Hip Pain in Adults: Evaluation and Differential Diagnosis

 

Am Fam Physician. 2021 Jan 15;103(2):81-89.

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

Author disclosure: No relevant financial affiliations.

Adults commonly present to their family physicians with hip pain, and diagnosing the cause is important for prescribing effective therapy. Hip pain is usually located anteriorly, laterally, or posteriorly. Anterior hip pain includes referred pain from intra-abdominal or intrapelvic causes; extra-articular etiologies, such as hip flexor injuries; and intra-articular etiologies. Intra-articular pain is often caused by a labral tear or femoroacetabular impingement in younger adults or osteoarthritis in older adults. Lateral hip pain is most commonly caused by greater trochanteric pain syndrome, which includes gluteus medius tendinopathy or tear, bursitis, and iliotibial band friction. Posterior hip pain includes referred pain such as lumbar spinal pathology, deep gluteal syndrome with sciatic nerve entrapment, ischiofemoral impingement, and hamstring tendinopathy. In addition to the history and physical examination, radiography, ultrasonography, or magnetic resonance imaging may be needed for a definitive diagnosis. Radiography of the hip and pelvis should be the initial imaging test. Ultrasound-guided anesthetic injections can aid in the diagnosis of an intra-articular cause of pain. Because femoroacetabular impingement, labral tears, and gluteus medius tendon tears typically have good surgical outcomes, advanced imaging and/or early referral may improve patient outcomes.

Hip pain is common in adults of all ages and activity levels. In nonelite adult soccer players, hip and groin injuries represent 28% to 45% of all injuries in women and 49% to 55% in men.1 The prevalence of the cam deformity (deformity of the femoral head) is 41% in nonelite male soccer players and 17% in male nonathletes.2 In adults older than 45 years, 6.7% to 9.7% have osteoarthritis of the hip, and one in four adults will develop symptomatic hip osteoarthritis in their lifetime.3 In the United States in 2009, hip replacements accounted for $13.7 billion in health care costs.3

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SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingComments

If imaging is performed in the evaluation of a patient with undifferentiated chronic hip pain, standing anteroposterior hip and pelvic radiographs should be the first choice.4,21

C

Expert opinion and consensus guidelines

For patients with anterior hip pain and history suggestive of a labral tear, stress fracture of the femoral neck, or early avascular necrosis, magnetic resonance imaging should be performed for accurate diagnosis.5,11,12,2123

C

Expert opinion and reviews of prospective and randomized trials

For intra-articular pain, ultrasound-guided anesthetic injection of the hip may be diagnostic, and corticosteroid injection may be therapeutic.30

C

Clinical review and expert opinion

For patients with greater trochanteric pain syndrome not responding to conservative therapy, ultrasonography or magnetic resonance imaging should be considered to evaluate for gluteus medius tendon tears.15,16,21

C

Clinical reviews and expert opinion


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 tohttps://www.aafp.org/afpsort.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingComments

If imaging is performed in the evaluation of a patient with undifferentiated chronic hip pain, standing anteroposterior hip and pelvic radiographs should be the first choice.4,21

C

Expert opinion and consensus guidelines

For patients with anterior hip pain and history suggestive of a labral tear, stress fracture of the femoral neck, or early avascular necrosis, magnetic resonance imaging should be performed for accurate diagnosis.5,11,12,2123

C

Expert opinion and reviews of prospective and randomized trials

For intra-articular pain, ultrasound-guided anesthetic injection of the hip may be diagnostic, and corticosteroid injection may be therapeutic.30

C

Clinical review and expert opinion

For patients with greater trochanteric pain syndrome not responding to conservative therapy, ultrasonography or magnetic resonance imaging should be considered to evaluate for gluteus medius tendon tears.15,16,21

C

Clinical reviews and expert opinion


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 tohttps://www.aafp.org/afpsort.

Approach to Evaluation

Hip pain is often localized to one of three locations: anterior, lateral,

The Author

RACHEL CHAMBERLAIN, MD, CAQSM, is the associate program director of the Sports Medicine Fellowship and an assistant professor in the Department of Family and Community Medicine at the University of New Mexico, Albuquerque.

Address correspondence to Rachel Chamberlain, MD, CAQSM, 1 University of New Mexico, Albuquerque, NM 87131 (email: rchamberlain@salud.unm.edu). Reprints are not available from the author.

Author disclosure: No relevant financial affiliations.

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