PRACTICE RECOMMENDATIONS
• Consider both musculoskeletal and nonmusculoskeletal causes in patients with vague complaints of hip and groin pain. B
• Use imaging studies to confirm a hip pain diagnosis. B
• Refer patients who fail to respond to nonsurgical treatment to a sports medicine specialist or an orthopedic surgeon. B
Strength of recommendation (SOR)
A Good-quality patient-oriented evidence
B Inconsistent or limited-quality patient-oriented evidence
C Consensus, usual practice, opinion, disease-oriented evidence, case series
Hip pain is a common complaint, and commonly misunderstood. Although the pain can be associated with a broad spectrum of conditions, the presentation is often vague and nonspecific.
Thus, hip pain and injury are frequently attributed, often incorrectly, to a “hip pointer”—a contusion of soft tissues against the iliac crest. It’s not unusual for patients who receive this diagnosis to be treated conservatively for prolonged periods, leading some previously active individuals to abandon their favorite sport or self-impose limits on the activities they engage in.1
But it doesn’t have to be this way.
Minimally invasive hip arthroscopy and advances in imaging, instrumentation, and devices have made it easier to identify and address underlying pathology associated with hip pain, helping patients return to their previous level of activity more rapidly.2,3 And, while many conditions associated with hip pain can be treated conservatively, family physicians—whom patients often go to first—should not hesitate to provide a referral when more aggressive treatment or diagnostic confirmation is needed.
We created this guide with family physicians in mind. Our focus here is primarily on anterior hip pain—the most common presentation—in active, or athletic, patients.
When did the pain begin? Where does it hurt?
Before performing a physical examination, find out as much as possible about the onset of pain and when and under what circumstances it occurs. (A review of hip anatomy is provided here.) Did it begin suddenly, after an acute injury or a particular physical maneuver? Or is the pain insidious, as was the case with one of our patients?
Hip anatomy: A brief review
Osseous morphology of the hip includes the anterior superior iliac spine, the origin of the sartorius muscle and the ilioinguinal ligament. The anterior inferior iliac spine attaches to the rectus femoris, a major hip flexor and knee extender. The adductors of the hip originate in the anterior pelvic region.
The inguinal canal contains the ilioinguinal nerve, which is responsible for radiation of pain to the anterior hip. The hip joint itself is a spheroid comprising the femoral head and acetabulum, with most of the articular hip innervated by the femoral or obturator nerves.
Most intra-articular conditions radiate to the anterior groin or hip, although there are cases in which the pain is referred to either the lateral aspect of the hip or the buttocks. The iliopsoas muscle is the major hip flexor, and crosses under the ilioinguinal ligament to insert on the lesser tuberosity after crossing over the anterior capsule of the hip. A large bursa surrounds it, helping the tendon glide smoothly over the hip.
CASE Mack Q, a 27-year-old man with an 8-month history of right hip pain, sought care at our medical center for an achy pain in his right groin; he also described an occasional “clicking and popping sensation” in his groin but denied any trauma. The pain worsened with prolonged sitting and certain activities, such as squatting, twisting, and putting on shoes and socks. Our patient had stopped playing soccer because it hurt too much. He had tried physical therapy, oral anti-inflammatories, and a corticosteroid injection, with little relief.
Start with a gait assessment
The physical examination should begin with a gait assessment. Consider the patient’s ability to bear weight and his or her foot angle.
An individual with a stress fracture will have difficulty bearing weight on the affected side, resulting in a limp, or antalgic gait. A patient with femoral acetabular impingement (FAI) will often exhibit greater external rotation of the foot on the affected side compared with the other foot. And a patient with weakened abductor muscles, typically because of severe osteoarthritis, will exhibit the Trendelenburg sign—a pelvic tilt when the weight is shifted to the affected extremity.
Although most individuals with hip pain will not have an obvious gait abnormality, any patient who walks with a limp or needs crutches requires an immediate referral to an orthopedic surgeon.
Include these elements in the physical exam
Examine the hip with the patient sitting on the side of the exam table. Assess range of motion (ROM), comparing the range of flexion, extension, and internal/external rotation on the affected and unaffected sides. Include the following maneuvers: