Hip pain is a common presentation that can affect patients of all ages. The differential diagnosis of hip pain is broad and includes both intra-articular and extra-articular pathology that varies by age. A thorough history and physical examination are essential to accurately diagnose the cause of hip pain. Initial imaging should include an x-ray of the pelvis and hip, while MRI is useful for detecting soft tissue injuries. Magnetic resonance arthrography is particularly helpful for diagnosing labral tears within the hip joint.
2. Hip Pain
SORT: KEY RECOMMENDATIONS FOR PRACTICE
Evidence
rating
References
Initial plain radiography of the hip should include an anteroposterior view of the pelvis and a frog-leg
lateral view of the symptomatic hip.
C
4
Magnetic resonance imaging should be used for detection of occult hip fractures, stress fractures,
and osteonecrosis of the femoral head.
C
23, 30, 33
Magnetic resonance arthrography is the diagnostic test of choice for labral tears.
C
6, 19
Ultrasonography is a helpful diagnostic modality for patients with suspected bursitis, joint effusion,
or functional causes of hip pain (e.g., snapping hip), and can be employed for therapeutic imagingguided injections and aspirations around the hip.
C
8, 9
Clinical recommendation
A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, diseaseoriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.
org/afpsort.
A
B
C
Figure 1. Gait testing. (A) C sign. Patients often localize pain by cupping the anterolateral hip with the thumb and forefinger in the shape of a “C.” (B) Gait analysis. The patient is observed while walking to evaluate for limp or antalgic
gait characteristics. (C) Modified Trendelenburg test (single leg stance phase). The patient stands with feet shoulder
width apart and lifts one leg. The examiner observes for a drop in the level of the iliac crest on the side of the lifted leg.
skeletally mature, hip pain is often a result of musculotendinous strain, ligamentous sprain, contusion, or
bursitis. In older adults, degenerative osteoarthritis and
fractures should be considered first.
Patients with hip pain should be asked about antecedent trauma or inciting activity, factors that increase
or decrease the pain, mechanism of injury, and time of
28 American Family Physician
onset. Questions related to hip function, such as the ease
of getting in and out of a car, putting on shoes, running,
walking, and going up and down stairs, can be helpful.3
Location of the pain is informative because hip pain
often localizes to one of three basic anatomic regions:
the anterior hip and groin, posterior hip and buttock,
and lateral hip (eFigure A).
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3. Hip Pain
Table 1. Physical Examination Tests for the Evaluation of Hip Pain
Test
Other names
Positioning
Positive findings
Differential diagnosis
Gait testing (C sign,
Figure 1A; gait analysis,
Figure 1B)
—
Standing
Antalgic gait, Trendelenburg gait,
pelvic wink (rotation of more
than 40 degrees in the axial plane
toward the affected hip when
terminally extending the hip),
excessive pronation or supination
of the ankles, and limps caused
by differing leg lengths
Hip labral tear, transient synovitis,
Legg-Calvé-Perthes disease,
SCFE
Modified Trendelenburg
test (Figure 1C)
Single leg
stance phase
Standing
2-cm drop in the level of the iliac
crest, indicating weakness on the
contralateral side
Hip labral tear, transient synovitis,
Legg-Calvé-Perthes disease,
SCFE
ROM testing (Figure 2)
—
Supine,
lateral, or
sitting
Pain with passive ROM, limited
ROM
Pain with passive ROM: Transient
synovitis, septic arthritis
Limited ROM: Loose bodies,
chondral lesions, osteoarthritis,
Legg-Calvé-Perthes disease,
osteonecrosis
FABER test (Figure 3)
Patrick test
Supine
Posterior pain localized to the
sacroiliac joint, lumbar spine, or
posterior hip; groin pain with the
test is sensitive for intra-articular
pathology
Hip labral tear, loose bodies,
chondral lesions, femoral
acetabular impingement,
osteoarthritis, sacroiliac joint
dysfunction, iliopsoas bursitis
FADIR test (Figure 4)
Impingement
test
Supine
Pain
Hip labral tear, loose bodies,
chondral lesions, femoral
acetabular impingement
Log roll test (Figure 5)
Passive supine
rotation,
Freiberg test
Supine
Restricted movement, pain
Piriformis syndrome, SCFE
Straight leg raise against
resistance test (Figure 6)
Stinchfield test
Supine
Weakness to resistance, pain
Athletic pubalgia (sports hernia),
SCFE, femoral acetabular
impingement
Ober test (eFigure B)
Passive
adduction
Lateral
Passive adduction past midline
cannot be achieved
External snapping hip, greater
trochanteric pain syndrome
FABER = flexion, abduction, external rotation; FADIR = flexion, adduction, internal rotation; ROM = range of motion; SCFE = slipped capital femoral
epiphysis.
