You Know These Hips Don’t Lie…

Anatomy

Fun facts about the hip:

• The hip joint is a ball-and-socket joint between the pelvis and the femur.  The hip itself is made up of 3 fused bones: ileum, pubis, and ischium. 
• Forces travel between the hip and spine via the pelvis, which underlies the connection in pain between these sites.
• There are 18 bursae in the hip region!

Where can the hip hurt? 

Differential diagnosis per pain location: 

• Anterior: sports hernia, meralgia paresthetica
• Anterolateral: femoral neck fracture / stress fracture, femoroacetabular impingement, hip labral tear, iliopsoas bursitis, Legg-Calve-Perthes disease, osteoarthritis, osteonecrosis, SCFE, transient synovitis
• Lateral: trochanteric bursitis, trochanteric pain syndrome, 
• Posterolateral: gluteal muscle tear / avulsion, iliac crest apophysis / avulsion
• Posterior: hamstring muscle strain / avulsion, ischiofemoral impingement, piriformis syndrome, sacroiliac joint dysfunction

Common Causes of Hip Pain

• Hip osteoarthritis
• Greater trochanteric bursitis/ pain syndrome (up to 25% of the population has lateral hip pain)
• Piriformis syndrome
• Claudication

The Hip Exam

• IPASS (inspection, palpation, active/passive ROM, strength, special tests)
  • Palpation of the greater trochanter
• Observe the patient’s gait
  • Trendelenburg gait seen is in trochanteric pain syndromes as well as classic gluteus medius paralysis
• Curious how to perform a telemedicine exam of the hip? Check out this article by the Mayo Clinic!

Special Tests

• FABER test (aka Patrick test or Figure 4 test): labral tear, internal snapping hip, femoroacetabular impingement, sacroiliac disease, osteoarthritis
  • Flexion, ABduction, External Rotation
  • Location of pain and ROM limitation with FABER helps to assess where the problem is (i.e. not just “negative” or “positive”)
• FADIR test: mainly femoroacetabular impingement
  • Flexion, ADduction, Internal Rotation

• Ober’s test: IT band syndrome
  • ABduction, Extension
• Check out the Stanford 25 for more special maneuvers!

Next steps: Imaging

• Always consider imaging if suspicious for fracture
• Imaging may provide confirmation of arthritis diagnosis
• Get XR pelvis AP – first step imaging, allows you to compare the 2 hip joints
• MRI is diagnostic for labral tears, occult fractures, stress fractures, osteonecrosis
  • Must order MRI arthrography to assess the labrum (regular MRI is only ~30% sensitive and specific, while arthrography is ~90%)

Blog post based on Med-Peds Forum talk by Julia Solomon, PGY2