Impingement testing. In patients with FAI and osteoarthritis, impingement testing—encompassing Flexion, ADDuction, and Internal Rotation (FADDIR)—will elicit pain. The maneuver can be tested starting at 45° of hip flexion, increasing to approximately 120°. Pain with <45° of hip flexion indicates that the impingement is severe.
Such testing can also reveal labral tears, which may be caused by FAI or other structural abnormalities. In a patient with anterior labral tears, FADDIR will produce groin pain; posterior labral tears will produce pain when the patient is sitting with legs hanging off the exam table and the contralateral leg is brought to the chest and the affected limb fully extended.
In patients with hip pain and bursitis, applying downward pressure will elicit a snapping sound as the iliopsoas snaps over the iliopectineal eminence or femoral head. Flexion, ABduction, and External Rotation (FABER) can also be used to diagnose iliopsoas tendonitis: The test is positive if it elicits pain in the affected extremity or in the sacroiliac joint on the opposite side.
Log roll. A painful response to this test, which involves internally and externally rotating the affected hip while it is relaxed and the knee fully extended, is an indication of synovitis of the hip caused by intra-articular pathology. To test hip stability, externally rotate the leg while it is extended. If the hip is stable, the leg will return to a neutral position; microinstability of the hip is likely if the leg remains in the rotated position.
Muscular strength testing. To assess for tendinopathy in the hip area, the patient should be in a seated position and contract the internal and external rotators and the adductor muscles while you apply resistance. To test abductor strength, have the patient assume a lateral position and hold and abduct the leg on the affected side while you apply resistance.
Hip flexion strength should be tested with the patient in both supine and seated positions. A patient with quadriceps tendonitis will have much greater pain with resisted hip flexion in the supine position vs the seated position; the opposite is true for a patient with iliopsoas tendonitis. (See “Did you know…? Hip pain facts and findings” on for additional diagnostic tips.)
Did you know … ? Hip pain facts and findings
- A patient with quadriceps tendonitis will have much greater pain with resisted hip flexion in a supine position vs a seated position. The opposite is true for a patient with iliopsoas tendonitis.
- Patients with femoral neck stress fractures typically present with activity-related anterior groin pain that is relieved by rest. Initially, they may be only mildly affected, but the condition worsens in those who continue to “work through the pain.”
- Plain radiography can confirm a diagnosis of osteonecrosis in patients with advanced disease, but magnetic resonance imaging is useful for evaluating earlier clinical presentations.
- Patients with labral tears often exhibit what has been called the “c-sign”—so named for the shape patients make with their hand as they grip their hip just above the greater trochanter to indicate where it hurts.
- Athletes who experience adductor strains often play sports in which kicking or frequent changes in direction are required, such as football, hockey, and soccer, and are generally able to tell you exactly what they were doing when the injury occurred.
- Unlike other hernias, a sports hernia (athletic pubalgia) does not involve a bulge of tissue protruding through one part of the body into another. Instead, it occurs when the oblique abdominal muscles strain or completely tear away from the pubis.
Perform a neurologic evaluation to rule out a back condition that might radiate pain into the anterior hip; ask the patient to do a sit-up while you apply resistance to test for abdominal wall pathology, as well.
Hip palpation. This aspect of the physical exam is important regardless of the cause of the pain but especially crucial for pediatric and adolescent patients, whose anterior hip pain may be related to apophyseal injury. Palpate the superior iliac spine (and over the inferior iliac spine in thin patients) to determine if the sartorius or rectus femoris has been injured. The area just lateral to the symphysis will be tender to palpation in patients with osteitis pubis.
Refer or treat? Here’s what to consider
While the history and physical should provide ample information for a differential diagnosis, imaging studies are generally required for confirmation. Clinical assessment— including physical exam, imaging, and intra-articular injection—of patients with hip pain is up to 98% accurate in identifying hip abnormalities, with arthroscopy as the gold standard.4