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January 1, 2014 ◆ Volume 89, Number 1 www.aafp.org/afp American Family Physician 27
Evaluation of the Patient with Hip PainJOHN J. WILSON, MD, MS, and MASARU FURUKAWA, MD, MS, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
Hip pain is a common presenta-tion 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 thera-peutic 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 accu-rately diagnose the cause of hip pain.
AnatomyThe hip joint is a ball-and-socket synovial joint designed to allow multiaxial motion while transferring loads between the upper and lower body. The acetabular rim is lined by fibrocartilage (labrum), which adds depth and stability to the femoroacetabular joint. The articular surfaces are covered by hya-line cartilage that dissipates shear and com-pressive forces during load bearing and hip motion. The hip’s major innervating nerves originate in the lumbosacral region, which can make it difficult to distinguish between primary hip pain and radicular lumbar pain.
The hip joint’s wide range of motion is sec-ond only to that of the glenohumeral joint
and is enabled by the large number of mus-cle groups that surround the hip. The flexor muscles include the iliopsoas, rectus femoris, pectineus, and sartorius muscles. The glu-teus maximus and hamstring muscle groups allow for hip extension. Smaller muscles, such as gluteus medius and minimus, piriformis, obturator externus and internus, and quadra-tus femoris muscles, insert around the greater trochanter, allowing for abduction, adduc-tion, and internal and external rotation.
In persons who are skeletally immature, there are several growth centers of the pelvis and femur where injuries can occur. Poten-tial sites of apophyseal injury in the hip region include the ischium, anterior superior iliac spine, anterior inferior iliac spine, iliac crest, lesser trochanter, and greater trochan-ter. The apophysis of the superior iliac spine matures last and is susceptible to injury up to 25 years of age.2
Evaluation of Hip PainHISTORY
Age alone can narrow the differential diag-nosis of hip pain. In prepubescent and ado-lescent patients, congenital malformations of the femoroacetabular joint, avulsion frac-tures, and apophyseal or epiphyseal inju-ries should be considered. In those who are
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 ana-tomic 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 syn-drome. 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, disloca-tions, 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. (Am Fam Physician. 2014;89(1):27-34. Copyright © 2014 American Academy of Family Physicians.)
▲
Patient information: A handout on this topic, written by the authors of this article, is avail-able at http://www.aafp.org/afp/2014/0101/p27-s1.html. Access to this handout is free and unrestricted.
More online at http://www.aafp.org/afp.
CME This clinical content conforms to AAFP criteria for continuing medical education (CME). See CME Quiz questions on page 6.
Author disclosure: No rel-evant financial affiliations.
Downloaded from the American Family Physician website at www.aafp.org/afp. Copyright © 2014 American Academy of Family Physicians. For the private, non-commercial use of one individual user of the website. All other rights reserved. Contact [email protected] for copyright questions and/or permission requests.
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28 American Family Physician www.aafp.org/afp Volume 89, Number 1 ◆ January 1, 2014
skeletally mature, hip pain is often a result of muscu-lotendinous strain, ligamentous sprain, contusion, or bursitis. In older adults, degenerative osteoarthritis and fractures should be considered first.
Patients with hip pain should be asked about ante-cedent trauma or inciting activity, factors that increase or decrease the pain, mechanism of injury, and time of
onset. Questions related to hip function, such as the ease of getting in and out of a car, putting on shoes, running, walking, and going up and down stairs, can be helpful.3 Location of the pain is informative because hip pain often localizes to one of three basic anatomic regions: the anterior hip and groin, posterior hip and buttock, and lateral hip (eFigure A).
Figure 1. Gait testing. (A) C sign. Patients often localize pain by cupping the anterolateral hip with the thumb and fore-finger in the shape of a “C.” (B) Gait analysis. The patient is observed while walking to evaluate for limp or antalgic gait characteristics. (C) Modified Trendelenburg test (single leg stance phase). The patient stands with feet shoulder width apart and lifts one leg. The examiner observes for a drop in the level of the iliac crest on the side of the lifted leg.
A CB
SORT: KEY RECOMMENDATIONS FOR PRACTICE
Clinical recommendationEvidence 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.
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January 1, 2014 ◆ Volume 89, Number 1 www.aafp.org/afp American Family Physician 29
PHYSICAL EXAMINATION
The hip examination should evaluate the hip, back, abdomen, and vascular and neurologic systems. It should start with a gait analysis and stance assessment (Figure 1), followed by evaluation of the patient in seated, supine, lateral, and prone positions (Figures 2 through 6, and eFigure B). Physical examination tests for the evalu-ation of hip pain are summarized in Table 1.
