1. Meg Pusateri, MD Brandon Hockenberry, MD
Approach to Hip Pain
Meg Pusateri, MD
Brandon Hockenberry, MD

2. Objectives Anatomy Review Key Questions Differential Diagnosis
Physical Exam
Pathology

7. KEY QUESTIONS: Approach to Hip Pain 1. History?
Adult vs. Peds?
Activities/Sports?
2. Is this actually the hip?
Back?
Knee?
3. Intra-articular vs. extra-articular?
4. Exam maneuvers?
5. Differential?
Approach to Hip Pain

8. Differential Diagnosis
Lateral Femoral Cutaneous
Intraarticular
Piriformis Syndrome
Intra or Extraarticular
Osteoarthritis
Labral Tear
Fractures
FAI (Femoral Acetabular Impingement)
Stress Fracture
Avulsion Fracture
Osteonecrosis (AVN)
Snapping Hip/IT Band Syndrome
Extraarticular
Malignancy
Soft Tissue Injury
Infection
Contusion
Septic Joint (Hip, SI)
Sprain
Osteomyelitis
Tendonitis
Pediatrics
Athletic Pubalgia/Sports Hernia
Osteitis Pubis
Legg-Calve-Perthes Disease
Greater Trochanteric Pain Syndrome
SCFE (Slipped Capital Femoral Epiphysis)
Nerve Entrapments
Apophysitis
Obturator
Transient Synovitis
Differential Diagnosis

9. Inspection Erythema, edema, wounds, gross deformity, etc. Leg Length
Internally/externally rotated?
Gait
Antalgic?
Trendelenberg?
Inspection

10. Palpation Greater Trochanter/Bursa
Anterior Superior Iliac Spine (ASIS)
Ischial Tuberosity
Iliac Crest
Iliotibial Band/TFL
Pubic Symphysis
Palpation

11. Range of Motion Flexion: 120-130o Extension: 10-20o Abduction: 40-50o
Adduction: 20-30o
Internal Rotation: 30-40o
External Rotation: 40-50o

12. Special Tests FADIR FABER or Patrick’s Test Log Roll Test Ober’s Test
Flexed, ADducted, and Internally Rotated
Hip/groin pain = positive
Possible labral tear, FAI
FABER or Patrick’s Test
Flexed, ABducted, and Externally Rotated
Hip or back pain = positive
Intraarticular lesions vs. iliopsoas pain vs. SI joint
Log Roll Test
Ober’s Test
Often measured in “fists”
Tight ITB
Stinchfield’s Test
Resisted straight leg raise
Labral Grind
Special Tests

13. Other Exam Considerations
Neurovascular Exam
Pulses
Sensory
Strength
Reflexes
Back/Spine Exam
Knee Exam
Other Exam Considerations

14. Osteoarthritis
Hip OA: 88/100,000 per year vs. Knee OA 240/100,000 per year
Risk Factors:
Articular trauma
Muscle weakness
High impact sports
Heavy, physical labor
Gender, female > male
Increasing age
Developmental abnormalities (ex: SCFE)

15. Femoro-acetabular Impingement (FAI)
Occurs due to impingement of the femoral head against the anterior edge of the acetabulum
CAM vs. Pincer lesion
CAM more common in young, active males
Pincer more common in active, middle age women
70-80% have a mixed lesion
Can cause secondary osteoarthritis, labral degeneration/tears, and cartilage damage/tears.
Femoro-acetabular Impingement (FAI)

18. Femoro-acetabular Impingement (FAI)
Among athletes, often seen among those who regularly perform movements that force the femoral head anteriorly, like hyperextension/flexion.
Ice Hockey
Soccer
Treatments include:
Observation
Physical Therapy
Intraarticular Injection
Surgery

19. Snapping Hip 3 Types: External Snapping Hip Internal Snapping Hip
ITB sliding over greater trochanter.
Often visible, palpate trochanter as hip flexed
Internal Snapping Hip
Most common
Reproduced by moving hip from an externally rotated/flexed position to an externally rotated/extended position.
Intra-articular Snapping Hip
Loose bodies
Labral Tears
Snapping Hip

21. Greater Trochanteric Pain Syndrome
Chronic regional pain caused by a combination of both gluteal tendon injuries and bursitis 
Previously, trochanteric bursitis was seen as the main pain source, but recent research indicates that bursitis is only seen in the minority
Can be caused by:
Direct trauma (ex: fall onto your side)
Prolonged pressure to the hip area
Repetitive movements (ex: walking/running)
Unaccustomed vigorous exercise
Weight-bearing on the one leg for long periods
Hip instability
Greater Trochanteric Pain Syndrome

22. Greater Trochanteric Pain Syndrome
Lateral hip pain per history and exam
NOT intraarticular
All of the following attach on the greater trochanter:
1. Gluteus Maximus
2. Gluteus Medius
3. Gluteus Minimus
4. Tensor Fascia Latae
Greater Trochanteric Pain Syndrome