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Am Fam Physician. 2014;89(1):34A-34C

DiagnosisPain characteristicsHistory/risk factorsExamination findingsAdditional testing
Anterior thigh pain
Meralgia parestheticaParesthesia, hypesthesiaObesity, pregnancy, tight pants or belt, conditions with increased intra-abdominal pressureAnterior thigh hypesthesia, dysesthesiaNone
Anterior groin pain
Athletic pubalgia (sports hernia)Dull, diffuse pain radiating to inner thigh; pain with direct pressure, sneezing, sit-ups, kicking, Valsalva maneuverSoccer, rugby, football, hockey playersNo hernia, tenderness of the inguinal canal or pubic tubercle, adductor origin, pain with resisted sit-up or hip flexionRadiography: No bony involvement
MRI: Can show tear or detachment of the rectus abdominis or adductor longus
Anterolateral hip and groin pain (C sign)
Femoral neck fracture/stress fractureDeep, referred pain; pain with weight bearingFemales (especially with female athlete triad), endurance athletes, low aerobic fitness, steroid use, smokersPainful ROM, pain on palpation of greater trochanterRadiography: Cortical disruption
MRI: Early bony edema
Femoroacetabular impingementDeep, referred pain; pain with standing after prolonged sittingPain with getting in and out of a carFADIR and FABER tests are sensitiveRadiography: Cam or pincer deformity, acetabular retroversion, coxa profunda
Hip labral tearDull or sharp, referred pain; pain with weight bearingMechanical symptoms, such as catching or painful clicking; history of hip dislocationTrendelenburg or antalgic gait, loss of internal rotation, positive FADIR and FABER testsMRI: Can show a labral tear
Magnetic resonance arthrography: offers added sensitivity and specificity
Iliopsoas bursitis (internal snapping hip)Deep, referred pain; intermittent catching, snapping, or poppingBallet dancers, runnersSnap with FABER to extension, adduction, and internal rotation; reproduction of snapping with extension of hip from flexed positionRadiography: No bony involvement
MRI: Bursitis and edema of the iliotibial band
Ultrasonography: Tendinopathy, bursitis, fluid around tendon
Dynamic ultrasonography: Snapping of iliopsoas or iliotibial band over greater trochanter
Legg-Calvé-Perthes diseaseDeep, referred pain; pain with weight bearing2 to 12 years of age, male predominanceAntalgic gait, limited ROM or stiffnessRadiography: Early small femoral epiphysis, sclerosis and flattening of the femoral head
Loose bodies and chondral lesionsDeep, referred pain; painful clickingMechanical symptoms, history of hip dislocation or low-energy trauma, history of Legg-Calvé-Perthes diseaseLimited ROM, catching and grinding with provocative maneuvers, positive FADIR and FABER testsRadiography: Can show ossified or osteochondral loose bodies
MRI: Can detect chondral and fibrous loose bodies
Osteoarthritis of the hipDeep, aching pain and stiffness; pain with weight bearingOlder than 50 years, pain with activity that is relieved with restInternal rotation < 15 degrees, flexion < 115 degreesRadiography: Presence of osteophytes at the acetabular joint margin, asymmetrical joint-space narrowing, subchondral sclerosis and cyst formation
Osteonecrosis of the hipDeep, referred pain; pain with weight bearingAdults: Lupus, sickle cell disease, human immunodeficiency virus infection, corticosteroid use, smoking, and alcohol use; insidious onset, but can be acute with history of traumaPain on ambulation, positive log roll test, gradual limitation of ROMRadiography: Femoral head lucency and subchondral sclerosis, subchondral collapse (i.e., crescent sign), flattening of the femoral head
MRI: Bony edema, subchondral collapse
Slipped capital femoral epiphysisDeep, referred pain; pain with weight bearing11 to 14 years of age, overweight (80th to 100th percentile)Antalgic gait with foot externally rotated on occasion, positive log roll and straight leg raise against resistance tests, pain with hip internal rotation relieved with external rotationRadiography: Widened epiphysis early, slippage of femur under epiphysis later
Septic arthritisRefusal to bear weight, pain with leg movementChildren: 3 to 8 years of age, fever, ill appearanceGuarding against any ROM; pain with passive ROMHip aspiration guided by fluoroscopy, computed tomography, or ultrasonography; Gram stain and culture of joint aspirate
Adults: Older than 80 years, diabetes mellitus, rheumatoid arthritis, recent joint surgery, hip or knee prostheses
MRI: Useful for differentiating septic arthritis from transient synovitis
Transient synovitisRefusal to bear weightChildren: 3 to 8 years of age, sometimes fever and ill appearancePain with extremes of ROM
Lateral pain
External snapping hip*Pain with direct pressure, radiation down lateral thigh, snapping or poppingAll age groups, audible snap with ambulationPositive Ober test, snap with Ober test, pain over greater trochanterRadiography: No bony involvement
MRI: Bursitis and edema of the iliotibial band
Ultrasonography: Tendinopathy, bursitis, fluid around tendon
Greater trochanteric bursitis*Pain with direct pressure, radiation down lateral thighRunners, middle-aged womenPain over greater trochanter
Dynamic ultrasonography: Snapping of iliopsoas or iliotibial band over greater trochanter
Greater trochanteric pain syndromePain with direct pressure, radiation down lateral thighAssociated with knee osteoarthritis, increased body mass index, low back pain; female predominanceProximal iliotibial band tenderness, Trendelenburg gait is sensitive and specific
Posterolateral pain
Gluteal muscle tear or avulsion*Pain with direct pressure, radiation down lateral thigh and buttockMiddle-aged womenWeak hip abduction, pain with resisted external rotation, Trendelenburg gait is sensitive and specificMRI: Gluteal muscle edema or tears
Iliac crest apophysis avulsionTenderness to direct palpationHistory of direct trauma, skeletal immaturity (younger than 25 years)Iliac crest tenderness and/or ecchymosisRadiography: Apophysis widening, soft tissue swelling around iliac crest
Posterior pain
Hamstring muscle strain or avulsionButtock pain, pain with direct pressureEccentric muscle contraction while hip flexed and leg extendedIschial tuberosity tenderness, ecchymosis, weakness to leg flexion, palpable gap in hamstringRadiography: Avulsion or strain of hamstring attachment to ischium
Ischial apophysis avulsionButtock pain, pain with direct pressureSkeletal immaturity, eccentric muscle contraction (cutting, kicking, jumping)MRI: Hamstring edema and retraction
Ischiofemoral impingementButtock or back pain with posterior thigh radiation, sciatica symptomsGroin and/or buttock pain that may radiate distallyNone establishedMRI: Soft tissue edema around quadratus femoris muscle
Piriformis syndromeButtock pain with posterior thigh radiation, sciatica symptomsHistory of direct trauma to buttock or pain with sitting, weakness and numbness are rare compared with lumbar radicular symptomsPositive log roll test, tenderness over the sciatic notchMRI: Lumbar spine has no disk herniation, piriformis muscle atrophy or hypertrophy, edema surrounding the sciatic nerve
Sacroiliac joint dysfunctionPain radiates to lumbar back, buttock, and groinFemale predominance, common in pregnancy, history of minor traumaFABER test elicits posterior pain localized to the sacroiliac joint, sacroiliac joint line tendernessRadiography: Possibly no findings, narrowing and sclerotic changes of the sacroiliac joint space

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