Evaluation of the Patient with Hip Pain

JOHN J. WILSON, MD, MS, and MASARU FURUKAWA, MD, MS, University of Wisconsin School of Medicine
and Public Health, Madison, Wisconsin

Hip pain is a common and disabling condition that affects patients of all ages. The differential diagnosis of hip pain
is broad, presenting a diagnostic challenge. Patients often express that their hip pain is localized to one of three anatomic regions: the anterior hip and groin, the posterior hip and buttock, or the lateral hip. Anterior hip and groin
pain is commonly associated with intra-articular pathology, such as osteoarthritis and hip labral tears. Posterior hip
pain is associated with piriformis syndrome, sacroiliac joint dysfunction, lumbar radiculopathy, and less commonly
ischiofemoral impingement and vascular claudication. Lateral hip pain occurs with greater trochanteric pain syndrome. Clinical examination tests, although helpful, are not highly sensitive or specific for most diagnoses; however,
a rational approach to the hip examination can be used. Radiography should be performed if acute fracture, dislocations, or stress fractures are suspected. Initial plain radiography of the hip should include an anteroposterior view of
the pelvis and frog-leg lateral view of the symptomatic hip. Magnetic resonance imaging should be performed if the
history and plain radiograph results are not diagnostic. Magnetic resonance imaging is valuable for the detection of
occult traumatic fractures, stress fractures, and osteonecrosis of the femoral head. Magnetic resonance arthrography
is the diagnostic test of choice for labral tears. (Am Fam Physician. 2014;89(1):27-34. Copyright 2014 American
Academy of Family Physicians.)

Patient information:
A handout on this topic,
written by the authors
of this article, is available at http://www.
aafp.org/afp/2014/0101/
p27-s1.html. Access to
this handout is free and
unrestricted.
More online
at http://www.
aafp.org/afp.
CME This clinical content
conforms to AAFP criteria
for continuing medical
education (CME). See CME
Quiz questions on page 6.

Author disclosure: No relevant financial affiliations.

ip pain is a common presentation in primary care and can

affect patients of all ages. In one
study, 14.3% of adults 60 years
and older reported significant hip pain on
most days over the previous six weeks.1 Hip
pain often presents a diagnostic and therapeutic challenge. The differential diagnosis
of hip pain (eTable A) is broad, including
both intra-articular and extra-articular
pathology, and varies by age. A history and
physical examination are essential to accurately diagnose the cause of hip pain.
Anatomy
The hip joint is a ball-and-socket synovial
joint designed to allow multiaxial motion
while transferring loads between the upper
and lower body. The acetabular rim is lined
by fibrocartilage (labrum), which adds depth
and stability to the femoroacetabular joint.
The articular surfaces are covered by hyaline cartilage that dissipates shear and compressive forces during load bearing and hip
motion. The hips major innervating nerves
originate in the lumbosacral region, which
can make it difficult to distinguish between
primary hip pain and radicular lumbar pain.
The hip joints wide range of motion is second only to that of the glenohumeral joint

and is enabled by the large number of muscle groups that surround the hip. The flexor
muscles include the iliopsoas, rectus femoris,
pectineus, and sartorius muscles. The gluteus maximus and hamstring muscle groups
allow for hip extension. Smaller muscles, such
as gluteus medius and minimus, piriformis,
obturator externus and internus, and quadratus femoris muscles, insert around the greater
trochanter, allowing for abduction, adduction, and internal and external rotation.
In persons who are skeletally immature,
there are several growth centers of the pelvis
and femur where injuries can occur. Potential sites of apophyseal injury in the hip
region include the ischium, anterior superior
iliac spine, anterior inferior iliac spine, iliac
crest, lesser trochanter, and greater trochanter. The apophysis of the superior iliac spine
matures last and is susceptible to injury up
to 25 years of age.2
Evaluation of Hip Pain
HISTORY

Age alone can narrow the differential diagnosis of hip pain. In prepubescent and adolescent patients, congenital malformations
of the femoroacetabular joint, avulsion fractures, and apophyseal or epiphyseal injuries should be considered. In those who are

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Hip Pain
SORT: KEY RECOMMENDATIONS FOR PRACTICE
Evidence
rating

References

Initial plain radiography of the hip should include an anteroposterior view of the pelvis and a frog-leg
lateral view of the symptomatic hip.