IMAGING
Radiography. Radiography of the hip should be per-formed if there is any suspicion of acute fracture, dislo-cation, or stress fracture. Initial plain radiography of the hip should include an anteroposterior view of the pelvis and a frog-leg lateral view of the symptomatic hip.4
Magnetic Resonance Imaging and Arthrography. Con-ventional magnetic resonance imaging (MRI) of the hip can detect many soft tissue abnormalities, and is the preferred imaging modality if plain radiography does not identify specific pathology in a patient with persis-tent pain.5 Conventional MRI has a sensitivity of 30% and an accuracy of 36% for diagnosing hip labral tears, whereas magnetic resonance arthrography provides added sensitivity of 90% and accuracy of 91% for the detection of labral tears.6,7
Ultrasonography. Ultrasonography is a useful tech-nique for evaluating individual tendons, confirm-ing suspected bursitis, and identifying joint effusions and functional causes of hip pain.8 Ultrasonography is especially useful for safely and accurately performing
Table 1. Physical Examination Tests for the Evaluation of Hip Pain
Test Other names Positioning Positive findings Differential diagnosis
Gait testing (C sign, Figure 1A; gait analysis, Figure 1B)
— Standing Antalgic gait, Trendelenburg gait, pelvic wink (rotation of more than 40 degrees in the axial plane toward the affected hip when terminally extending the hip), excessive pronation or supination of the ankles, and limps caused by differing leg lengths
Hip labral tear, transient synovitis, Legg-Calvé-Perthes disease, SCFE
Modified Trendelenburg test (Figure 1C)
Single leg stance phase
Standing 2-cm drop in the level of the iliac crest, indicating weakness on the contralateral side
Hip labral tear, transient synovitis, Legg-Calvé-Perthes disease, SCFE
ROM testing (Figure 2) — Supine, lateral, or sitting
Pain with passive ROM, limited ROM
Pain with passive ROM: Transient synovitis, septic arthritis
Limited ROM: Loose bodies, chondral lesions, osteoarthritis, Legg-Calvé-Perthes disease, osteonecrosis
FABER test (Figure 3) Patrick test Supine Posterior pain localized to the sacroiliac joint, lumbar spine, or posterior hip; groin pain with the test is sensitive for intra-articular pathology
Hip labral tear, loose bodies, chondral lesions, femoral acetabular impingement, osteoarthritis, sacroiliac joint dysfunction, iliopsoas bursitis
FADIR test (Figure 4) Impingement test
Supine Pain Hip labral tear, loose bodies, chondral lesions, femoral acetabular impingement
Log roll test (Figure 5) Passive supine rotation, Freiberg test
Supine Restricted movement, pain Piriformis syndrome, SCFE
Straight leg raise against resistance test (Figure 6)
Stinchfield test Supine Weakness to resistance, pain Athletic pubalgia (sports hernia), SCFE, femoral acetabular impingement
Ober test (eFigure B) Passive adduction
Lateral Passive adduction past midline cannot be achieved
External snapping hip, greater trochanteric pain syndrome
FABER = flexion, abduction, external rotation; FADIR = flexion, adduction, internal rotation; ROM = range of motion; SCFE = slipped capital femoral epiphysis.
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30 American Family Physician www.aafp.org/afp Volume 89, Number 1 ◆ January 1, 2014
Figure 2. Hip range-of-motion testing (photos demonstrate normal range of motion). (A) Abduction. (B) Adduction. (C) Extension. (D) Internal and external rotation.
A
C
B D
45°
20-30°
10°
20-35°
30-70°
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January 1, 2014 ◆ Volume 89, Number 1 www.aafp.org/afp American Family Physician 31
Figure 4. FADIR test (flexion, adduction, internal rotation; impingement test). The examiner passively moves the leg into (A) full flexion, then into (B) adduction and internal rotation.
A B
Figure 3. FABER test (flexion, abduction, external rotation; Patrick test). The examiner moves the leg into 45 degrees of flexion, then (A) externally rotates and (B) abducts the leg so that the ankle rests proximal to the knee of the contralateral leg.
A B
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32 American Family Physician www.aafp.org/afp Volume 89, Number 1 ◆ January 1, 2014
imaging-guided injections and aspirations around the hip.9 It is ideal for an experienced ultrasonographer to perform the diagnostic study; however, emerging evidence suggests that less experienced clinicians with appro-priate training can make diagnoses with reliability similar to that of an experienced musculoskeletal ultrasonographer.10,11
Differential Diagnosis of Anterior Hip Pain Anterior hip or groin pain suggests involve-ment of the hip joint itself. Patients often localize pain by cupping the anterolateral hip with the thumb and forefinger in the shape of a “C.” This is known as the C sign (Figure 1A).
OSTEOARTHRITIS
Osteoarthritis is the most likely diagnosis in older adults with limited motion and gradual onset of symptoms. Patients have a constant, deep, aching pain and stiffness that are worse with prolonged standing and weight bear-ing. Examination reveals decreased range of motion, and extremes of hip motion often cause pain. Plain radiographs demonstrate the presence of asymmetrical joint-space narrowing, osteophytosis, and subchondral sclerosis and cyst formation.12
FEMOROACETABULAR IMPINGEMENT
Patients with femoroacetabular impinge-ment are often young and physically active. They describe insidious onset of pain that is worse with sitting, rising from a seat, getting in or out of a car, or leaning forward.13 The pain is located primarily in the groin with occasional radiation to the lateral hip and anterior thigh.14 The FABER test (flexion, abduction, external rotation; Figure 3) has a sensitivity of 96% to 99%. The FADIR test (flexion, adduction, internal rota-tion; Figure 4), log roll test (Figure 5), and straight leg raise against resistance test (Figure 6) are also effective, with sensitivities of 88%, 56%, and 30%, respectively.14,15 In addition to the anteroposterior and lateral radiograph views, a Dunn view should be obtained to help detect subtle lesions.16
HIP LABRAL TEAR
Hip labral tears cause dull or sharp groin pain, and one-half of patients with a labral tear have pain that radi-ates to the lateral hip, anterior thigh, and buttock. The
pain usually has an insidious onset, but occasionally begins acutely after a traumatic event. About one-half of patients with this injury also have mechanical symp-toms, such as catching or painful clicking with activity.17 The FADIR and FABER tests are effective for detect-ing intra-articular pathology (the sensitivity is 96% to 75% for the FADIR test and is 88% for the FABER test), although neither test has high specificity.14,15,18 Magnetic resonance arthrography is considered the diagnostic test of choice for labral tears.6,19 However, if a labral tear is not suspected, other less invasive imaging modalities, such as plain radiography and conventional MRI, should be used first to rule out other causes of hip and groin pain.
ILIOPSOAS BURSITIS (INTERNAL SNAPPING HIP)
Patients with this condition have anterior hip pain when extending the hip from a flexed position, often associated
Figure 6. Straight leg raise against resistance test (Stinchfield test). The patient lifts the straight leg to 45 degrees while the examiner applies downward force on the thigh.
Figure 5. Log roll test (passive supine rotation; Freiberg test). Patient’s leg is extended and relaxed on examination table as the examiner internally and externally rotates the leg (log roll).
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with intermittent catching, snapping, or popping of the hip.20 Dynamic real-time ultrasonography is particularly useful in evaluating the various forms of snapping hip.8
OCCULT OR STRESS FRACTURE
Occult or stress fracture of the hip should be consid-ered if trauma or repetitive weight-bearing exercise is involved, even if plain radiograph results are negative.21 Clinically, these injuries cause anterior hip or groin pain that is worse with activity.21 Pain may be present with extremes of motion, active straight leg raise, the log roll test, or hopping.22 MRI is useful for the detection of occult traumatic fractures and stress fractures not seen on plain radiographs.23
TRANSIENT SYNOVITIS AND SEPTIC ARTHRITIS
Acute onset of atraumatic anterior hip pain that results in impaired weight bearing should raise suspicion for transient synovitis and septic arthritis. Risk factors for septic arthritis in adults include age older than 80 years, diabetes mellitus, rheumatoid arthritis, recent joint sur-gery, and hip or knee prostheses.24 Fever, complete blood count, erythrocyte sedimentation rate, and C-reactive protein level should be used to evaluate the risk of sep-tic arthritis.25,26 MRI is useful for differentiating septic arthritis from transient synovitis.27,28 However, hip aspi-ration using guided imaging such as fluoroscopy, com-puted tomography, or ultrasonography is recommended if a septic joint is suspected.29
OSTEONECROSIS
Legg-Calvé-Perthes disease is an idiopathic osteone-crosis of the femoral head in children two to 12 years of age, with a male-to-female ratio of 4:1.4 In adults, risk factors for osteonecrosis include systemic lupus erythe-matosus, sickle cell disease, human immunodeficiency virus infection, smoking, alcoholism, and corticosteroid use.30,31 Pain is the presenting symptom and is usually insidious. Range of motion is initially preserved but can become limited and painful as the disease progresses.32 MRI is valuable in the diagnosis and prognostication of osteonecrosis of the femoral head.30,33
Differential Diagnosis of Posterior Hip and Buttock PainPIRIFORMIS SYNDROME AND ISCHIOFEMORAL IMPINGEMENT
Piriformis syndrome causes buttock pain that is aggra-vated by sitting or walking, with or without ipsilateral radiation down the posterior thigh from sciatic nerve compression.34,35 Pain with the log roll test is the most
sensitive test, but tenderness with palpation of the sciatic notch can help with the diagnosis.35
Ischiofemoral impingement is a less well-understood condition that can lead to nonspecific buttock pain with radiation to the posterior thigh.36,37 This condition is thought to be a result of impingement of the quadratus femoris muscle between the lesser trochanter and the ischium.
