History

The medical history for a patient presenting with hip pain should include age, onset (and mechanism of injury, if applicable), distribution, quality, severity, progression, exacerbating factors, alleviating factors, and other associated signs/symptoms.

The differential diagnosis for hip pain can vary based on the age of the athlete. In the pediatric and adolescent athlete presenting with hip and groin pain, consideration should be given to apophyseal injuries, Legg-Calve-Perthes disease, and slipped capital femoral epiphysis. In contrast, older athletes are often affected by osteoarthritis (OA) of the hip.

Hip pain with acute onset has a distinct differential diagnosis from hip pain that is chronic or of insidious onset. A detailed mechanism of injury should be elicited with hip pain of acute onset. For example, sudden forceful muscle contractions (particularly eccentric) often result in muscle strains or tears in adults and apophyseal avulsions in adolescents. The adductor muscles are often involved, particularly in soccer, football, and hockey athletes. Adductor strain is the most common cause of groin pain in athletes. Further, fracture should be considered in athletes with sudden onset of pain associated with a specific event. The event may not have seemed to be significant enough to cause a bony fracture, but athletes with an underlying bone mineralization deficit may become symptomatic with a seemingly benign event.

The distribution of hip pain is wide and variable but should be assessed by the health care provider to assist in making a diagnosis and to reassess following treatment. Anterior groin pain is often associated with intra-articular hip disorders. These disorders include femoral or acetabular fracture, avascular necrosis, OA, synovitis, ligamentum teres tear, and prearthritic hip disorders (isolated acetabular labral tears, developmental hip dysplasia [DDH], and femoroacetabular impingement [FAI] with and without acetabular labral tears). Extra-articular sources associated with anterior groin pain include the pubic rami, iliopsoas, adductor group, and abdominal muscles. Sports hernia typically involves injury to the abdominal muscles, particularly the external oblique muscle and aponeurosis, with possible injury to the adductors. In addition to the muscles and surrounding soft tissues, higher lumbar radiculopathy should also be considered as a source of an athlete’s groin pain.

Lateral hip pain can be associated with intra-articular hip disorders, including all of those listed for anterior distribution of pain. In isolation, lateral hip pain is often associated with extra-articular disorders, including greater trochanteric bursitis or greater trochanteric pain syndrome, which may include gluteus medius or minimus tendinopathy, or pain related to tensor fascia lata/iliotibial band dysfunction. Lumbar spine disorders, particularly those involving the L4 to L5 distribution, can present with lateral hip pain.

Posterior pelvic pain is the area of great overlap between the hip, pelvic girdle, and lumbar spine and is not fully understood. Multiple structures contribute to posterior pelvic pain, including the sacroiliac joints, ischial bursa, and the insertion of the proximal hamstring. The European guidelines for evaluation and treatment of pelvic girdle pain continue to provide a comprehensive resource for understanding the relationships of the pelvic girdle and lumbar spine and include diagnostic and therapeutic evidence-based reviews. Increased tone, fatigue, or dysfunction of the hip abductors, extensors, lateral rotators, and the lumbopelvic fascia are confounding factors. Lumbar spine disorders also commonly present with pain in the posterior pelvis and can range from structural and physiologic changes of the intervertebral disc, facet joint, and central or foraminal canal, ranging from L1 to S1 myotome and dermatome levels. Less understood is the role of the hip in posterior pelvic pain. In a previous descriptive study, 20% of patients successfully treated with hip arthroscopy for acetabular labral tears in isolation with pain unresponsive to conservative treatment reported posterior pelvic pain as part of the distribution of pain before surgery. In a series of descriptive studies, posterior pelvic pain was reported by patients before surgery in 17.3% of patients with DDH, 29% of patients with FAI, and 38% of patients with isolated acetabular labral tears. Patients with FAI also reported a 23% incidence of low back pain and 12% incidence of posterior thigh pain. Lumbar spine, pelvic girdle, and hip disorders can present with a variety of distributions of pain that overlap across regions. Recognizing this overlap in the distribution of symptoms enables the sports medicine provider to consider an underlying hip disorder in athletes with isolated groin pain as well as in the lumbopelvic region.

Pain quality, severity, progression, exacerbating factors, and alleviating factors provide additional information to narrow the differential diagnosis. Burning pain is often associated with a neuropathic cause. Pain with active contraction or passive stretch of a particular muscle suggests a tendinopathy or muscle strain/tear. Symptoms that are worse with coughing or sneezing and causing an increase in intra-abdominal and intraspinal pain may suggest an intervertebral disc or abdominal or inguinal hernia as a source of pain.

