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Home , Groin, Hip examination, Hip pain, Transient synovitis

Evaluation of the Patient with Pain JOHN J. WILSON, MD, MS, and MASARU FURUKAWA, MD, MS, University of Wisconsin School of and Public Health, Madison, Wisconsin

Hip pain is a common and disabling condition that affects patients of all ages. The of is broad, presenting a diagnostic challenge. Patients often express that their hip pain is localized to one of three ana- tomic regions: the anterior hip and , the posterior hip and buttock, or the lateral hip. Anterior hip and groin pain is commonly associated with intra-articular , such as and hip labral tears. Posterior hip pain is associated with , sacroiliac dysfunction, lumbar , and less commonly ischiofemoral impingement and vascular claudication. Lateral hip pain occurs with greater trochanteric pain syn- drome. 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, disloca- tions, or stress fractures are suspected. Initial plain radiography of the hip should include an anteroposterior view of the 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: ip pain is a common presenta- and is enabled by the large number of mus- A handout on this topic, tion in primary care and can cle groups that surround the hip. The flexor written by the authors of this article, is avail- affect patients of all ages. In one muscles include the iliopsoas, rectus femoris, able at http://www. study, 14.3% of adults 60 years pectineus, and sartorius muscles. The glu- aafp.org/afp/2014/0101/ H and older reported significant hip pain on teus maximus and muscle groups p27-s1.html. Access to most days over the previous six weeks.1 Hip allow for hip extension. Smaller muscles, such this handout is free and unrestricted. pain often presents a diagnostic and thera- as gluteus medius and minimus, piriformis, peutic challenge. The differential diagnosis obturator externus and internus, and quadra- More online of hip pain (eTable A) is broad, including tus femoris muscles, insert around the greater at http://www. both intra-articular and extra-articular trochanter, allowing for abduction, adduc- aafp.org/afp. pathology, and varies by age. A history and tion, and internal and external rotation. CME This clinical content are essential to accu- In persons who are skeletally immature, conforms to AAFP criteria rately diagnose the cause of hip pain. there are several growth centers of the pelvis for continuing medical and where can occur. Poten- education (CME). See CME Anatomy Quiz questions on page 6. tial sites of apophyseal in the hip The hip joint is a ball-and-socket synovial region include the ischium, anterior superior Author disclosure: No rel- joint designed to allow multiaxial motion iliac spine, anterior inferior iliac spine, iliac evant financial affiliations. while transferring loads between the upper crest, lesser trochanter, and greater trochan- and lower body. The acetabular rim is lined ter. The apophysis of the superior iliac spine by fibrocartilage (labrum), which adds depth matures last and is susceptible to injury up and stability to the femoroacetabular joint. to 25 years of age.2 The articular surfaces are covered by hya- line that dissipates shear and com- Evaluation of Hip Pain pressive forces during load bearing and hip HISTORY motion. The hip’s major innervating nerves Age alone can narrow the differential diag- originate in the lumbosacral region, which nosis of hip pain. In prepubescent and ado- can make it difficult to distinguish between lescent patients, congenital malformations primary hip pain and radicular lumbar pain. of the femoroacetabular joint, avulsion frac- The hip joint’s wide is sec- tures, and apophyseal or epiphyseal inju- ond only to that of the glenohumeral joint ries should be considered. In those who are

DownloadedJanuary 1, from2014 the ◆ VolumeAmerican 89, Family Number Physician 1 website at www.aafp.org/afp.www.aafp.org/afp Copyright © 2014 American Academy of FamilyAmerican Physicians. ForFamily the private, Physician non- 27 commercial use of one individual user of the website. All other rights reserved. Contact [email protected] for copyright questions and/or permission requests. Hip Pain SORT: KEY RECOMMENDATIONS FOR PRACTICE

Evidence Clinical recommendation rating References

Initial plain radiography of the hip should include an anteroposterior view of the pelvis and a frog-leg C 4 lateral view of the symptomatic hip. Magnetic resonance imaging should be used for detection of occult hip fractures, stress fractures, C 23, 30, 33 and osteonecrosis of the femoral head. Magnetic resonance arthrography is the diagnostic test of choice for labral tears. C 6, 19 Ultrasonography is a helpful diagnostic modality for patients with suspected , joint effusion, C 8, 9 or functional causes of hip pain (e.g., snapping hip), and can be employed for therapeutic imaging- guided injections and aspirations around the hip.