Unlike sciatica from disc herniation, piriformis syn-drome and ischiofemoral impingement are exacerbated by active external hip rotation. MRI is useful for diagnos-ing these conditions.38
OTHER
Other causes of posterior hip pain include sacroiliac joint dysfunction,39 lumbar radiculopathy,40 and vascular clau-dication.41 The presence of a limp, groin pain, and lim-ited internal rotation of the hip is more predictive of hip disorders than disorders originating from the low back.42
Differential Diagnosis of Lateral Hip PainGREATER TROCHANTERIC PAIN SYNDROME
Lateral hip pain affects 10% to 25% of the general pop-ulation.43 Greater trochanteric pain syndrome refers to pain over the greater trochanter. Several disorders of the lateral hip can lead to this type of pain, including ilio-tibial band thickening, bursitis, and tears of the gluteus medius and minimus muscle attachment.43-45 Patients may have mild morning stiffness and may be unable to sleep on the affected side. Gluteus minimus and medius injuries present with pain in the posterior lateral aspect of the hip as a result of partial or full-thickness tearing at the gluteal insertion. Most patients have an atraumatic, insidious onset of symptoms from repetitive use.43,45,46
Data Sources: We searched articles on hip pathology in American Fam-ily Physician, along with their references. We also searched the Agency for Healthcare Research and Quality Evidence Reports, Clinical Evidence, Institute for Clinical Systems Improvement, the U.S. Preventive Services Task Force guidelines, the National Guideline Clearinghouse, and UpTo-Date. We performed a PubMed search using the keywords greater tro-chanteric pain syndrome, hip pain physical examination, imaging femoral hip stress fractures, imaging hip labral tear, imaging osteomyelitis, ischiofemoral impingement syndrome, meralgia paresthetica review, MRI arthrogram hip labrum, septic arthritis systematic review, and ultrasound hip pain. Search dates: March and April 2011, and August 15, 2013.
The authors thank Kristen Prewitt, DO, (model examiner in the figures) and Grace Trabulsi (model patient) for their assistance.
The AuthorsJOHN 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.
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34 American Family Physician www.aafp.org/afp Volume 89, Number 1 ◆ January 1, 2014
MASARU FURUKAWA, MD, MS, is a postgraduate trainee in the Depart-ment 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: [email protected]). Reprints are not available from the authors.
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7. Czerny C, Hofmann S, Urban M, et al. MR arthrography of the adult acetabular capsular-labral complex. AJR Am J Roentgenol. 1999;173(2): 345-349.
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17. Burnett RS, Della Rocca GJ, Prather H, et al. Clinical presentation of patients with tears of the acetabular labrum. J Bone Joint Surg Am. 2006;88(7):1448-1457.
18. Leunig M, Werlen S, Ungersböck A, et al. Evaluation of the acetabular labrum by MR arthrography [published correction appears in J Bone Joint Surg Br. 1997;79(4):693]. J Bone Joint Surg Br. 1997;79(2):230-234.