Magnetic resonance imaging should be used for detection of occult hip fractures, stress fractures,
and osteonecrosis of the femoral head.

23, 30, 33

Magnetic resonance arthrography is the diagnostic test of choice for labral tears.

6, 19

Ultrasonography is a helpful diagnostic modality for patients with suspected bursitis, joint effusion,
or functional causes of hip pain (e.g., snapping hip), and can be employed for therapeutic imagingguided injections and aspirations around the hip.

8, 9

Clinical recommendation

A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, diseaseoriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.
org/afpsort.

Figure 1. Gait testing. (A) C sign. Patients often localize pain by cupping the anterolateral hip with the thumb and forefinger in the shape of a C. (B) Gait analysis. The patient is observed while walking to evaluate for limp or antalgic
gait characteristics. (C) Modified Trendelenburg test (single leg stance phase). The patient stands with feet shoulder
width apart and lifts one leg. The examiner observes for a drop in the level of the iliac crest on the side of the lifted leg.

skeletally mature, hip pain is often a result of musculotendinous strain, ligamentous sprain, contusion, or
bursitis. In older adults, degenerative osteoarthritis and
fractures should be considered first.
Patients with hip pain should be asked about antecedent trauma or inciting activity, factors that increase
or decrease the pain, mechanism of injury, and time of
28 American Family Physician

onset. Questions related to hip function, such as the ease

of getting in and out of a car, putting on shoes, running,
walking, and going up and down stairs, can be helpful.3
Location of the pain is informative because hip pain
often localizes to one of three basic anatomic regions:
the anterior hip and groin, posterior hip and buttock,
and lateral hip (eFigure A).

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Hip Pain
Table 1. Physical Examination Tests for the Evaluation of Hip Pain
Test

Other names

Positioning

Positive findings

Differential diagnosis

Gait testing (C sign,

Figure 1A; gait analysis,
Figure 1B)

Standing

Antalgic gait, Trendelenburg gait,

pelvic wink (rotation of more
than 40 degrees in the axial plane
toward the affected hip when
terminally extending the hip),
excessive pronation or supination
of the ankles, and limps caused
by differing leg lengths

Hip labral tear, transient synovitis,

Legg-Calv-Perthes disease,
SCFE

Modified Trendelenburg
test (Figure 1C)

Single leg
stance phase

Standing

2-cm drop in the level of the iliac

crest, indicating weakness on the
contralateral side

Hip labral tear, transient synovitis,

Legg-Calv-Perthes disease,
SCFE

ROM testing (Figure 2)

Supine,
lateral, or
sitting

Pain with passive ROM, limited

ROM

Pain with passive ROM: Transient

synovitis, septic arthritis
Limited ROM: Loose bodies,
chondral lesions, osteoarthritis,
Legg-Calv-Perthes disease,
osteonecrosis

FABER test (Figure 3)

Patrick test

Supine

Posterior pain localized to the

sacroiliac joint, lumbar spine, or
posterior hip; groin pain with the
test is sensitive for intra-articular
pathology

Hip labral tear, loose bodies,

chondral lesions, femoral
acetabular impingement,
osteoarthritis, sacroiliac joint
dysfunction, iliopsoas bursitis

FADIR test (Figure 4)

Impingement
test

Supine

Pain

Hip labral tear, loose bodies,

chondral lesions, femoral
acetabular impingement

Log roll test (Figure 5)

Passive supine
rotation,
Freiberg test

Supine

Restricted movement, pain

Piriformis syndrome, SCFE

Straight leg raise against

resistance test (Figure 6)

Stinchfield test

Supine

Weakness to resistance, pain

Athletic pubalgia (sports hernia),

SCFE, femoral acetabular
impingement

Ober test (eFigure B)

Passive
adduction

Lateral

Passive adduction past midline

cannot be achieved

External snapping hip, greater

trochanteric pain syndrome

FABER = flexion, abduction, external rotation; FADIR = flexion, adduction, internal rotation; ROM = range of motion; SCFE = slipped capital femoral
epiphysis.

PHYSICAL EXAMINATION

The hip examination should evaluate the hip, back,

abdomen, and vascular and neurologic systems. It
should start with a gait analysis and stance assessment
(Figure 1), followed by evaluation of the patient in seated,
supine, lateral, and prone positions (Figures 2 through 6,
and eFigure B). Physical examination tests for the evaluation of hip pain are summarized in Table 1.
IMAGING

Radiography. Radiography of the hip should be performed if there is any suspicion of acute fracture, dislocation, or stress fracture. Initial plain radiography of the
hip should include an anteroposterior view of the pelvis
and a frog-leg lateral view of the symptomatic hip.4
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Magnetic Resonance Imaging and Arthrography. Conventional magnetic resonance imaging (MRI) of the hip
can detect many soft tissue abnormalities, and is the
preferred imaging modality if plain radiography does
not identify specific pathology in a patient with persistent pain.5 Conventional MRI has a sensitivity of 30%
and an accuracy of 36% for diagnosing hip labral tears,
whereas magnetic resonance arthrography provides
added sensitivity of 90% and accuracy of 91% for the
detection of labral tears.6,7
Ultrasonography. Ultrasonography is a useful technique for evaluating individual tendons, confirming suspected bursitis, and identifying joint effusions
and functional causes of hip pain.8 Ultrasonography is
especially useful for safely and accurately performing

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American Family Physician29

Hip Pain

45

10

20-30

20-35
30-70

Figure 2. Hip range-of-motion testing (photos demonstrate normal range of motion). (A) Abduction. (B) Adduction.
(C) Extension. (D) Internal and external rotation.

30 American Family Physician

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Hip Pain

Figure 3. FABER test (flexion, abduction, external rotation; Patrick test). The examiner moves
the leg into 45 degrees of flexion, then (A) externally rotates and (B) abducts the leg so that
the ankle rests proximal to the knee of the contralateral leg.

Figure 4. FADIR test (flexion, adduction, internal rotation; impingement test). The examiner
passively moves the leg into (A) full flexion, then into (B) adduction and internal rotation.
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American Family Physician31

Hip Pain

imaging-guided injections and aspirations

around the hip.9 It is ideal for an experienced
ultrasonographer to perform the diagnostic
study; however, emerging evidence suggests
that less experienced clinicians with appropriate training can make diagnoses with
reliability similar to that of an experienced
musculoskeletal ultrasonographer.10,11
Differential Diagnosis
of Anterior Hip Pain
Anterior hip or groin pain suggests involvement of the hip joint itself. Patients often
localize pain by cupping the anterolateral hip
with the thumb and forefinger in the shape of
a C. This is known as the C sign (Figure 1A).

Figure 5. Log roll test (passive supine rotation; Freiberg test). Patients
leg is extended and relaxed on examination table as the examiner
internally and externally rotates the leg (log roll).

OSTEOARTHRITIS

Osteoarthritis is the most likely diagnosis in

older adults with limited motion and gradual
onset of symptoms. Patients have a constant,
deep, aching pain and stiffness that are worse
with prolonged standing and weight bearing. Examination reveals decreased range of
motion, and extremes of hip motion often
cause pain. Plain radiographs demonstrate
the presence of asymmetrical joint-space
narrowing, osteophytosis, and subchondral
sclerosis and cyst formation.12
FEMOROACETABULAR IMPINGEMENT

Figure 6. Straight leg raise against resistance test (Stinchfield test).