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

A B C

Figure 1. Gait testing. (A) C sign. Patients often localize pain by cupping the anterolateral hip with the and fore- in the shape of a “C.” (B) Gait analysis. The patient is observed while walking to evaluate for or antalgic gait characteristics. (C) Modified Trendelenburg test (single leg stance phase). The patient stands with feet 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 muscu- onset. Questions related to hip function, such as the ease lotendinous strain, ligamentous sprain, contusion, or of getting in and out of a car, putting on shoes, running, bursitis. In older adults, degenerative osteoarthritis and walking, and going up and down stairs, can be helpful.3 fractures should be considered first. Location of the pain is informative because hip pain Patients with hip pain should be asked about ante- often localizes to one of three basic anatomic regions: cedent trauma or inciting activity, factors that increase the anterior hip and groin, posterior hip and buttock, or decrease the pain, mechanism of injury, and time of and lateral hip (eFigure A).

28 American Family Physician www.aafp.org/afp Volume 89, Number 1 ◆ January 1, 2014 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, — Standing Antalgic gait, , Hip labral tear, transient , Figure 1A; gait analysis, pelvic wink (rotation of more Legg-Calvé-Perthes disease, Figure 1B) than 40 degrees in the axial plane SCFE toward the affected hip when terminally extending the hip), excessive pronation or supination of the , and caused by differing leg lengths

Modified Trendelenburg Single leg Standing 2-cm drop in the level of the iliac Hip labral tear, , test (Figure 1C) stance phase crest, indicating weakness on the Legg-Calvé-Perthes disease, contralateral side SCFE

ROM testing (Figure 2) — Supine, Pain with passive ROM, limited Pain with passive ROM: Transient lateral, or ROM synovitis, septic sitting Limited ROM: Loose bodies, chondral lesions, osteoarthritis, Legg-Calvé-Perthes disease, osteonecrosis

FABER test (Figure 3) Patrick test Supine Posterior pain localized to the Hip labral tear, loose bodies, sacroiliac joint, lumbar spine, or chondral lesions, femoral posterior hip; groin pain with the acetabular impingement, test is sensitive for intra-articular osteoarthritis, sacroiliac joint pathology dysfunction, iliopsoas bursitis

FADIR test (Figure 4) Impingement Supine Pain Hip labral tear, loose bodies, test chondral lesions, femoral acetabular impingement

Log roll test (Figure 5) Passive supine Supine Restricted movement, pain Piriformis syndrome, SCFE rotation, Freiberg test

Straight leg raise against Stinchfield test Supine Weakness to resistance, pain (sports ), resistance test (Figure 6) SCFE, femoral acetabular impingement

Ober test (eFigure B) Passive Lateral Passive adduction past midline External snapping hip, greater adduction cannot be achieved trochanteric pain syndrome

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

PHYSICAL EXAMINATION Magnetic Resonance Imaging and Arthrography. Con- The hip examination should evaluate the hip, back, ventional magnetic resonance imaging (MRI) of the hip , and vascular and neurologic systems. It can detect many soft tissue abnormalities, and is the should start with a gait analysis and stance assessment preferred imaging modality if plain radiography does (Figure 1), followed by evaluation of the patient in seated, not identify specific pathology in a patient with persis- supine, lateral, and prone positions (Figures 2 through 6, tent pain.5 Conventional MRI has a sensitivity of 30% and eFigure B). Physical examination tests for the evalu- and an accuracy of 36% for diagnosing hip labral tears, ation of hip pain are summarized in Table 1. whereas magnetic resonance arthrography provides added sensitivity of 90% and accuracy of 91% for the IMAGING detection of labral tears.6,7 Radiography. Radiography of the hip should be per- Ultrasonography. Ultrasonography is a useful tech- formed if there is any suspicion of acute fracture, dislo- nique for evaluating individual tendons, confirm- cation, or stress fracture. Initial plain radiography of the ing suspected bursitis, and identifying joint effusions hip should include an anteroposterior view of the pelvis and functional causes of hip pain.8 Ultrasonography is and a frog-leg lateral view of the symptomatic hip.4 especially useful for safely and accurately performing

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45°

10°

A

C

20-30°

20-35° 30-70°

B D

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 www.aafp.org/afp Volume 89, Number 1 ◆ January 1, 2014 Hip Pain

A B

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 rests proximal to the of the contralateral leg.

