Am Fam Physician. 2014;89(1):34A-34C
| 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 and groin pain (C sign) | ||||
| Femoral neck fracture/stress fracture | Deep, referred pain; pain with weight bearing | Females (especially with female athlete triad), endurance athletes, low aerobic fitness, steroid use, smokers | Painful ROM, pain on palpation of greater trochanter | Radiography: Cortical disruption |
| MRI: Early bony edema | ||||
| Femoroacetabular impingement | Deep, referred pain; pain with standing after prolonged sitting | Pain with getting in and out of a car | FADIR and FABER tests are sensitive | Radiography: Cam or pincer deformity, acetabular retroversion, coxa profunda |
| Hip labral tear | Dull or sharp, referred pain; pain with weight bearing | Mechanical symptoms, such as catching or painful clicking; history of hip dislocation | Trendelenburg or antalgic gait, loss of internal rotation, positive FADIR and FABER tests | MRI: 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 popping | Ballet dancers, runners | Snap with FABER to extension, adduction, and internal rotation; reproduction of snapping with extension of hip from flexed position | Radiography: 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 disease | Deep, referred pain; pain with weight bearing | 2 to 12 years of age, male predominance | Antalgic gait, limited ROM or stiffness | Radiography: Early small femoral epiphysis, sclerosis and flattening of the femoral head |
| Loose bodies and chondral lesions | Deep, referred pain; painful clicking | Mechanical symptoms, history of hip dislocation or low-energy trauma, history of Legg-Calvé-Perthes disease | Limited ROM, catching and grinding with provocative maneuvers, positive FADIR and FABER tests | Radiography: Can show ossified or osteochondral loose bodies |
| MRI: Can detect chondral and fibrous loose bodies | ||||
| Osteoarthritis of the hip | Deep, aching pain and stiffness; pain with weight bearing | Older than 50 years, pain with activity that is relieved with rest | Internal rotation < 15 degrees, flexion < 115 degrees | Radiography: Presence of osteophytes at the acetabular joint margin, asymmetrical joint-space narrowing, subchondral sclerosis and cyst formation |
| Osteonecrosis of the hip | Deep, referred pain; pain with weight bearing | Adults: Lupus, sickle cell disease, human immunodeficiency virus infection, corticosteroid use, smoking, and alcohol use; insidious onset, but can be acute with history of trauma | Pain on ambulation, positive log roll test, gradual limitation of ROM | Radiography: 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 epiphysis | Deep, referred pain; pain with weight bearing | 11 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 rotation | Radiography: Widened epiphysis early, slippage of femur under epiphysis later |
| Septic arthritis | Refusal to bear weight, pain with leg movement | Children: 3 to 8 years of age, fever, ill appearance | Guarding against any ROM; pain with passive ROM | Hip 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 synovitis | Refusal to bear weight | Children: 3 to 8 years of age, sometimes fever and ill appearance | Pain with extremes of ROM | |
| Lateral pain | ||||
| External snapping hip* | Pain with direct pressure, radiation down lateral thigh, snapping or popping | All age groups, audible snap with ambulation | Positive Ober test, snap with Ober test, pain over greater trochanter | Radiography: 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 thigh | Runners, middle-aged women | Pain over greater trochanter | |
| Dynamic ultrasonography: Snapping of iliopsoas or iliotibial band over greater trochanter | ||||
| Greater trochanteric pain syndrome | Pain with direct pressure, radiation down lateral thigh | Associated with knee osteoarthritis, increased body mass index, low back pain; female predominance | Proximal 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 buttock | Middle-aged women | Weak hip abduction, pain with resisted external rotation, Trendelenburg gait is sensitive and specific | MRI: Gluteal muscle edema or tears |
| Iliac crest apophysis avulsion | Tenderness to direct palpation | History of direct trauma, skeletal immaturity (younger than 25 years) | Iliac crest tenderness and/or ecchymosis | Radiography: Apophysis widening, soft tissue swelling around iliac crest |
| Posterior pain | ||||
| Hamstring muscle strain or avulsion | Buttock pain, pain with direct pressure | Eccentric muscle contraction while hip flexed and leg extended | Ischial tuberosity tenderness, ecchymosis, weakness to leg flexion, palpable gap in hamstring | Radiography: Avulsion or strain of hamstring attachment to ischium |
| Ischial apophysis avulsion | Buttock pain, pain with direct pressure | Skeletal immaturity, eccentric muscle contraction (cutting, kicking, jumping) | MRI: Hamstring edema and retraction | |
| Ischiofemoral impingement | Buttock or back pain with posterior thigh radiation, sciatica symptoms | Groin and/or buttock pain that may radiate distally | None established | MRI: Soft tissue edema around quadratus femoris muscle |
| Piriformis syndrome | Buttock pain with posterior thigh radiation, sciatica symptoms | History of direct trauma to buttock or pain with sitting, weakness and numbness are rare compared with lumbar radicular symptoms | Positive log roll test, tenderness over the sciatic notch | MRI: Lumbar spine has no disk herniation, piriformis muscle atrophy or hypertrophy, edema surrounding the sciatic nerve |
| Sacroiliac joint dysfunction | Pain radiates to lumbar back, buttock, and groin | Female predominance, common in pregnancy, history of minor trauma | FABER test elicits posterior pain localized to the sacroiliac joint, sacroiliac joint line tenderness | Radiography: Possibly no findings, narrowing and sclerotic changes of the sacroiliac joint space |
