendelenburg gait). A Trendelenburg gait is characterized by a lateral tilting of the pelvis and torso on the side of the body where the leg is being raised (See Figure 4). This indicates that the contralateral hip abductors are unable to contract with the force needed to keep the pelvis level. In these patients, range of motion is typically not impacted and complaints of groin pain are absent.
Tendon Avulsion/Tear
Tendon tears about the hip are typically the result of a traumatic hyperextension or eccentric hip flexion injury and typically involve the proximal hamstring posteriorly or the proximal rectus femoris anteriorly. These injuries can be associated with significant pain and difficulty bearing weight. In younger patients, they can be associated with a bony avulsion, where the tendon pulls a fragment of bone off the pelvis. In older patients who are skeletally mature, the tendon usually tears from the bone and radiographs can appear normal. Proximal hamstring tears, in particular, are associated with significant weakness and difficulty bearing weight.
Arthritis
Hip arthritis is a common cause of hip pain in patients over the age of 60. Like all arthritis, it is characterized by a loss of normal articular cartilage, which can lead to loss of joint space, inflammation and pain. As arthritis progresses, a patient can typically notice increasing pain in the groin and occasionally down the front of the leg. Decreasing range of motion often precedes pain, sometimes making it difficult to complete simple activities of daily living.
Diagnosis of Hip Pain
The diagnosis of hip disorders commonly follows the path of 1) patient history, 2) physical examination, including inspection, palpation, range of motion testing, strength testing and provocative maneuvers, and 3) radiographs.
“Acute sports injuries make it more likely for tendon tears or labral tears to be the cause of pain; whereas, chronic pain without a reported injury may indicate pathology such as arthritis or tendinopathies.”
Patient History
When a patient presents with complaints of hip pain, the duration of symptoms and mechanism of injury should be determined. Acute sports injuries make it more likely for tendon tears or labral tears to be the cause of pain; whereas, chronic pain without a reported injury may indicate pathology such as arthritis or tendinopathies.
Another crucial point to clarify when obtaining a patient’s history for hip pain is the exact location of the hip pain. Very often, when patients report “hip pain,” they may point to the lateral aspect of the hip, over the greater trochanter of the proximal femur. This indicates a more likely diagnosis of extra-articular, peri-trochanteric pain syndrome as opposed to intra-articular hip pathology (i.e., labral tear or FAI) that would be localized to the groin.
If the patient localizes the pain to the groin, and also reports mechanical symptoms, such as clicking, catching or popping, the examiner should be highly suspicious of a labral tear.
These simple points of clarification during the taking of a patient’s history can lead to a more focused physical exam and a higher likelihood of obtaining a proper diagnosis.
Physical Examination
Physical examination of the painful hip can be difficult given how deep the joint is compared to other joints. Careful attention to a patient’s history and review of available radiographs can often cue the physician to certain pathologies that need to be ruled out while doing the exam. An organized, methodical approach to the hip physical examination can considerably narrow one’s differential diagnosis.
Inspection: The hip exam is similar to other musculoskeletal exams in that inspection of the painful area occurs first. The practitioner should ask the patient to localize the pain with his or her finger and focus much of the exam to that area. The entirety of the hip/pelvis region should also be inspected for signs of abnormality such as swelling, erythema, ecchymosis or skin break down. In musculoskeletal injuries, the most common positive finding noted during inspection is ecchymosis (see Figure 5), typically indicating a tendon avulsion or tendon tear (i.e., proximal hamstring or rectus femoris).
Palpation: Palpation of the affected area should occur first in areas that are not expected to produce pain and finish with the most painful areas. Palpation is an important aspect of the hip exam that is often neglected due to the hip joint itself being localized too deep to palpate. Despite this, the surrounding soft tissues, tendons, muscles and bursa can be easily palpated and often give confirmatory information regarding the diagnosis.
Palpation can proceed in whatever order the physician desires; however, all pertinent areas should be palpated and any tenderness should be recorded. A methodical approach would be to start proximally and progress distally along the hip. Palpation of the pelvic brim and musculature occurs first, followed by palpation anteriorly along the anterior superior iliac spine (ASIS) where the sartorius muscle originates and extends distally. Palpation can then occur medially along the adductor tendons and finally laterally along the greater trochanter of the proximal femur.
“Typically, patients with bursitis, tendinitis and/or tendon tears will have tenderness on exam, while patients with labral tears, FAI or arthritis, will have non-tender examinations.”
Common causes of tenderness while palpating the hip are sartorius tendinitis (anterior tenderness), adductor strains (medial tenderness), or greater trochanteric pain syndrome (lateral tenderness). Typically, patients with bursitis, tendinitis and/or tendon tears will have tenderness on exam, while patients with labral tears, FAI or arthritis, will have non-tender examinations.
Range of Motion Testing: With the patient in the supine position, passive range of motion in multiple planes can be assessed. If pain occurs with passive range of motion, the examiner should document at what degree of motion the pain occurs and compare it to the contralateral hip. The examiner should be aware that if the patient has bilateral pathology, such as FAI or arthritis, both hips may show restricted range of motion.