Patients with femoroacetabular impinge- The patient lifts the straight leg to 45 degrees while the examiner
ment are often young and physically active. applies downward force on the thigh.
They describe insidious onset of pain that is
worse with sitting, rising from a seat, getting in or out of pain usually has an insidious onset, but occasionally
a car, or leaning forward.13 The pain is located primarily begins acutely after a traumatic event. About one-half
in the groin with occasional radiation to the lateral hip of patients with this injury also have mechanical sympand anterior thigh.14 The FABER test (flexion, abduction, toms, such as catching or painful clicking with activity.17
external rotation; Figure 3) has a sensitivity of 96% to The FADIR and FABER tests are effective for detect99%. The FADIR test (flexion, adduction, internal rota- ing intra-articular pathology (the sensitivity is 96% to
tion; Figure 4), log roll test (Figure 5), and straight leg 75% for the FADIR test and is 88% for the FABER test),
raise against resistance test (Figure 6) are also effective, although neither test has high specificity.14,15,18 Magnetic
with sensitivities of 88%, 56%, and 30%, respectively.14,15 resonance arthrography is considered the diagnostic test
In addition to the anteroposterior and lateral radiograph of choice for labral tears.6,19 However, if a labral tear is not
views, a Dunn view should be obtained to help detect suspected, other less invasive imaging modalities, such
subtle lesions.16
as plain radiography and conventional MRI, should be
used first to rule out other causes of hip and groin pain.
HIP LABRAL TEAR

Hip labral tears cause dull or sharp groin pain, and onehalf of patients with a labral tear have pain that radiates to the lateral hip, anterior thigh, and buttock. The
32 American Family Physician

ILIOPSOAS BURSITIS (INTERNAL SNAPPING HIP)

Patients with this condition have anterior hip pain when

extending the hip from a flexed position, often associated

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Hip Pain

with intermittent catching, snapping, or popping of the

hip.20 Dynamic real-time ultrasonography is particularly
useful in evaluating the various forms of snapping hip.8
OCCULT OR STRESS FRACTURE

Occult or stress fracture of the hip should be considered if trauma or repetitive weight-bearing exercise is
involved, even if plain radiograph results are negative.21
Clinically, these injuries cause anterior hip or groin pain
that is worse with activity.21 Pain may be present with
extremes of motion, active straight leg raise, the log roll
test, or hopping.22 MRI is useful for the detection of
occult traumatic fractures and stress fractures not seen
on plain radiographs.23
TRANSIENT SYNOVITIS AND SEPTIC ARTHRITIS

Acute onset of atraumatic anterior hip pain that results

in impaired weight bearing should raise suspicion for
transient synovitis and septic arthritis. Risk factors for
septic arthritis in adults include age older than 80 years,
diabetes mellitus, rheumatoid arthritis, recent joint surgery, and hip or knee prostheses.24 Fever, complete blood
count, erythrocyte sedimentation rate, and C-reactive
protein level should be used to evaluate the risk of septic arthritis.25,26 MRI is useful for differentiating septic
arthritis from transient synovitis.27,28 However, hip aspiration using guided imaging such as fluoroscopy, computed tomography, or ultrasonography is recommended
if a septic joint is suspected.29
OSTEONECROSIS

Legg-Calv-Perthes disease is an idiopathic osteonecrosis of the femoral head in children two to 12 years of
age, with a male-to-female ratio of 4:1.4 In adults, risk
factors for osteonecrosis include systemic lupus erythematosus, sickle cell disease, human immunodeficiency
virus infection, smoking, alcoholism, and corticosteroid
use.30,31 Pain is the presenting symptom and is usually
insidious. Range of motion is initially preserved but can
become limited and painful as the disease progresses.32
MRI is valuable in the diagnosis and prognostication of
osteonecrosis of the femoral head.30,33
Differential Diagnosis of Posterior Hip
and Buttock Pain

Piriformis syndrome causes buttock pain that is aggravated by sitting or walking, with or without ipsilateral
radiation down the posterior thigh from sciatic nerve
compression.34,35 Pain with the log roll test is the most

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OTHER

Other causes of posterior hip pain include sacroiliac joint

dysfunction,39 lumbar radiculopathy,40 and vascular claudication.41 The presence of a limp, groin pain, and limited internal rotation of the hip is more predictive of hip
disorders than disorders originating from the low back.42
Differential Diagnosis of Lateral Hip Pain
GREATER TROCHANTERIC PAIN SYNDROME