19. Groh MM, Herrera J. A comprehensive review of hip labral tears. Curr Rev Musculoskelet Med. 2009;2(2):105-117.
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nec
k fr
actu
re/s
tres
s fr
actu
re
Dee
p, r
efer
red
pain
; pai
n w
ith
wei
ght
bear
ing
Fem
ales
(es
peci
ally
with
fem
ale
athl
ete
tria
d),
end
uran
ce a
thle
tes,
low
ae
robi
c fit
ness
, ste
roid
use
, sm
oker
s
Pain
ful R
OM
, pai
n on
pal
patio
n of
gr
eate
r tr
ocha
nter
Radi
ogra
phy:
Cor
tical
dis
rupt
ion
MRI
: Ear
ly b
ony
edem
a
Fem
oroa
ceta
bula
r im
ping
emen
t D
eep,
ref
erre
d pa
in; p
ain
with
st
andi
ng a
fter
pro
long
ed
sitt
ing
Pain
with
get
ting
in a
nd o
ut o
f a
car
FAD
IR a
nd F
ABE
R te
sts
are
sens
itive
Ra
diog
raph
y: C
am o
r pi
ncer
def
orm
ity,
ace
tabu
lar
retr
over
sion
, cox
a pr
ofun
da
Hip
labr
al t
ear
Dul
l or
shar
p, r
efer
red
pain
; pa
in w
ith w
eigh
t be
arin
gM
echa
nica
l sym
ptom
s, s
uch
as
catc
hing
or
pain
ful c
licki
ng; h
isto
ry
of h
ip d
islo
catio
n
Tren
dele
nbur
g or
ant
algi
c ga
it, lo
ss o
f in
tern
al r
otat
ion,
pos
itive
FA
DIR
and
FA
BER
test
s
MRI
: Can
sho
w a
labr
al t
ear
Mag
netic
res
onan
ce a
rthr
ogra
phy:
off
ers
adde
d se
nsiti
vity
and
spe
cific
ity
Iliop
soas
bur
sitis
(in
tern
al s
napp
ing
hip
)
Dee
p, r
efer
red
pain
; in
term
itte
nt c
atch
ing,
sn
appi
ng, o
r po
ppin
g
Balle
t da
ncer
s, r
unne
rsSn
ap w
ith F
ABE
R to
ext
ensi
on,
addu
ctio
n, a
nd in
tern
al r
otat
ion
; re
prod
uctio
n of
sna
ppin
g w
ith
exte
nsio
n of
hip
fro
m fl
exed
pos
ition
Radi
ogra
phy:
No
bony
invo
lvem
ent
MRI
: Bur
sitis
and
ede
ma
of t
he il
iotib
ial b
and
Ultr
ason
ogra
phy:
Ten
dino
path
y, b
ursi
tis, fl
uid
arou
nd
tend
on
Dyn
amic
ultr
ason
ogra
phy:
Sna
ppin
g of
ilio
psoa
s or
ili
otib
ial b
and
over
gre
ater
tro
chan
ter
Legg
-Cal
vé-P
erth
es
dise
ase
Dee
p, r
efer
red
pain
; pai
n w
ith
wei
ght
bear
ing
2 to
12
year
s of
age
, mal
e pr
edom
inan
ceA
ntal
gic
gait,
lim
ited
ROM
or
stif
fnes
sRa
diog
raph
y: E
arly
sm
all f
emor
al e
piph
ysis
, scl
eros
is
and
flatt
enin
g of
the
fem
oral
hea
d
Loos
e bo
dies
and
ch
ondr
al le
sion
sD
eep,
ref
erre
d pa
in; p
ainf
ul
clic
king
Mec
hani
cal s
ympt
oms,
his
tory
of
hip
disl
ocat
ion
or lo
w-e
nerg
y tr
aum
a,
hist
ory
of L
egg-
Cal
vé-P
erth
es d
isea
se
Lim
ited
ROM
, cat
chin
g an
d gr
indi
ng
with
pro
voca
tive
man
euve
rs, p
ositi
ve
FAD
IR a
nd F
ABE
R te
sts
Radi
ogra
phy:
Can
sho
w o
ssifi
ed o
r os
teoc
hond
ral
loos
e bo
dies
MRI
: Can
det
ect
chon
dral
and
fibr
ous
loos
e bo
dies
Ost
eoar
thrit
is
of t
he h
ip
Dee
p, a
chin
g pa
in a
nd
stif
fnes
s; p
ain
with
wei
ght
bear
ing
Old
er t
han
50 y
ears
, pai
n w
ith a
ctiv
ity
that
is r
elie
ved
with
res
tIn
tern
al r
otat
ion
< 1
5 de
gree
s, fl
exio
n
< 1
15 d
egre
esRa
diog
raph
y: P
rese
nce
of o
steo
phyt
es a
t th
e ac
etab
ular
join
t m
argi
n, a
sym
met
rical
join
t-sp
ace
narr
owin
g, s
ubch
ondr
al s
cler
osis
and
cys
t fo
rmat
ion
cont
inue
d
FABE
R =
flex
ion,
abd
uctio
n, e
xter
nal r
otat
ion;
FA
DIR
= fl
exio
n, a
dduc
tion,
inte
rnal
rot
atio
n; M
RI =
mag
netic
res
onan
ce im
agin
g; R
OM
= r
ange
of
mot
ion.