The end point for hip flexion (typically >90 deg) is most accurately determined by placing one hand on the pelvic brim in order to better determine when compensatory pelvic motion occurs.12 The recorded hip flexion should be at the point where the examiner feels the pelvis begin to rotate off the table. Internal and external rotation testing is best assessed with the hip at 90 degrees of flexion. Normal internal rotation of the hip has been reported to range from 10 degrees to 40 degrees, with an average of 28 degrees.12 The range can be considerably decreased in the setting of FAI and associated with significant pain. External rotation arcs typically range from 20 degrees to 50 degrees. Hip abduction range of motion can be assessed with the hip in full extension and averages approximately 40 degrees.13
The examiner should also document obligate passive external rotation of the hip with flexion. This could indicate underlying FAI or arthritis and has been described as the Drehmann sign.14 In this instance, a cam deformity on the femoral head/neck junction—or in the case of arthritis, an osteophyte—may make hip flexion painful as the bony abnormality impinges on the acetabulum. To minimize pain, the hip unavoidably externally rotates in order to make space for the femoral head during flexion, thus minimizing impingement.
Strength Testing: This is an important part of any physical examination. A focused physical exam of the hip should assess strength of hip flexion, extension, abduction and adduction. The standard muscle strength grading system can be used for documentation (see Table 1).
Table 1. Standard Muscle Strength Grading System
Grade | Physical Exam Finding |
|---|---|
| 0 | No contraction |
| 1 | Flicker of contraction |
| 2 | Active movement: can’t resist gravity |
| 3 | Active movement against gravity |
| 4 | Active movement against resistance |
| 5 | Normal strength |
With the patient in the supine position, a patient’s hip flexion, abduction and adduction can be assessed. Any weakness in these planes should alert the provider to a possible disruption or injury to the musculotendinous unit, most commonly the hip abductors. If the pain is posterior along the hamstring, the patient should be placed in the prone position and an assessment of hip extension and knee flexion should be evaluated to check the function of the hamstring and rule out a proximal hamstring rupture.
Provocative Maneuvers: These tests are the final part of the physical examination of the hip. They can be useful to confirm or rule out suspected diagnoses that have been developed during a patient’s history or physical examine findings.
The Stinchfield test is a sensitive test used to assess for intra-articular pathology. While the patient is in the supine position, he or she is asked to flex the hip forward 20 – 30 degrees, while keeping the leg straight. The examiner then applies a downward force to the distal leg, while asking the patient to resist the force and keep the leg off the table. If this maneuver causes pain in the anterior part of the hip, it is considered positive, and can indicate that labral tear or arthritis is present (see Figure 6).
An anterior impingement test, also known as the flexion adduction internal rotation (FADIR) test, is the most sensitive test for FAI.14 While in the supine position, the patient’s hip is passively flexed to 90 degrees, adducted towards the midline and then internally rotated (see Figure 7). The presence of anterior groin pain with less than 20 degrees of internal rotation, is indicative of a positive test.
A posterior impingement test is considered positive if forced external rotation of the leg in full extension produces posterior pain. It is sometimes helpful to move the patient down on the bed so the hip can extend beyond the edge of the examining table.
A Patrick test, also known as the flexion abduction external rotation (FABER) test, is also used to assess for posterior impingement. With this test, the patient’s hip is flexed to 90 degrees passively, then abducted and externally rotated. If this causes pain posteriorly or postero-laterally, then it is considered positive.14
The Thomas test is performed with the patient in the supine position It can be useful to rule out contractions of the rectus femoris, which can cause anterior pain and limited motion. The examiner should passively flex the contralateral hip to full flexion, and, if the affected hip lifts of the table, then a fixed flexion deformity of the rectus is confirmed.
Radiographs: When a patient presents to the office or clinic with complaints of hip pain, standard radiographs should be ordered prior to any advanced imaging. Standard antero-posterior (AP) and lateral views of the affected hip provide baseline information that can be helpful in initiating proper treatment. Commonly seen hip ailments can be associated with easily identified radiographic findings that should not be overlooked as they often indicate that further advanced imaging is required (see Figures 8–12).
Figure 8.
AP and Lateral Views of a Normal-Appearing X-ray
Figure 9.
Chronic Greater Trochanteric Bursitis
Figure 10.
Chronic Greater Trochanteric Bursitis
Figure 11.
Proximal Hamstring Avulsion
Figure 12.
Hip Arthritis
Putting It All Together
Regardless of the presentation, a systematic, methodical approach to the evaluation of a patient with hip pain is imperative. By keeping one’s approach logical and organized, and then taking into consideration a patient’s age and injury mechanism (if there is one), the primary care provider can often initiate suitable therapeutic treatment at a patient’s first office visit.
Ordering appropriate x-rays at the initial encounter can further help solidify an accurate diagnosis when the provider is aware of common radiographic findings seen on plain films with many common hip pathologies.
In general, more chronic ailments with no history of trauma can be reliably treated initially by the primary care physician with a course of anti-inflammatories and physical therapy. If this treatment does not improve symptoms after six weeks, then advanced imaging and a referral to a specialist is warranted. Conversely, the more acute injuries that are directly related to a trauma and may involve a tendon or labrum tear, should be referred to a specialist for definitive treatment more expeditiously. Obtaining advanced imaging in the form of an MRI is helpful in acute injuries, however, should not delay referral to a specialist.
