Approach to hip pain: Clinical sciences

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Introduction0:00–0:24

Hip pain is a common presentation in the primary care setting. It’s important to first identify if your patient’s hip pain is due to trauma or infection.
Other possible types of hip pain are assessed based on anatomic location and include either anterior, lateral, or posterior hip pain.
If your patient presents with hip pain, start with a focused history and physical examination. Patients report pain in the hip, while the exam might reveal edema, erythema, warmth, hip tenderness, gait abnormalities, and limited joint range of motion.

Focused H&P0:24–0:43

Fracture/dislocation0:43–1:28

Your next step is to assess for trauma. This includes an obvious mechanism of injury, like a motor vehicle collision or sports injury, or if there’s a joint deformity or ligamentous laxity.
If trauma is present, think fracture, dislocation, or labral tear. Patients with fractures or dislocations are likely older and may have osteoporosis.
Physical exam reveals an inability to walk on the affected limb and a shortened externally rotated abducted leg. With these findings, consider fracture or dislocation and obtain a hip x-ray.
If it shows a fracture or dislocation, that’s your diagnosis. Now, patients with labral tears are typically young athletic adults with abrupt onset of pain that might be from a sports injury or repetitive motion.

Labral tear1:28–2:11

They may also report a popping, catching, or clicking sound. Exam typically reveals a positive FADIR test which is when you reproduce pain in the groin when performing flexion, adduction, and internal rotation of the hip.
They might also have a positive FABER test which is when you elicit hip pain with hip flexion, abduction, and external rotation.
With these findings, consider a labral tear and obtain a hip MRI. If it shows a defect of the labrum, diagnose a labral tear.
On the other hand, if trauma is not present, assess for signs of infection like fever, chills, myalgias, and localized tenderness.

Septic arthritis2:11–3:30

If signs of infections are present, your patient may report difficulty moving their hip joint due to pain and swelling. Physical exam will reveal warmth, erythema, and tenderness to palpation over the hip as well as limited and painful range of motion.
Based on these findings, consider septic arthritis and aspirate synovial fluid for analysis of cell count and differential, gram stain, culture, and the presence of crystals.
If the synovial fluid has a cloudy or purulent appearance, a white blood cell count of 50,000 or more, the gram stain and culture are positive for bacteria, and the sample is negative for crystals, diagnose septic arthritis.
Here’s a clinical pearl! Hip ultrasound and MRI are not necessary for diagnosis but might help with the evaluation and management of septic arthritis.
Ultrasound determines the size and location of joint effusion and is often used to guide optimal needle placement for joint aspiration, while MRI helps characterize the effusion and identify inflammation of surrounding structures.
Alright, if there are no signs of infection, assess the location of the pain. If the pain is in the anterior hip, assess the underlying cause.

Hip flexor tendonitis3:30–4:20

Let’s start with hip flexor tendonitis. History typically reveals overuse activity of hip flexors which is common in high-intensity sports requiring repetitive motion at the hip, like running or cycling.
In some cases, your patient might describe a clicking or snapping over the hip. On exam, there is pain with hip flexion, especially against resistance, and tenderness to palpation over the anterior superior iliac spine, or ASIS, the anterior inferior iliac spine, or AIIS, or the pubic symphysis.
With these findings, diagnose hip flexor tendonitis. Next up is femoroacetabular impingement.

Femoroacetabular Impingement4:20–5:23

These patients report a gradual onset of pain exacerbated by flexion and internal rotation, while physical exam reveals positive FADIR and FABER tests.
In this case, consider femoroacetabular impingement and obtain hip and pelvis x-rays. Imaging will reveal a cam deformity, which is an abnormal bony prominence at the junction of the femoral head and neck, and a pincer deformity, which involves excessive bony overcoverage of the acetabulum over the femoral head.
With these findings, diagnose femoroacetabular impingement. Here's a clinical pearl!
Pediatric hip disorders including slipped capital femoral epiphysis, developmental dysplasia, and Legg-Calvé-Perthes disease can result in bony changes in the femur and acetabulum that contribute to the development of femoroacetabular impingement.
Moving on to osteoarthritis. Your patient is typically older and reports gradual onset of pain with prolonged weight bearing.

Osteoarthritis5:23–5:53

Exam reveals an antalgic gait, pain with flexion and rotation, and limited range of motion. With these findings, consider osteoarthritis and obtain hip and pelvis x-rays.
If imaging shows joint space narrowing, osteophyte formation, and subchondral sclerosis, that’s osteoarthritis. Let’s go back a step.