PHYSICAL EXAMINATION
The hip examination should evaluate the hip, back,
abdomen, and vascular and neurologic systems. It
should start with a gait analysis and stance assessment
(Figure 1), followed by evaluation of the patient in seated,
supine, lateral, and prone positions (Figures 2 through 6,
and eFigure B). Physical examination tests for the evaluation of hip pain are summarized in Table 1.
IMAGING
Radiography. Radiography of the hip should be performed if there is any suspicion of acute fracture, dislocation, or stress fracture. Initial plain radiography of the
hip should include an anteroposterior view of the pelvis
and a frog-leg lateral view of the symptomatic hip.4
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Magnetic Resonance Imaging and Arthrography. Conventional magnetic resonance imaging (MRI) of the hip
can detect many soft tissue abnormalities, and is the
preferred imaging modality if plain radiography does
not identify specific pathology in a patient with persistent pain.5 Conventional MRI has a sensitivity of 30%
and an accuracy of 36% for diagnosing hip labral tears,
whereas magnetic resonance arthrography provides
added sensitivity of 90% and accuracy of 91% for the
detection of labral tears.6,7
Ultrasonography. Ultrasonography is a useful technique for evaluating individual tendons, confirming suspected bursitis, and identifying joint effusions
and functional causes of hip pain.8 Ultrasonography is
especially useful for safely and accurately performing
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American Family Physician 29
4. Hip Pain
45°
10°
A
C
20-30°
20-35°
30-70°
B
D
Figure 2. Hip range-of-motion testing (photos demonstrate normal range of motion). (A) Abduction. (B) Adduction.
(C) Extension. (D) Internal and external rotation.
30 American Family Physician
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5. Hip Pain
A
B
Figure 3. FABER test (flexion, abduction, external rotation; Patrick test). The examiner moves
the leg into 45 degrees of flexion, then (A) externally rotates and (B) abducts the leg so that
the ankle rests proximal to the knee of the contralateral leg.
A
B
Figure 4. FADIR test (flexion, adduction, internal rotation; impingement test). The examiner
passively moves the leg into (A) full flexion, then into (B) adduction and internal rotation.
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American Family Physician 31
6. Hip Pain
imaging-guided injections and aspirations
around the hip.9 It is ideal for an experienced
ultrasonographer to perform the diagnostic
study; however, emerging evidence suggests
that less experienced clinicians with appropriate training can make diagnoses with
reliability similar to that of an experienced
musculoskeletal ultrasonographer.10,11
Differential Diagnosis
of Anterior Hip Pain
Anterior hip or groin pain suggests involvement of the hip joint itself. Patients often
localize pain by cupping the anterolateral hip
with the thumb and forefinger in the shape of
a “C.” This is known as the C sign (Figure 1A).
Figure 5. Log roll test (passive supine rotation; Freiberg test). Patient’s
leg is extended and relaxed on examination table as the examiner
internally and externally rotates the leg (log roll).
