Hip pain is a common complaint in athletes and can result in a significant amount of time lost from sport. Diagnosis of the source of hip pain can be a clinical challenge because of the deep location of the hip and the extensive surrounding soft tissue envelope. Establishing whether the source of hip pain is intra-articular or extra-articular is the first step in the process. A thorough history and a consistent and comprehensive physical examination are the foundation for the proper management of athletes with hip pain.
Key points
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Determining the source of athletic hip pain can be a clinical challenge.
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Obtaining a thorough history and performing a consistent, comprehensive physical examination are the vital initial steps in the proper management of athletes with hip pain.
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The first delineation is whether the source of hip pain is intra-articular or extra-articular.
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Intra-articular sources of pain are generally not tender to palpation, or exacerbated with resisted muscle testing.
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Common sources of hip pain in athletes include impingement and labral tears, hip microinstability, hip flexor and adductor muscle strains, and core muscle injuries.
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Other causes of nonmusculoskeletal hip-related pain, such as hernias, intra-abdominal and genitourinary disorders, or lumbar radiculopathy, should be identified and evaluated when present.
Introduction
Athletes are constantly subjecting their hip joints to high forces, large ranges of motion (ROMs), and compromising positions as they run, jump, cut, pivot, and kick. A 3-year study at Stanford University found that nearly 10% of all musculoskeletal complaints to athletic trainers by athletes involved the hip (Safran, unpublished data, 2013). Thus, hip pain is a common complaint in athletes and can lead to a significant amount of time lost from sport. In recent years, the identification of hip injuries and appreciation for hip-related disorders has increased among team physicians and other clinicians caring for athletes. Whether the evaluation of an athlete with hip pain starts on the field, in the training room, or in the office, the clinician must obtain a reliable history and perform a consistent and comprehensive physical examination to provide an accurate and timely diagnosis.
Correct diagnosis can lead to efficient and effective treatment of hip pain; however, making the correct diagnosis about the hip has traditionally been thought to be difficult because of the difficulty of examining this deep structure, as well as the broad differential diagnosis of hip pain resulting from many surrounding structures and pain that may radiate to the hip joint ( Table 1 ). However, with a thorough history and physical examination, clinicians can narrow down the diagnoses and, combined with appropriate imaging, can identify the true source of hip pain and formulate a treatment plan to get the athletes back to their sports.
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Discussion
History of Hip Pain
Initial evaluation of an athlete with hip pain should include a thorough history of the patient’s hip pain. The clinician should start with the athlete’s sport and level of play, and the presence of a specific inciting event or injury that caused the pain. Onset, duration, and aggravating and relieving maneuvers or positions should be elicited. Any history of hip-related disorders and/or treatment should be noted. Patients with a history of acetabular dysplasia or femoral-sided disorders such as slipped capital femoral epiphysis or Legg-Calve-Perthes syndrome may be predisposed to developing hip pain, particularly in athletes.
The location of the athlete’s pain can help to differentiate between an intra-articular and extra-articular source of the pain. Importantly, clinicians must differentiate between groin, lateral hip, and low back pain, while ruling out referred and radiating intra-abdominal disorders, hernias, and other nonmusculoskeletal causes of pain around the hip. Pain within the hip joint typically manifests as anterior groin pain, along the inguinal crease. However, referred pain to the thigh or even down to the knee can be a finding in patients with intra-articular hip disorders. Patients with intra-articular pain often form what is called the C sign with their hands when asked to show the location of their pain, noting that the pain is deep, between the 2 fingers forming the C , ( Fig. 1 ).
Pain localized posteriorly in the buttocks or that radiates to the posterior or lateral thigh or distally past the knee is concerning for a lumbar spine origin, although piriformis syndrome, sacroiliac (SI) joint dysfunction, and hamstring disorders may also be the cause of buttock pain. Pain localized to the adductor tubercle or the lower abdominal muscles at the pubic tubercle are more consistent with a proximal adductor strain or core muscle injury/athletic pubalgia. Lateral hip pain at the greater trochanter may be the result of a several sources, now grouped as greater trochanteric pain syndrome, including trochanteric bursitis and gluteus medius strain or syndrome, and can coincide with iliotibial band tightness and snapping that is pathognomonic for external snapping hip syndrome. Posterolateral hip pain may be more consistent with piriformis syndrome, whereas pain just proximal to the greater trochanter may be caused by a gluteus medius strain. Pain and snapping anteriorly in the groin are often secondary to iliopsoas inflammation and internal snapping hip syndrome.
Clinicians should ask the patients to qualitatively describe their symptoms. The presence of mechanical symptoms, such as locking, clicking, or catching in the hip, is concerning for intra-articular disorders, specifically a labral tear or chondral flap. Duration and frequency of pain, as well as certain motions, movements, or activities that aggravate or relieve the symptoms, should be documented.