Downloaded from the American Family Physician website at www.aafp.org/afp. Copyright © 2013 American Academy of Family Physicians. For the private, non-commercial use of one individual user of the website. All other rights reserved. Contact [email protected] for copyright questions and/or permission requests.
eTab
le A
. Dif
fere
nti
al D
iag
no
sis
of
Hip
Pai
n (c
on
tin
ued
)
Dia
gnos
isPa
in c
hara
cter
istic
sH
isto
ry/r
isk
fact
ors
Exam
inat
ion
findi
ngs
Add
ition
al t
estin
g
An
tero
late
ral h
ip a
nd
gro
in p
ain
(C
sig
n)
(con
tinue
d)
Ost
eone
cros
is
of t
he h
ipD
eep,
ref
erre
d pa
in; p
ain
with
w
eigh
t be
arin
g A
dults
: Lup
us, s
ickl
e ce
ll di
seas
e,
hum
an im
mun
odefi
cien
cy v
irus
infe
ctio
n, c
ortic
oste
roid
use
, sm
okin
g,
and
alco
hol u
se; i
nsid
ious
ons
et, b
ut
can
be a
cute
with
his
tory
of
trau
ma
Pain
on
ambu
latio
n, p
ositi
ve lo
g ro
ll te
st,
grad
ual l
imit
atio
n of
RO
MRa
diog
raph
y: F
emor
al h
ead
luce
ncy
and
subc
hond
ral
scle
rosi
s, s
ubch
ondr
al c
olla
pse
(i.e.
, cre
scen
t si
gn),
fla
tten
ing
of t
he f
emor
al h
ead
MRI
: Bon
y ed
ema,
sub
chon
dral
col
laps
e
Slip
ped
capi
tal
fem
oral
epi
phys
is
Dee
p, r
efer
red
pain
; pai
n w
ith
wei
ght
bear
ing
11 t
o 14
yea
rs o
f ag
e, o
verw
eigh
t (8
0th
to
100
th p
erce
ntile
)A
ntal
gic
gait
with
foo
t ex
tern
ally
rot
ated
on
occ
asio
n, p
ositi
ve lo
g ro
ll an
d st
raig
ht le
g ra
ise
agai
nst
resi
stan
ce
test
s, p
ain
with
hip
inte
rnal
rot
atio
n re
lieve
d w
ith e
xter
nal r
otat
ion
Radi
ogra
phy:
Wid
ened
epi
phys
is e
arly
, slip
page
of
fem
ur u
nder
epi
phys
is la
ter
Sept
ic a
rthr
itis
Refu
sal t
o be
ar w
eigh
t, p
ain
with
leg
mov
emen
t C
hild
ren
: 3 t
o 8
year
s of
age
, fev
er, i
ll ap
pear
ance
Adu
lts:
Old
er t
han
80
year
s, d
iabe
tes
mel
litus
, rhe
umat
oid
arth
ritis
, rec
ent
join
t su
rger
y, h
ip o
r kn
ee p
rost
hese
s
Gua
rdin
g ag
ains
t an
y RO
M; p
ain
with
pa
ssiv
e RO
MH
ip a
spira
tion
guid
ed b
y flu
oros
copy
, com
pute
d to
mog
raph
y, o
r ul
tras
onog
raph
y; G
ram
sta
in a
nd
cultu
re o
f jo
int
aspi
rate
MRI
: Use
ful f
or d
iffe
rent
iatin
g se
ptic
art
hriti
s fr
om
tran
sien
t sy
novi
tis
Tran
sien
t sy
novi
tisRe
fusa
l to
bear
wei
ght
Chi
ldre
n: 3
to
8 ye
ars
of a
ge,
som
etim
es f
ever
and
ill a
ppea
ranc
ePa
