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
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!
- 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