Lateral hip pain affects 10% to 25% of the general population.43 Greater trochanteric pain syndrome refers to
pain over the greater trochanter. Several disorders of the
lateral hip can lead to this type of pain, including iliotibial band thickening, bursitis, and tears of the gluteus
medius and minimus muscle attachment.43-45 Patients
may have mild morning stiffness and may be unable to
sleep on the affected side. Gluteus minimus and medius
injuries present with pain in the posterior lateral aspect
of the hip as a result of partial or full-thickness tearing at
the gluteal insertion. Most patients have an atraumatic,
insidious onset of symptoms from repetitive use.43,45,46
Data Sources: We searched articles on hip pathology in American Family Physician, along with their references. We also searched the Agency
for Healthcare Research and Quality Evidence Reports, Clinical Evidence,
Institute for Clinical Systems Improvement, the U.S. Preventive Services
Task Force guidelines, the National Guideline Clearinghouse, and UpToDate. We performed a PubMed search using the keywords greater trochanteric pain syndrome, hip pain physical examination, imaging femoral
hip stress fractures, imaging hip labral tear, imaging osteomyelitis,
ischiofemoral impingement syndrome, meralgia paresthetica review, MRI
arthrogram hip labrum, septic arthritis systematic review, and ultrasound
hip pain. Search dates: March and April 2011, and August 15, 2013.
The authors thank Kristen Prewitt, DO, (model examiner in the figures)
and Grace Trabulsi (model patient) for their assistance.

PIRIFORMIS SYNDROME
AND ISCHIOFEMORAL IMPINGEMENT

January 1, 2014

sensitive test, but tenderness with palpation of the sciatic

notch can help with the diagnosis.35
Ischiofemoral impingement is a less well-understood
condition that can lead to nonspecific buttock pain with
radiation to the posterior thigh.36,37 This condition is
thought to be a result of impingement of the quadratus
femoris muscle between the lesser trochanter and the
ischium.
Unlike sciatica from disc herniation, piriformis syndrome and ischiofemoral impingement are exacerbated
by active external hip rotation. MRI is useful for diagnosing these conditions.38

The Authors
JOHN J. WILSON, MD, MS, is an assistant professor in the Department of
Family Medicine at the University of Wisconsin School of Medicine and
Public Health in Madison. He is also a team physician for the University of
Wisconsin Intercollegiate Athletics.

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Hip Pain

MASARU FURUKAWA, MD, MS, is a postgraduate trainee in the Department of Family Medicine at the University of Wisconsin School of Medicine
and Public Health.
Address correspondence to John J. Wilson, MD, MS, University of
WisconsinMadison, 1685 Highland Ave., Madison, WI 53705 (e-mail:
Wilson@Ortho.wisc.edu). Reprints are not available from the authors.
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Dull, diffuse pain radiating to

inner thigh; pain with direct
pressure, sneezing, sit-ups,
kicking, Valsalva maneuver

Paresthesia, hypesthesia

Pain characteristics

Deep, referred pain; pain with

standing after prolonged
sitting

Dull or sharp, referred pain;

pain with weight bearing

Deep, referred pain;

intermittent catching,
snapping, or popping

Deep, referred pain; pain with

weight bearing

Deep, referred pain; painful

clicking

Deep, aching pain and

stiffness; pain with weight
bearing

Femoroacetabular
impingement

Hip labral tear

Iliopsoas bursitis
(internal snapping
hip)

Legg-Calv-Perthes
disease

Loose bodies and

chondral lesions

Osteoarthritis
of the hip

Older than 50 years, pain with activity

that is relieved with rest

Mechanical symptoms, history of hip

dislocation or low-energy trauma,
history of Legg-Calv-Perthes disease

2 to 12 years of age, male

predominance

Ballet dancers, runners

Mechanical symptoms, such as

catching or painful clicking; history
of hip dislocation

Pain with getting in and out of a car

Females (especially with female athlete

triad), endurance athletes, low
aerobic fitness, steroid use, smokers

Soccer, rugby, football, hockey players

Obesity, pregnancy, tight pants or belt,

conditions with increased intraabdominal pressure

History/risk factors

Internal rotation < 15 degrees, flexion

< 115 degrees

Limited ROM, catching and grinding

with provocative maneuvers, positive
FADIR and FABER tests

Antalgic gait, limited ROM or stiffness

Snap with FABER to extension,

adduction, and internal rotation;
reproduction of snapping with
extension of hip from flexed position

Trendelenburg or antalgic gait, loss of

internal rotation, positive FADIR and
FABER tests

FADIR and FABER tests are sensitive

Painful ROM, pain on palpation of

greater trochanter

No hernia, tenderness of the inguinal

canal or pubic tubercle, adductor
origin, pain with resisted sit-up or hip
flexion

Anterior thigh hypesthesia, dysesthesia

Examination findings

FABER = flexion, abduction, external rotation; FADIR = flexion, adduction, internal rotation; MRI = magnetic resonance imaging; ROM = range of motion.