in w
ith e
xtre
mes
of
ROM
Late
ral p
ain
Exte
rnal
sna
ppin
g hi
p*Pa
in w
ith d
irect
pre
ssur
e,
radi
atio
n do
wn
late
ral
thig
h, s
napp
ing
or p
oppi
ng
All
age
grou
ps, a
udib
le s
nap
with
am
bula
tion
Posi
tive
Obe
r te
st, s
nap
with
Obe
r te
st,
pain
ove
r gr
eate
r tr
ocha
nter
Radi
ogra
phy:
No
bony
invo
lvem
ent
MRI
: Bur
sitis
and
ede
ma
of t
he il
iotib
ial b
and
Ultr
ason
ogra
phy:
Ten
dino
path
y, b
ursi
tis, fl
uid
arou
nd
tend
on
Dyn
amic
ultr
ason
ogra
phy:
Sna
ppin
g of
ilio
psoa
s or
ili
otib
ial b
and
over
gre
ater
tro
chan
ter
Gre
ater
tro
chan
teric
bu
rsiti
s*Pa
in w
ith d
irect
pre
ssur
e,
radi
atio
n do
wn
late
ral t
high
Runn
ers,
mid
dle-
aged
wom
enPa
in o
ver
grea
ter
troc
hant
er
Gre
ater
tro
chan
teric
pa
in s
yndr
ome
Pain
with
dire
ct p
ress
ure,
ra
diat
ion
dow
n la
tera
l thi
ghA
ssoc
iate
d w
ith k
nee
oste
oart
hriti
s,
incr
ease
d bo
dy m
ass
inde
x, lo
w b
ack
pain
; fem
ale
pred
omin
ance
Prox
imal
ilio
tibia
l ban
d te
nder
ness
, Tr
ende
lenb
urg
gait
is s
ensi
tive
and
spec
ific
Post
ero
late
ral p
ain
Glu
teal
mus
cle
tear
or
avu
lsio
n*Pa
in w
ith d
irect
pre
ssur
e,
radi
atio
n do
wn
late
ral t
high
an
d bu
ttoc
k
Mid
dle-
aged
wom
enW
eak
hip
abdu
ctio
n, p
ain
with
res
iste
d ex
tern
al r
otat
ion,
Tre
ndel
enbu
rg g
ait
is
sens
itive
and
spe
cific
MRI
: Glu
teal
mus
cle
edem
a or
tea
rs
Iliac
cre
st a
poph
ysis
av
ulsi
onTe
nder
ness
to
dire
ct
palp
atio
nH
isto
ry o
f di
rect
tra
uma,
ske
leta
l im
mat
urit
y (y
oung
er t
han
25 y
ears
)Ili
ac c
rest
ten
dern
ess
and
/or
ecch
ymos
isRa
diog
raph
y: A
poph
ysis
wid
enin
g, s
oft
tissu
e sw
ellin
g ar
ound
ilia
c cr
est
cont
inue
d
FABE
R =
flex
ion,
abd
uctio
n, e
xter
nal r
otat
ion;
FA
DIR
= fl
exio
n, a
dduc
tion,
inte
rnal
rot
atio
n; M
RI =
mag
netic
res
onan
ce im
agin
g; R
OM
= r
ange
of
mot
ion.
*—C
ondi
tions
ass
ocia
ted
with
gre
ater
tro
chan
teric
pai
n sy
ndro
me.
34B American Family Physician www.aafp.org/afp Volume 89, Number 1 ◆ January 1, 2014Downloaded from the American Family Physician website at www.aafp.org/afp. Copyright © 2013 American Academy of Family Physicians. For the private, non-commercial use of one individual user of the website. All other rights reserved. Contact [email protected] for copyright questions and/or permission requests.