OSTEOARTHRITIS
Osteoarthritis is the most likely diagnosis in
older adults with limited motion and gradual
onset of symptoms. Patients have a constant,
deep, aching pain and stiffness that are worse
with prolonged standing and weight bearing. Examination reveals decreased range of
motion, and extremes of hip motion often
cause pain. Plain radiographs demonstrate
the presence of asymmetrical joint-space
narrowing, osteophytosis, and subchondral
sclerosis and cyst formation.12
FEMOROACETABULAR IMPINGEMENT
Figure 6. Straight leg raise against resistance test (Stinchfield test).
Patients with femoroacetabular impinge- The patient lifts the straight leg to 45 degrees while the examiner
ment are often young and physically active. applies downward force on the thigh.
They describe insidious onset of pain that is
worse with sitting, rising from a seat, getting in or out of pain usually has an insidious onset, but occasionally
a car, or leaning forward.13 The pain is located primarily begins acutely after a traumatic event. About one-half
in the groin with occasional radiation to the lateral hip of patients with this injury also have mechanical sympand anterior thigh.14 The FABER test (flexion, abduction, toms, such as catching or painful clicking with activity.17
external rotation; Figure 3) has a sensitivity of 96% to The FADIR and FABER tests are effective for detect99%. The FADIR test (flexion, adduction, internal rota- ing intra-articular pathology (the sensitivity is 96% to
tion; Figure 4), log roll test (Figure 5), and straight leg 75% for the FADIR test and is 88% for the FABER test),
raise against resistance test (Figure 6) are also effective, although neither test has high specificity.14,15,18 Magnetic
with sensitivities of 88%, 56%, and 30%, respectively.14,15 resonance arthrography is considered the diagnostic test
In addition to the anteroposterior and lateral radiograph of choice for labral tears.6,19 However, if a labral tear is not
views, a Dunn view should be obtained to help detect suspected, other less invasive imaging modalities, such
subtle lesions.16
as plain radiography and conventional MRI, should be
used first to rule out other causes of hip and groin pain.
HIP LABRAL TEAR
Hip labral tears cause dull or sharp groin pain, and onehalf of patients with a labral tear have pain that radiates to the lateral hip, anterior thigh, and buttock. The
32 American Family Physician
ILIOPSOAS BURSITIS (INTERNAL SNAPPING HIP)
Patients with this condition have anterior hip pain when
extending the hip from a flexed position, often associated
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7. Hip Pain
with intermittent catching, snapping, or popping of the
hip.20 Dynamic real-time ultrasonography is particularly
useful in evaluating the various forms of snapping hip.8
OCCULT OR STRESS FRACTURE
Occult or stress fracture of the hip should be considered if trauma or repetitive weight-bearing exercise is
involved, even if plain radiograph results are negative.21
Clinically, these injuries cause anterior hip or groin pain
that is worse with activity.21 Pain may be present with
extremes of motion, active straight leg raise, the log roll
test, or hopping.22 MRI is useful for the detection of
occult traumatic fractures and stress fractures not seen
on plain radiographs.23
TRANSIENT SYNOVITIS AND SEPTIC ARTHRITIS
Acute onset of atraumatic anterior hip pain that results
in impaired weight bearing should raise suspicion for
transient synovitis and septic arthritis. Risk factors for
septic arthritis in adults include age older than 80 years,
diabetes mellitus, rheumatoid arthritis, recent joint surgery, and hip or knee prostheses.24 Fever, complete blood
count, erythrocyte sedimentation rate, and C-reactive
protein level should be used to evaluate the risk of septic arthritis.25,26 MRI is useful for differentiating septic
arthritis from transient synovitis.27,28 However, hip aspiration using guided imaging such as fluoroscopy, computed tomography, or ultrasonography is recommended
if a septic joint is suspected.29
OSTEONECROSIS
Legg-Calvé-Perthes disease is an idiopathic osteonecrosis of the femoral head in children two to 12 years of
