Evaluation of the Patient with Hip Pain



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Am Fam Physician. 2014 Jan 1;89(1):27-34.

  Patient information: See related handout on hip pain, written by the authors of this article.

This version of the article contains supplemental content.

This clinical content conforms to AAFP criteria for continuing medical education (CME). See CME Quiz questions.

Author disclosure: No relevant financial affiliations.

Hip pain is a common and disabling condition that affects patients of all ages. The differential diagnosis of hip pain is broad, presenting a diagnostic challenge. Patients often express that their hip pain is localized to one of three anatomic regions: the anterior hip and groin, the posterior hip and buttock, or the lateral hip. Anterior hip and groin pain is commonly associated with intra-articular pathology, such as osteoarthritis and hip labral tears. Posterior hip pain is associated with piriformis syndrome, sacroiliac joint dysfunction, lumbar radiculopathy, and less commonly ischiofemoral impingement and vascular claudication. Lateral hip pain occurs with greater trochanteric pain syndrome. Clinical examination tests, although helpful, are not highly sensitive or specific for most diagnoses; however, a rational approach to the hip examination can be used. Radiography should be performed if acute fracture, dislocations, or stress fractures are suspected. Initial plain radiography of the hip should include an anteroposterior view of the pelvis and frog-leg lateral view of the symptomatic hip. Magnetic resonance imaging should be performed if the history and plain radiograph results are not diagnostic. Magnetic resonance imaging is valuable for the detection of occult traumatic fractures, stress fractures, and osteonecrosis of the femoral head. Magnetic resonance arthrography is the diagnostic test of choice for labral tears.

Hip pain is a common presentation in primary care and can affect patients of all ages. In one study, 14.3% of adults 60 years and older reported significant hip pain on most days over the previous six weeks.1  Hip pain often presents a diagnostic and therapeutic challenge. The differential diagnosis of hip pain (eTable A) is broad, including both intra-articular and extra-articular pathology, and varies by age. A history and physical examination are essential to accurately diagnose the cause of hip pain.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendation 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 imaging-guided injections and aspirations around the hip.

C

8, 9


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

View Table

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendation 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 imaging-guided injections and aspirations around the hip.

C

8, 9


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.

eTable A

Differential Diagnosis of Hip Pain

Diagnosis Pain characteristics History/risk factors Examination findings Additional testing

Anterior thigh pain

Meralgia paresthetica

Paresthesia, hypesthesia

Obesity, pregnancy, tight pants or belt, conditions with increased intra-abdominal pressure

Anterior thigh hypesthesia, dysesthesia

None

Anterior groin pain

Athletic pubalgia (sports hernia)

Dull, diffuse pain radiating to inner thigh; pain with direct pressure, sneezing, sit-ups, kicking, Valsalva maneuver

Soccer, rugby, football, hockey players

No hernia, tenderness of the inguinal canal or pubic tubercle, adductor origin, pain with resisted sit-up or hip flexion

Radiography: No bony involvement

MRI: Can show tear or detachment of the rectus abdominis or adductor longus

Anterolateral hip

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.

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.

The authors thank Kristen Prewitt, DO, (model examiner in the figures) and Grace Trabulsi (model patient) for their assistance.

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