Hip Pain
eTab
le A
. Dif
fere
nti
al D
iag
no
sis
of
Hip
Pai
n (c
on
tin
ued
)
Dia
gnos
isPa
in c
hara
cter
istic
sH
isto
ry/r
isk
fact
ors
Exam
inat
ion
findi
ngs
Add
ition
al t
estin
g
Post
erio
r p
ain
Ham
strin
g m
uscl
e
stra
in o
r av
ulsi
onBu
ttoc
k pa
in, p
ain
with
dire
ct
pres
sure
Ecce
ntric
mus
cle
cont
ract
ion
whi
le h
ip
flexe
d an
d le
g ex
tend
edIs
chia
l tub
eros
ity
tend
erne
ss,
ecch
ymos
is, w
eakn
ess
to le
g fle
xion
, pa
lpab
le g
ap in
ham
strin
g
Radi
ogra
phy:
Avu
lsio
n or
str
ain
of h
amst
ring
atta
chm
ent
to is
chiu
m
MRI
: Ham
strin
g ed
ema
and
retr
actio
nIs
chia
l apo
phys
is
avul
sion
Butt
ock
pain
, pai
n w
ith d
irect
pr
essu
reSk
elet
al im
mat
urit
y, e
ccen
tric
mus
cle
cont
ract
ion
(cut
ting,
kic
king
, ju
mpi
ng)
Isch
iofe
mor
al
impi
ngem
ent
Butt
ock
or b
ack
pain
with
po
ster
ior
thig
h ra
diat
ion,
sc
iatic
a sy
mpt
oms
Gro
in a
nd/o
r bu
ttoc
k pa
in t
hat
may
ra
diat
e di
stal
lyN
one
esta
blis
hed
MRI
: Sof
t tis
sue
edem
a ar
ound
qua
drat
us f
emor
is
mus
cle
Pirif
orm
is s
yndr
ome
Butt
ock
pain
with
pos
terio
r th
igh
radi
atio
n, s
ciat
ica
sym
ptom
s
His
tory
of
dire
ct t
raum
a to
but
tock
or
pai
n w
ith s
ittin
g, w
eakn
ess
and
num
bnes
s ar
e ra
re c
ompa
red
with
lu
mba
r ra
dicu
lar
sym
ptom
s
Posi
tive
log
roll
test
, ten
dern
ess
over
the
sc
iatic
not
chM
RI: L
umba
r sp
ine
has
no d
isk
hern
iatio
n, p
irifo
rmis
m
uscl
e at
roph
y or
hyp
ertr
ophy
, ede
ma
surr
ound
ing
the
scia
tic n
erve
Sacr
oilia
c jo
int
dysf
unct
ion
Pain
rad
iate
s to
lum
bar
back
, bu
ttoc
k, a
nd g
roin
Fe
mal
e pr
edom
inan
ce, c
omm
on in
pr
egna
ncy,
his
tory
of
min
or t
raum
aFA
BER
test
elic
its
post
erio
r pa
in lo
caliz
ed
to t
he s
acro
iliac
join
t, s
acro
iliac
join
t lin
e te
nder
ness
Radi
ogra
phy:
Pos
sibl
y no
find
ings
, nar
row
ing
and
scle
rotic
cha
nges
of
the
sacr
oilia
c jo
int
spac
e
FABE
R =
flex
ion,
abd
uctio
n, e
xter
nal r
otat
ion;
FA
DIR
= fl
exio
n, a
dduc
tion,
inte
rnal
rot
atio
n; M
RI =
mag
netic
res
onan
ce im
agin
g; R
OM
= r
ange
of
mot
ion.
*—C
ondi
tions
ass
ocia
ted
with
gre
ater
tro
chan
teric
pai
n sy
ndro
me.
January 1, 2014 ◆ Volume 89, Number 1 www.aafp.org/afp American Family Physician 34CDownloaded from the American Family Physician website at www.aafp.org/afp. Copyright © 2013 American Academy of Family Physicians. For the private, non-commercial use of one individual user of the website. All other rights reserved. Contact [email protected] for copyright questions and/or permission requests.
Hip Pain
34D American Family Physician www.aafp.org/afp Volume 89, Number 1 ◆ January 1, 2014
eFigure A. Localization of hip pain. (A) Posterior view. (B) Anterior view.
eFigure B. Ober test (passive adduction). The patient is positioned on his or her side, with the unaffected hip on the examination table. The examiner stands behind the patient with one hand on the patient’s hip, and the other hand supporting the lower leg. (A) To evaluate the tensor fasciae latae: The hip and knee are held at 0 degrees of extension and allowed to passively adduct with gravity. (B) The gluteus medius: The hip is held at 0 degrees of extension and 45 to 90 degrees of knee flexion. (C) The gluteus maximus: The shoulders are rotated back toward the table, with the hip in flexion and knee in extension.
A B C
The rights holder did not grant the American Academy of Family Physicians the right to sublicense this material to a third party. For the missing item, see the original print version of this publication.
Downloaded from the American Family Physician website at www.aafp.org/afp. Copyright © 2013 American Academy of Family Physicians. For the private, non-commercial use of one individual user of the website. All other rights reserved. Contact [email protected] for copyright questions and/or permission requests.