Question 1 – Is the pain attributable to hip disorders?
Any back pain, radiating pain, numbness, or tingling in the legs?
Any pelvic pain, radiating to the groin, temporal relation to menstrual cycle?
Pain with coughing/straining (hernias, muscle strains)
Is the thigh and knee pain referred from the hip?
Is a hip condition causing secondary pain in the pelvis or low back?
Question 2 – Is the hip pain mechanical in nature? Rule out non mechanical pain and causes.
Fever, chills, night pain, rest pain?
Steroid use, alcoholism, trauma
Clues to mechanical causes
Pain with prolonged standing and walking – Dysplasia (rim loading, labral degeneration, abductor fatigue) foveal impingement, cartilage defects, abductor dysfunction.
Pain with sitting, getting in and out of a car (intra articular impingement). Inability to squat or sit cross legged- Intra or extra articular causes of impingement.
Groin pain. Intra-articular- Anterior labral tear from FAI or anterior dysplasia, synovitis, any other joint irritation Extra-articular – Subspine impingement, Iliopsoas tendinitis, bursitis, snapping, adductor strain Non hip conditions – Hernia, inguinal lymphadenopathy, upper lumbar radiculopathy, pelvic referred pain.
Lateral hip pain – Commonly referred from all intra-articular hip conditions, anterolateral hip impingement, Gluteus medius and minimus tendinopathy, abductor fatigue/insufficiency, trochanteric bursitis, ITB irritation and snapping.
Posterior hip pain – Posterior hip impingement, posterior dysplasia, piriformis syndrome, other sciatic entrapment, GT impingement, LT impingement, proximal hamstring tear, pudendal nerve entrapment, G. max tendinitis, referred pain from SI joint and lumbar spine.
Common to dysplasia and impingement are lateral hip, thigh, or knee pain and labral tear. On exam, internal rotation at 90 degrees of flexion is increased to 30-60 degrees in dysplasia or type 2 FAI and restricted with types 1 impingement.
Impingement sign is positive in both as well as in pretty much all hip conditions. But lack of pain in other directions and lack of rest pain differentiate mechanical pain from diseases like AVN, synovitis, and transient osteoporosis.
Impingement usually causes pain and damage with flexion activities like squatting, deep flexion sitting, getting in and out of a car. The pain can be in the groin, thigh, or knee. About 20% have pain with running.
Dysplasia usually causes lateral hip pain after prolonged standing and walking.
My basic hip exam after talking with the patient starts with doing a standing exam, and checking their gait and strength. Externally snapping is best reproduced by the patient while standing.
Standing exam from behind.
Spine for deformity, flexibility and aggravation of hip pain, tenderness of spine, quick neuro exam routinely.
Leg length assessment is most accurate while standing with feet flat, hips and knees extended and palpating the iliac crest height on both sides. I check for thigh and calf atrophy and continue watching during gait exam.
Palpation of posterior iliac crest, SI joint, Sciatic notch, ischial tuberosity for posterior hip pain complaints like piriformis syndrome, Gluteus maximus enthesopathy, hamstring tears, pudendal nerve entrapment.
Antalgic – Shortened single limb stance time on the painful side.
Trendelenburg – Commonly described for abductor insufficiency. Can be from unstable head, varus neck, muscle weakness. Can be an adaptation to decrease hip pain by generating less joint forces. But waddling increases shear stress on the hip cartilage and valgus stress on the knee joint.
Circumduction – typically seen in unilateral weakness like in hemiparesis but can be a compensation to decrease joint forces and coronal plane contractures. Also with iliopsoas tendinitis.
Short swing – Hip stiffness, flexion deformity, lesser trochanteric impingement
Short limb – shoulder dip in ingle leg stance on the short side. Toe walking on the shorter side and knee flexion on the long side are other compensations for limb shortening.
Intoeing – increased femoral anteversion, anterior dysplasia, LT impingement.
Outtoeing – Slipped epiphysis, femoral and acetabular retroversion. Anterior dysplasia makes outtoeing gait uncomfortable in the groin. Lesser trochanter impingement causes gluteal pain and shortened stride length.
Neurological exam – Heel walking, toes walking, single leg hop on each limb tests the strength, spasticity, coordination, and overall limb function efficiently.
Supine hip exam
It is very important to square the pelvis in supine position on a firm exam table. All the following tests can be done in a minute or two. I don’t do every test in everybody, but the following tests from 2-6 are routine for me. And I do more than one test to confirm each positive finding.
Palpate anterior crest, ASIS, inguinal canal, pubic tubercle, symphysis, adductor origin for upper groin pain. Can check with coughing and straining for hernias, resisted sit up test for sports hernia, resisted adduction for adductor strain.
- I start with a straight leg raise to check for back pain, sciatica, hamstring tightness, and posterior apprehension for posterior dysplasia. Impinging hips usually have tight hamstrings.
- Bring the hip back to extension, bend the knee and flex the hip slowly in neutral rotation and abduction looking for range, bony block and groin pain. Look for flexion deformity of the opposite hip (Thomas test) AIIS impingement, anterior capsular or labral irritation can cause groin pain with this test.
- Flexion internal rotation (FIR). Hold the hip and knee at 90 degrees and neutral abd/adduction. Let the hip external rotate if necessary to get to 90 of flexion. Carefully internally rotate looking for pain and the end point before the pelvis starts to move. Healthy range is 20-30 degrees.
- Restricted motion with a clear bony block and pain at the end is classic FAI especially when movements I other directions are not painful.
- Pain through most of the range of FIR can be FAI, but every other hip conditions also cause this pain.
- Increased FIR with pain at the end range is typical of anterior dysplasia.
- Resisted internal rotation in 90 degrees of flexion tests Gluteus medius and minimus strength and pain suggests strain or tear.
- Impingement sign – forced flexion, adduction, and internal rotation pinch the anterior labrum and cause groin pain in anterior impingement, anterior dysplasia, and every hip condition. Posterior hip pain with this test is a sign of posterior dysplasa, instability, or posterior labral and chondral damage from contr coup forces.
- Flexing and extending the hip during impingement testing compress the anterior labrum in different locations.
- Pushing the flexed thigh posteriorly is another test for posterior apprehension.
- FABER causing lateral pain and restricted range support lateral FAI. Posterior pain suggests SI joint problems.
- Hyperextension external rotation tests posterior impingement and anterior apprehension.
- Internal snapping test from FABER position to extension, adduction, and internal rotation, resisted flexion beyond 90 degrees for iliopsoas tendinitis, piriformis stretch pain, hamstring activation at 45 and 90, LT and GT impingement tests, and Ober’s test are done based on symptoms.
Exam in lateral position is to isolate gluteus medius for strength testing and palpating greater trochanter, trochanteric bursa, and gluteal insertion. Anterior apprehension can be more effective with addition of anterior translator force to the femoral head.
Exam in prone position can check femoral version and anterior apprehension.