Specific motions or weight bearing associated with snapping, catching, or locking can be associated with extra-articular and intra-articular hip disorders. Snapping hip is commonly associated with hip pain and has been estimated to occur in 5% to 10% of the general population, but is especially seen in athletes such as soccer players, runners, weight lifters, and dancers who perform significant hip flexion and extension movements. It is most commonly associated with snapping of the iliotibial band or the gluteus maximus over the greater trochanter that occurs during return to full extension of the hip. Another common cause of anterior snapping hip is aberrant movement of the iliopsoas tendon snapping over the iliopectineal eminence. This snapping often occurs while climbing stairs, getting out of a car, or rising from a chair. Catching or locking symptoms are also associated with hip pain and can suggest acetabular labral tear or loose body. In patients undergoing surgical treatment of acetabular labral tears, 53% report mechanical symptoms of popping or snapping, whereas 41% report true locking or catching.

Neurologic deficits in strength and sensation imply nerve root damage (radiculopathy) or peripheral nerve entrapment. Affected nerves can include the obturator, pudendal, superior gluteal, inferior gluteal, genitofemoral, iliohypogastric, ilioinguinal, and lateral femoral cutaneous nerves. Past surgical history may often be associated with peripheral nerve entrapments.

Providers should be aware of signs and symptoms that may indicate nonmusculoskeletal sources of hip pain, including various gastrointestinal and genitourinary disorders. Further questioning regarding bowel and bladder function, sexual activity, and menstrual history should be considered.

Physical Examination

The physical examination for hip pain should be guided by each athlete’s history. In general, it should include inspection, range of motion, palpation, a neurologic examination, and provocative hip testing.

Inspection should assess seated and standing postures, transfers, ability to bear weight, and gait. Areas of asymmetry, including muscle atrophy or masses, should be noted. Antalgic and asymmetric movements with transfers and gait should also be noted to help further characterize the underlying disorder. Foot position preference in standing and with ambulation should be noted because it is an initial indicator of pain, bony abnormality, and/or soft tissue adaptation or restriction. Observing a Trendelenburg gait gives the sports medicine provider an initial impression of gluteal weakness that has implications for dysfunctions across regions including the lumbar spine, pelvic girdle, and hip.

Active and passive range of motion of the hip should be performed, assessing for asymmetries from side to side and available end range. Hip range-of-motion parameters are variable in the literature. Age, gender, bony deformity, and soft tissue laxity and restrictions can all influence hip range of motion but are not consistently controlled for in studies assessing active and passive hip range of motion, which likely contributes to the variability of reported normal. Asymptomatic elite female soccer athletes showed variability in hip passive range of motion by age and experience. Specific hip disorders have been found to be associated with patterns of reduced hip range of motion. Patients with FAI have reduced hip flexion and internal rotation, whereas those with hip OA may first experience reduced hip internal rotation and progress to a loss of motion in all planes. Active range of motion of the lumbar spine should be performed to assess whether pain is provoked in a specific direction, which may help determine whether a spine disorder is contributing to the constellation of symptoms associated with a hip disorder.

Palpation of relevant anatomic structures (as described earlier) of the lumbar spine, posterior pelvis, lateral hip, and anterior groin can help identify underlying disorders when pain is provoked or asymmetries are palpated in the bony and soft tissue structures. Dynamic palpation tests can also be used, such as palpation of the inguinal canal during coughing in the setting of a possible inguinal hernia. Abdominal hernia can be assessed by palpation of the abdominal muscle insertion in the midline on the superior pubis insertion during lower abdominal contraction. If an asymmetrical fullness is noted with pain at the time of contraction versus at rest, abdominal hernia becomes a consideration. Palpation of the iliopsoas tendon with concentric and eccentric contraction may elicit the pain and the snap. Likewise, palpation of the iliotibial band during hip flexion and abduction may provoke a painful snap.

Evaluation of strength and length in the muscles about the hip can identify areas of movement system breakdown that may be contributing to the patient’s hip pain. For example, extra-articular muscle imbalances between posterior hip abductors and external rotators in combination with shortened hip flexors and iliotibial band can lead to groin and lateral hip pain.

A neurologic examination consisting of sensory, motor, reflex, and neural tension provocative tests can further assess neurologic involvement in the patient’s hip pain. If any of the neurologic examination tests are positive, regional sources for pain in the pelvis and lumbar spine should be considered.

Several provocative hip tests can help assess intra-articular versus extra-articular hip disorders ( Table 1 ). None are specific enough to be used in isolation but collective assessment can help direct further diagnostic evaluation and treatment. The log roll test, anterior hip impingement, and flexion, abduction, external rotation (FABER)/Patrick test have been shown to have high inter-rater agreement in asymptomatic young adults ( Figs. 1 and 2 ).

Log roll test.

Anterior hip impingement test.