Meralgia Paresthetica5:53–7:07

If your patient’s hip pain is localized to the lateral hip, then assess the underlying cause. First up is meralgia paresthetica, which occurs when the lateral femoral cutaneous nerve is impinged at or near its point of passage through the inguinal ligament.
History might reveal burning or numbness of the upper lateral thigh worsened with prolonged hip extension including walking and standing.
Patients might also report wearing tight-fitting clothes around the waist, recent trauma to the hip region, weight gain, or pregnancy.
Physical exam might reveal numbness and allodynia of the anterior thigh, as well as a positive Tinel’s test with pain elicited when tapping over the inguinal ligament near the ASIS.
Lastly, perform the pelvic compression test by positioning the patient in the lateral recumbent position with the symptomatic side facing up.
Apply a downward compression force to the pelvis, which slackens the inguinal ligament, and hold for 45 seconds. If the patient reports alleviation of symptoms, this is diagnostic for meralgia paresthetica.

Greater Trochanteric Pain Syndrome7:07–7:57

Next up is greater trochanteric pain syndrome, which includes greater trochanteric bursitis, iliotibial band dysfunction, and tears of the gluteus medius or minimus muscle attachments on the greater trochanter.
Your patient is likely a biological female and obese. They report pain in the lateral thigh aggravated by prolonged sitting, walking upstairs, or lying on the affected side.
Physical exam usually reveals tenderness to palpation over the greater trochanter with painful abduction and adduction of the hip.
There might be positive FABER and FADIR tests, or you might see the Trendelenburg sign, which indicates weakness in the gluteus medius and gluteus minimus muscles.
With these findings, diagnose greater trochanteric pain syndrome. Now that we’ve reviewed conditions that cause anterior and lateral hip pain, let’s move on to the posterior hip and assess for an underlying cause.

Lumbar Radiculopathy7:57–9:24

First up is lumbar radiculopathy. Your patient will report an insidious onset of burning or lancinating pain radiating from the low back towards the buttock, hip, and down the leg in a dermatomal distribution.
The exam might reveal a positive straight leg raise test, myotomal weakness, dermatomal sensory deficit, and reduced patellar or Achilles reflexes.
With these findings, diagnose lumbar radiculopathy. Here’s a clinical pearl!
Radiculopathy refers to a dermatomal pattern of pain radiation with accompanying neurologic findings on exam, generally caused by spinal nerve root compression.
Radiculitis is due to an inflamed spinal nerve root causing dermatomal radicular pain usually without neurologic findings.
On the other hand, referred pain has a distribution of pain that is not in a dermatomal distribution. For example, pseudo-radiculitis is a characteristic referred pain distribution down the thigh in a non-dermatomal distribution that rarely radiates past the knee, usually associated with posterior hip structures.

Piriformis Syndrome9:24–10:05

Next up is piriformis syndrome. History usually reveals pain in the buttock worsened by external hip rotation, prolonged sitting, or getting out of bed.
Patients might also describe pain in the posterolateral thigh, consistent with pseudoradicular pain. Physical exam might reveal tenderness to palpation around the sciatic notch, a positive straight leg raise test, and a positive FADIR test; where flexion, adduction, and internal rotation stretch the piriformis muscle, irritating the sciatic nerve and reproducing the patient’s symptoms.
With these findings, diagnose piriformis syndrome. Moving on to sacroiliac joint dysfunction.

Sacroiliac Dysfunction10:05–10:49

These patients report pain in the lumbar spinal and buttock region that is exacerbated by sitting or climbing stairs. They might also describe pain in their posterolateral thigh, consistent with pseudoradicular pain.
There are often inciting events like a fall, repetitive exercise, or pregnancy. Physical exam might reveal a positive FABER test with reproduction of pain in the affected sacroiliac joint.
Also, your patient might have a positive sacral thrust test, where downward force is applied to the sacrum, reproducing the pain.
With these findings, diagnose sacroiliac dysfunction. Last up is hamstring injury.

Hamstring Injury10:49–11:24

In this case, patients report an abrupt onset of posterior thigh pain that’s often sports-related due to overuse and rapid shifts between acceleration and deceleration.
Physical exam reveals tenderness to palpation in the posterior thigh along the hamstring, especially at its proximal attachment to the ischial tuberosity.
There might be hamstring weakness, limited painful range of motion, edema, and ecchymoses. If you see these findings, diagnose hamstring injury.
Alright, as a quick recap... When your patient presents with hip pain, first assess for trauma causing a fracture, dislocation, or labral tear.

Review11:24–12:07

Next, assess for an infection in the hip to rule out septic arthritis. If there is no infection, assess the anatomic location of the pain.
Causes of anterior hip pain include hip flexor tendonitis, femoroacetabular impingement, and osteoarthritis. Lateral pain stems from meralgia paresthetica and greater trochanteric pain syndrome.
Finally, causes of posterior hip pain include lumbar radiculopathy, piriformis syndrome, sacroiliac dysfunction, and hamstring injury.