Deep, referred pain; pain with

weight bearing

Femoral neck
fracture/stress
fracture

Anterolateral hip and groin pain (C sign)

Athletic pubalgia
(sports hernia)

Anterior groin pain

Meralgia
paresthetica

Anterior thigh pain

Diagnosis

eTable A. Differential Diagnosis of Hip Pain

continued

Radiography: Presence of osteophytes at the

acetabular joint margin, asymmetrical joint-space
narrowing, subchondral sclerosis and cyst formation

MRI: Can detect chondral and fibrous loose bodies

Radiography: Can show ossified or osteochondral

loose bodies

Radiography: Early small femoral epiphysis, sclerosis

and flattening of the femoral head

Dynamic ultrasonography: Snapping of iliopsoas or

iliotibial band over greater trochanter

Ultrasonography: Tendinopathy, bursitis, fluid around

tendon

MRI: Bursitis and edema of the iliotibial band

Radiography: No bony involvement

Magnetic resonance arthrography: offers added

sensitivity and specificity

MRI: Can show a labral tear

Radiography: Cam or pincer deformity, acetabular

retroversion, coxa profunda

MRI: Early bony edema

Radiography: Cortical disruption

MRI: Can show tear or detachment of the rectus

abdominis or adductor longus

Radiography: No bony involvement

None

Additional testing

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Pain characteristics

Deep, referred pain; pain with

weight bearing

Refusal to bear weight, pain

with leg movement

Refusal to bear weight

Slipped capital
femoral epiphysis

Septic arthritis

Transient synovitis

Pain with direct pressure,

radiation down lateral thigh

Pain with direct pressure,

radiation down lateral thigh

Greater trochanteric
bursitis*

Greater trochanteric
pain syndrome

Tenderness to direct
palpation

Iliac crest apophysis

avulsion

History of direct trauma, skeletal

immaturity (younger than 25 years)

Middle-aged women

Associated with knee osteoarthritis,

increased body mass index, low back
pain; female predominance

Runners, middle-aged women

All age groups, audible snap with

ambulation

Children: 3 to 8 years of age,

sometimes fever and ill appearance

Adults: Older than 80 years, diabetes

mellitus, rheumatoid arthritis, recent
joint surgery, hip or knee prostheses

Children: 3 to 8 years of age, fever, ill

appearance

11 to 14 years of age, overweight

(80th to 100th percentile)

Adults: Lupus, sickle cell disease,

human immunodeficiency virus
infection, corticosteroid use, smoking,
and alcohol use; insidious onset, but
can be acute with history of trauma

History/risk factors

Iliac crest tenderness and/or ecchymosis

Weak hip abduction, pain with resisted

external rotation, Trendelenburg gait is
sensitive and specific

Proximal iliotibial band tenderness,

Trendelenburg gait is sensitive and
specific

Pain over greater trochanter

Positive Ober test, snap with Ober test,

pain over greater trochanter

Pain with extremes of ROM

Guarding against any ROM; pain with

passive ROM

Antalgic gait with foot externally rotated

on occasion, positive log roll and
straight leg raise against resistance
tests, pain with hip internal rotation
relieved with external rotation

Pain on ambulation, positive log roll test,

gradual limitation of ROM

Examination findings

*Conditions associated with greater trochanteric pain syndrome.

FABER = flexion, abduction, external rotation; FADIR = flexion, adduction, internal rotation; MRI = magnetic resonance imaging; ROM = range of motion.