age, with a male-to-female ratio of 4:1.4 In adults, risk
factors for osteonecrosis include systemic lupus erythematosus, sickle cell disease, human immunodeficiency
virus infection, smoking, alcoholism, and corticosteroid
use.30,31 Pain is the presenting symptom and is usually
insidious. Range of motion is initially preserved but can
become limited and painful as the disease progresses.32
MRI is valuable in the diagnosis and prognostication of
osteonecrosis of the femoral head.30,33
Differential Diagnosis of Posterior Hip
and Buttock Pain
Piriformis syndrome causes buttock pain that is aggravated by sitting or walking, with or without ipsilateral
radiation down the posterior thigh from sciatic nerve
compression.34,35 Pain with the log roll test is the most
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OTHER
Other causes of posterior hip pain include sacroiliac joint
dysfunction,39 lumbar radiculopathy,40 and vascular claudication.41 The presence of a limp, groin pain, and limited internal rotation of the hip is more predictive of hip
disorders than disorders originating from the low back.42
Differential Diagnosis of Lateral Hip Pain
GREATER TROCHANTERIC PAIN SYNDROME
Lateral hip pain affects 10% to 25% of the general population.43 Greater trochanteric pain syndrome refers to
pain over the greater trochanter. Several disorders of the
lateral hip can lead to this type of pain, including iliotibial band thickening, bursitis, and tears of the gluteus
medius and minimus muscle attachment.43-45 Patients
may have mild morning stiffness and may be unable to
sleep on the affected side. Gluteus minimus and medius
injuries present with pain in the posterior lateral aspect
of the hip as a result of partial or full-thickness tearing at
the gluteal insertion. Most patients have an atraumatic,
insidious onset of symptoms from repetitive use.43,45,46
Data Sources: We searched articles on hip pathology in American Family Physician, along with their references. We also searched the Agency
for Healthcare Research and Quality Evidence Reports, Clinical Evidence,
Institute for Clinical Systems Improvement, the U.S. Preventive Services
Task Force guidelines, the National Guideline Clearinghouse, and UpToDate. We performed a PubMed search using the keywords greater trochanteric pain syndrome, hip pain physical examination, imaging femoral
hip stress fractures, imaging hip labral tear, imaging osteomyelitis,
ischiofemoral impingement syndrome, meralgia paresthetica review, MRI
arthrogram hip labrum, septic arthritis systematic review, and ultrasound
hip pain. Search dates: March and April 2011, and August 15, 2013.
The authors thank Kristen Prewitt, DO, (model examiner in the figures)
and Grace Trabulsi (model patient) for their assistance.
PIRIFORMIS SYNDROME
AND ISCHIOFEMORAL IMPINGEMENT
January 1, 2014
sensitive test, but tenderness with palpation of the sciatic
notch can help with the diagnosis.35
Ischiofemoral impingement is a less well-understood
condition that can lead to nonspecific buttock pain with
radiation to the posterior thigh.36,37 This condition is
thought to be a result of impingement of the quadratus
femoris muscle between the lesser trochanter and the
ischium.
Unlike sciatica from disc herniation, piriformis syndrome and ischiofemoral impingement are exacerbated
by active external hip rotation. MRI is useful for diagnosing these conditions.38
The Authors
JOHN J. WILSON, MD, MS, is an assistant professor in the Department of
Family Medicine at the University of Wisconsin School of Medicine and
Public Health in Madison. He is also a team physician for the University of
Wisconsin Intercollegiate Athletics.
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American Family Physician 33
8. Hip Pain
MASARU FURUKAWA, MD, MS, is a postgraduate trainee in the Department of Family Medicine at the University of Wisconsin School of Medicine
and Public Health.
Address correspondence to John J. Wilson, MD, MS, University of
Wisconsin–Madison, 1685 Highland Ave., Madison, WI 53705 (e-mail:
Wilson@Ortho.wisc.edu). Reprints are not available from the authors.
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