Evaluation and management of hip pain: an algorithmic approach

Journal of Family Practice, August, 2003 by Katherine Margo, Jonathan Drezner, Daphne Motzkin

TABLE 1
Integrating the history and physical examination to diagnose hip pain

            Disorder             Presentation and exam findings

Anterior    Osteoarthritis       Gradual onset anterior thigh/groin
pain                               pain worsening with weight-bearing
                                 Limited range of motion with pain,
                                   especially internal rotation
                                   (LOE=1b) (12)
                                 Abnormal FABER test

            Hip flexor muscle    History of overuse or sports injury
            strain/tendonitis    Pain with resisted muscle testing
                                 Tenderness over specific muscle or
                                   tendon

            Iliopsoas bursitis   Anterior pain and associated snapping
                                   sensation
                                 Tenderness with deep palpation over
                                   femoral triangle
                                 Positive snapping hip maneuver
                                 Etiology from overuse, acute trauma,
                                   or rheumatoid arthritis
            Hip fracture         Fall or trauma followed by inability
            (proximal femur)       to walk
                                 Limb externally rotated, abducted,
                                   and shortened
                                 Pain with any movement

            Stress fracture      History of overuse or osteoporosis
                                 Pain with weight-bearing activity;
                                   antalgic gait
                                 Limited range of motion, sensitivity
                                   87% (LOE=4) (13)

            Inflammatory         Morning stiffness or associated
            arthritis              systemic symptoms
                                 Previous history of inflammatory
                                   arthritis
                                 Limited range of motion and pain with
                                   passive motion

            Acetabular           Activity-related sharp groin/anterior
            labral tear            thigh pain, esp. upon hip extension
                                 Deep clicking felt, sensitivity 89%
                                   (LOE=4) (13)
                                 Positive Thomas flexion-extension test

            Avascular necrosis   Dull ache in groin, thigh, and buttock
            of femoral head        usually with risk factors (corti-
                                   costeroid exposure, alcohol abuse)
                                 Limited range of movement with pain

Lateral     Greater              Female:male 4:1, fourth to sixth
pain        trochanteric           decade
            bursitis             Spontaneous, insidious onset lateral
                                   hip pain
                                 Point tenderness over greater
                                   trochanter

            Gluteus medius       Pain with resisted hip abduction
            muscle dysfunction   Tender over gluteus medius (cephalad
                                   to greater trochanter)
                                 Trendelenburg test: sensitivity 72.7%,
                                   specificity 76.9% for detecting
                                   gluteus medius muscle tear
                                   (LOE=2b) (9)

            Iliotibial band      Lateral hip pain or snapping
            syndrome               associated with walking, jogging,
                                   or cycling
                                 Positive Ober's test

            Meralgia             Numbness, tingling, and burning pain
            paresthetica           over anterolateral thigh
                                 Aggravated by extension of hip and
                                   with walking
                                 Pressure over nerve may reproduce
                                   dysesthesia in distribution of
                                   lateral femoral cutaneous nerve
                                   (LOE=5) (15)

Posterior   Referred pain from   History of low back pain
pain        lumbar spine         Pain reproduced with isolated lumbar
                                   flexion or extension
                                 Radicular symptoms or history
                                   consistent with spinal stenosis

            Sacroiliac joint     Controversial diagnosis
            dysfunction          Posterior hip or buttocks pain usually
                                   in runners
                                 Pelvic asymmetry found on exam

            Hip extensor or      History of overuse or acute injury
            rotator muscle       Pain with resisted muscle testing
            strain               Tender over gluteal muscles

LOE, level of evidence. For an explanation of levels of evidence,
see page 626.

TABLE 2
Indications for diagnostic imaging studies

                                                           Level of
Disorder             Test                                  evidence

Osteoarthritis       AP and lateral hip x-ray                 2
                     studies-weight-bearing (17)

Muscle strain/       None needed initially; consider MRI      5
tendonitis           if not resolving

Greater              None needed initially; consider MRI      4
trochanteric         if not resolving (9)
pain syndrome

Hip fracture         AP pelvis and cross table lateral        *
(proximal femur)     x-ray studies

Stress fracture      MRI-sensitivity 100% (13)                4

Iliopsoas bursitis   None needed initially; consider MRI      4
                       if not resolving
                     Can also use iliopsoas bursa
                       imaging (18-20)

Iliotibial band      None needed initially; consider MRI      5
syndrome             if not resolving

Meralgia             Usually diagnosed by history. Can        4
paresthetica         use sensory nerve conduction
                     study (21)

Inflammatory         Complete blood count, erythrocyte        *
arthritis            sedimentation rate or C-reactive
                     protein, arthrocentesis, x-ray
                     study

Referred pain from   MRI of lumbar spine                      *
lumbar spine

Avascular necrosis   AP and lateral hip x-rays                4
of femoral head      MRI for staging (22)

Acetabular labral    MR arthrography-sensitivity 91%,         4
tear                   specificity 71% (23-25)

* Level of evidence nospecific references could not be found.
AP anteroposterior; MRI, resonance imaging