Pain with direct pressure,

radiation down lateral thigh
and buttock

Gluteal muscle tear

or avulsion*

Posterolateral pain

Pain with direct pressure,

radiation down lateral
thigh, snapping or popping

External snapping
hip*

Lateral pain

Deep, referred pain; pain with

weight bearing

Osteonecrosis
of the hip

Anterolateral hip and groin pain (C sign) (continued)

Diagnosis

eTable A. Differential Diagnosis of Hip Pain (continued)

Radiography: Apophysis widening, soft tissue swelling

around iliac crest
continued

MRI: Gluteal muscle edema or tears

Dynamic ultrasonography: Snapping of iliopsoas or

iliotibial band over greater trochanter

Ultrasonography: Tendinopathy, bursitis, fluid around

tendon

MRI: Bursitis and edema of the iliotibial band

Radiography: No bony involvement

MRI: Useful for differentiating septic arthritis from

transient synovitis

Hip aspiration guided by fluoroscopy, computed

tomography, or ultrasonography; Gram stain and
culture of joint aspirate

Radiography: Widened epiphysis early, slippage of

femur under epiphysis later

MRI: Bony edema, subchondral collapse

Radiography: Femoral head lucency and subchondral

sclerosis, subchondral collapse (i.e., crescent sign),
flattening of the femoral head

Additional testing

Buttock pain, pain with direct

pressure

Buttock or back pain with

posterior thigh radiation,
sciatica symptoms

Buttock pain with posterior

thigh radiation, sciatica
symptoms

Pain radiates to lumbar back,

buttock, and groin

Ischial apophysis
avulsion

Ischiofemoral
impingement

Piriformis syndrome

Sacroiliac joint
dysfunction

Female predominance, common in

pregnancy, history of minor trauma

History of direct trauma to buttock

or pain with sitting, weakness and
numbness are rare compared with
lumbar radicular symptoms

Groin and/or buttock pain that may

radiate distally

Skeletal immaturity, eccentric muscle

contraction (cutting, kicking,
jumping)

Eccentric muscle contraction while hip

flexed and leg extended

History/risk factors

FABER test elicits posterior pain localized

to the sacroiliac joint, sacroiliac joint
line tenderness

Positive log roll test, tenderness over the

sciatic notch

None established

Ischial tuberosity tenderness,

ecchymosis, weakness to leg flexion,
palpable gap in hamstring

Examination findings

*Conditions associated with greater trochanteric pain syndrome.

FABER = flexion, abduction, external rotation; FADIR = flexion, adduction, internal rotation; MRI = magnetic resonance imaging; ROM = range of motion.

Buttock pain, pain with direct

pressure

Pain characteristics

Hamstring muscle
strain or avulsion

Posterior pain

Diagnosis

eTable A. Differential Diagnosis of Hip Pain (continued)

Radiography: Possibly no findings, narrowing and

sclerotic changes of the sacroiliac joint space

MRI: Lumbar spine has no disk herniation, piriformis

muscle atrophy or hypertrophy, edema surrounding
the sciatic nerve

MRI: Soft tissue edema around quadratus femoris

muscle

MRI: Hamstring edema and retraction

Radiography: Avulsion or strain of hamstring

attachment to ischium

Additional testing

Hip Pain

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Hip Pain

Posterior
and buttock
Lateral

Lateral

ILLUSTRATIONS BY TODD BUCK

Anterior
and groin

eFigure A. Localization of hip pain. (A) Posterior view. (B) Anterior view.

eFigure B. Ober test (passive adduction). The patient is positioned on his or her side, with the unaffected hip on the
examination table. The examiner stands behind the patient with one hand on the patients hip, and the other hand
supporting the lower leg. (A) To evaluate the tensor fasciae latae: The hip and knee are held at 0 degrees of extension
and allowed to passively adduct with gravity. (B) The gluteus medius: The hip is held at 0 degrees of extension and
45 to 90 degrees of knee flexion. (C) The gluteus maximus: The shoulders are rotated back toward the table, with the
hip in flexion and knee in extension.

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2013 American Academy
Volume
89, Number
1 For
January
1, 2014
the American
Family Physician website at www.aafp.org/afp.
Copyright
of Family
Physicians.
the private,
non

commercial use of one individual user of the website. All other rights reserved. Contact copyrights@aafp.org for copyright questions and/or permission requests.