The initial history can provide the clinician with a short list of preliminary diagnoses and allow a more focused physical examination of the athlete with hip pain. An extensive list of physical examination maneuvers of the hip to be combined with the thorough history outlined earlier are presented here.
Physical Examination of the Hip
The hip can be a challenging joint to examine because of the deep location and extensive surrounding soft tissue envelope. However, if approached in a focused and stepwise manner based on the patient’s complaints and injury history, clinicians can begin to narrow down the potential causes of hip pain and formulate an accurate diagnosis. The patient should be in clothing that allows unrestricted hip motion, usually short pants or possibly leggings.
The first step is determining whether pain is coming from the hip, thus ruling out a remote source of radiating pain such as hernias, intra-abdominal and genitourinary pain, or lumbar spine pain. It is then important to delineate whether the pain is originating from an intra-articular or extra-articular source with reference to the femoroacetabular joint. Although intra-articular disorders are typically exacerbated by passive motion of the hip, extra-articular disorders often become more painful with palpation or resisted active motion. It is important that examiners approach the examination of athletes with hip pain in a comprehensive and stepwise manner. The examination begins when the patient enters the office, because the clinician should observe the patient’s gait, how the patient is sitting, and how the patient transitions between positions. A comprehensive hip examination is described later, organized by patient positioning, beginning with the standing examination, followed by the seated, supine, lateral, and prone examinations , , ( Table 2 ).
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Standing examination
A basic standing examination can provide important initial information, such as height, body habitus, and gross lower extremity standing alignment, as well as whether the patient does not want to fully bear weight on the affected extremity. The patient should be asked to walk down the hall to observe the gait. In an antalgic gait, the patient has a shortened stance phase to attempt to limit the duration of weight bearing on the affected side, whereas, in a coxalgic (also known as Trendelenburg) gait, the patient lurches the center of gravity toward the affected side to distribute forces more evenly across the hip joint. A pelvic wink is seen when the patient rotates toward the affected side to allow full terminal hip extension and may be a sign of hip intra-articular disorders, ligamentous laxity, or abnormal femoral version. Any obvious lower extremity malalignment and foot progression angle should be noted. The examiner should have the patient perform short and long stride walking as well as internal and external foot progression angle walking. Patients with instability or ischiofemoral impingement have pain in terminal extension with long stride walking. Ischiofemoral impingement in particular is more painful in extension and external rotation. Patients with femoroacetabular impingement (FAI) have more pain with internal foot progression angle walking, whereas those with instability have more pain with external foot progression angle walking.
Simply observing the patients walk into the office and transition from sit to stand can often provide a great deal of information, with particular attention paid to the patients compensating or favoring 1 side more than the other and whether they use their arms to get out of the chair. Patients with FAI often avoid sitting straight up in the chair to decrease hip flexion and impingement, and they also do not like to sit in low chairs, like a low couch. Patients with piriformis syndrome often lean toward the contralateral hip to avoid putting pressure on the affected side.
A Trendelenburg gait is where the patient’s contralateral hip drops toward the floor during the stance phase of gait because of abductor weakness of the standing leg. Patients may compensate by doing an abductor lurch, leaning toward the weight-bearing side. Abductor weakness can also be identified using a single-leg stand, or Trendelenburg sign. With the clinician assessing from posterior and visualizing the posterior ilium, the clinician’s hands are placed on the athlete’s iliac crests ( Fig. 2 A), and the athlete lifts 1 leg off the ground. If the pelvis on the side that is lifted rises up ( Fig. 2 B), the Trendelenburg sign is negative, signaling good gluteus medius strength. If the ipsilateral pelvis drops or the athlete shifts the upper body away from the lifted side, the test is considered positive ( Fig. 2 C), suggesting abductor weakness. , In conjunction with the Trendelenburg sign, the clinician can assess for pelvic tilt and any gross leg length discrepancies. A quantification of leg length discrepancy can be performed by using wooden blocks under the shorter side until the pelvis is level.
Seated examination
The patient moves to the seated position with the legs hanging over the side of the examination table and knees bent 90°. In the seated position, the examiner can obtain an initial assessment of hip ROM and iliopsoas strength testing as well as perform a complete bilateral lower extremity neurovascular examination.
Range of motion and strength
Hip internal and external rotation should be tested in the seated position and documented compared with ROM in the supine and prone positions ( Table 3 ). In the seated position, the pelvis is grounded on the table with the hip flexed at 90°, so the examiner is able to obtain an accurate measurement of actual hip motion while avoiding side-to-side rocking of the pelvis.
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