You Know These Hips Don’t Lie…

Anatomy

Source: TeachMeAnatomy.info

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? 

Source: AAFP Evaluation of the Patient with Hip Pain

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

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