This is a corrected version of the article that appeared in print.
Am Fam Physician. 2021;103(2):81-89
Related letter: Additional Differential Diagnosis for Adult Hip Pain
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
| Clinical recommendation | Evidence rating | Comments |
|---|---|---|
| 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, orearly avascular necrosis, magnetic resonance imaging should be performed for accurate diagnosis.5,11,12,21–23 | 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 |
Approach to Evaluation
| Type of pain | History | Physical examination |
|---|---|---|
| Anterior | ||
| Referred | ||
| Intra-abdominal or intrapelvic4–6 | Pain associated with urinary or bowel symptoms, cyclic pain associated with menses | Abdominal and/or pelvic examination |
| Extra-articular | ||
| Flexor tendon5,6 | Overuse activities, acute strain or injury with hip flexion activities | Pain over the hip bony prominence, anterior superior iliac spine, anterior inferior iliac spine, or pubic symphysis; pain with hip flexion strength testing |
| Intra-articular | ||
| Femoroacetabular impingement2,5,7,8 | Young, athletic patient; gradual onset; pain with hip range of motion; history of slipped capital femoral epiphysis or developmental dysplasia | Positive FADDIR and FABER test results |
| Labral tear5,9 | Young, athletic patient; acute injury (vs. gradual onset); pain with hip range of motion; mechanical symptoms | Positive FADDIR and FABER test results |
| Femoral neck stress fracture5,10 | Overuse/overtraining, energy imbalance in athletes | Antalgic gait, pain with range of motion and ambulating |
| Avascular necrosis11,12 | Middle or older age, smoking, alcohol use, systemic corticosteroid use, hemoglobinopathies, chemotherapy, metabolic syndrome, and obesity | Antalgic gait, pain with range of motion, limited range of motion |
| Osteoarthritis3,4,7,13 | Older age, gradual onset, pain with sitting or ambulating for long periods | Antalgic gait, pain with flexion and internal and external rotation, limited range of motion |
| Hip fracture4,14 | Older age, osteoporosis, fall/trauma | Inability to walk on the affected limb; shortened, externally rotated, abducted leg |
| Lateral | ||
| Greater trochanteric pain syndrome, including bursitis, gluteus medius tendinopathy or tear, external snapping, or iliotibial band friction7,15,16 | No injury, middle age, female sex, overweight, pain with sleeping on affected hip, pain aggravated by physical activity or sitting for long periods | Tenderness to palpation over the lateral hip/greater trochanter, Trendelenburg gait or positive Trendelenburg test, positive resisted external derotation test |
| Posterior | ||
| Referred pain | ||
| Intra-abdominal or intrapelvic4,17 | Pain associated with urinary or bowel symptoms, cyclic pain associated with menses | Abdominal and/or pelvic examination |
| Deep gluteal syndrome17,18 | Deep buttock pain; no injury; worse with sitting, especially in a car; sciatica (burning pain shooting down the leg) | Seated piriformis stretch test |
| Ischiofemoral impingement19 | Gradual onset of deep buttock pain that worsens with activities requiring a long stride (e.g., running) | Long-stride walking test |
| Lumbar spine or muscle4,17 | Pain in the low back (above L5) and hip/buttock, history of lumbar spinal problems | Tenderness over the lumbar spine or lumbar musculature above L5 |
| Sacroiliac joint pain17 | No history of lumbar spinal issues | Tenderness over the sacroiliac joint, no tenderness above L5 |
| Proximal hamstring tendinopathy or tear20 | Overuse injury with hip extension activities (vs. acute injury with forceful hip extension) | Tenderness to palpation over the ischial tuberosity, pain with hamstring strength testing; acute tears cause ecchymosis of the posterior thigh |
The history should include personal history of developmental hip dysplasia, slipped capital femoral epiphysis, sports activities, and injuries; family history of hip problems; and the location and quality of pain, aggravating and alleviating factors, and mechanical symptoms.4,8 Physical examination should include gait analysis with particular attention to antalgic or Trendelenburg gait, evaluation of the range of motion in the hip joint and associated pain, strength testing of the muscles overlying the hip joint, palpation of the painful area, and special tests as indicated.
If imaging is performed in the evaluation of a patient with undifferentiated chronic hip pain, standing anteroposterior hip and pelvic radiography is typically the initial imaging study.4,21 Magnetic resonance imaging (MRI) or ultrasonography may be helpful in the diagnosis, depending on history and physical examination findings.21–23
Anterior Hip Pain
Intra-articular hip pain predominately presents anteriorly.4,5 In young adults, anterior hip or groin pain that is aggravated by hip flexion or rotation warrants evaluation for intra-articular pathologies. Hip flexor strains, tears, and avulsion fractures can cause anterior hip pain, with the patient history often including a sports-related or traumatic incident consistent with a flexor injury.5 Because referred pain from intra-abdominal problems can present as anterior hip pain, the abdomen should be examined for gastrointestinal causes of pain, such as a mass; appendicitis; hernia; or pain originating in the bladder (e.g., from a mass) or the female reproductive system (e.g., from ovarian cysts).4,6
FEMOROACETABULAR IMPINGEMENT
Femoroacetabular impingement is one of the most common causes of hip pain in young adults.24 It can be caused by a cam deformity, which is bony overgrowth of the femoral head and neck, a pincer deformity of the acetabulum (too much coverage of the femoral head), or both (Figure 225 ). Femoroacetabular impingement often has a gradual onset without a specific injury. It usually presents earlier in the disease process with less bony changes in athletes than in nonathletes and is more bothersome to athletes whose activities require hyperflexion and wide range of motion at the hip joint.2,5,9 Positive results on the flexion adduction internal rotation and flexion abduction external rotation tests (Figure 3 and Figure 4) are indicative of intra-articular hip pathology.4,7
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