A B

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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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 appro- priate 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 involve- ment of the hip joint itself. Patients often localize pain by cupping the anterolateral hip Figure 5. Log roll test (passive supine rotation; Freiberg test). Patient’s with the thumb and forefinger in the shape of leg is extended and relaxed on examination table as the examiner a “C.” This is known as the C sign (Figure 1A). 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 bear- ing. 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. 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 . 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 symp- and 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 detect- 99%. 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 one- ILIOPSOAS BURSITIS (INTERNAL SNAPPING HIP) half of patients with a labral tear have pain that radi- Patients with this condition have anterior hip pain when ates to the lateral hip, anterior thigh, and buttock. The extending the hip from a flexed position, often associated

32 American Family Physician www.aafp.org/afp Volume 89, Number 1 ◆ January 1, 2014 Hip Pain

with intermittent catching, snapping, or popping of the sensitive test, but tenderness with of the sciatic hip.20 Dynamic real-time ultrasonography is particularly notch can help with the diagnosis.35 useful in evaluating the various forms of snapping hip.8 Ischiofemoral impingement is a less well-understood condition that can lead to nonspecific buttock pain with OCCULT OR STRESS FRACTURE radiation to the posterior thigh.36,37 This condition is Occult or stress fracture of the hip should be consid- thought to be a result of impingement of the quadratus ered if trauma or repetitive weight-bearing exercise is femoris muscle between the lesser trochanter and the involved, even if plain radiograph results are negative.21 ischium. Clinically, these injuries cause anterior hip or groin pain Unlike from disc herniation, piriformis syn- that is worse with activity.21 Pain may be present with drome and ischiofemoral impingement are exacerbated extremes of motion, active straight leg raise, the log roll by active external hip rotation. MRI is useful for diagnos- test, or hopping.22 MRI is useful for the detection of ing these conditions.38 occult traumatic fractures and stress fractures not seen on plain radiographs.23 OTHER Other causes of posterior hip pain include sacroiliac joint TRANSIENT SYNOVITIS AND dysfunction,39 lumbar radiculopathy,40 and vascular clau- Acute onset of atraumatic anterior hip pain that results dication.41 The presence of a limp, groin pain, and lim- in impaired weight bearing should raise suspicion for ited internal rotation of the hip is more predictive of hip transient synovitis and septic arthritis. Risk factors for disorders than disorders originating from the low back.42 septic arthritis in adults include age older than 80 years, diabetes mellitus, rheumatoid arthritis, recent joint sur- Differential Diagnosis of Lateral Hip Pain gery, and hip or knee prostheses.24 , complete blood GREATER TROCHANTERIC PAIN SYNDROME count, erythrocyte sedimentation rate, and C-reactive Lateral hip pain affects 10% to 25% of the general pop- protein level should be used to evaluate the risk of sep- ulation.43 Greater trochanteric pain syndrome refers to tic arthritis.25,26 MRI is useful for differentiating septic pain over the greater trochanter. Several disorders of the arthritis from transient synovitis.27,28 However, hip aspi- lateral hip can lead to this type of pain, including ilio- ration using guided imaging such as fluoroscopy, com- tibial band thickening, bursitis, and tears of the gluteus puted tomography, or ultrasonography is recommended medius and minimus muscle attachment.43-45 Patients if a septic joint is suspected.29 may have mild morning stiffness and may be unable to sleep on the affected side. Gluteus minimus and medius OSTEONECROSIS injuries present with pain in the posterior lateral aspect Legg-Calvé-Perthes disease is an idiopathic osteone- of the hip as a result of partial or full-thickness tearing at crosis of the femoral head in children two to 12 years of the gluteal insertion. Most patients have an atraumatic, age, with a male-to-female ratio of 4:1.4 In adults, risk insidious onset of symptoms from repetitive use.43,45,46 factors for osteonecrosis include systemic lupus erythe- Data Sources: We searched articles on hip pathology in American Fam- matosus, sickle cell disease, human immunodeficiency ily Physician, along with their references. We also searched the Agency virus infection, smoking, alcoholism, and corticosteroid for Healthcare Research and Quality Evidence Reports, Clinical Evidence, use.30,31 Pain is the presenting symptom and is usually Institute for Clinical Systems Improvement, the U.S. Preventive Services Task Force guidelines, the National Guideline Clearinghouse, and UpTo- insidious. Range of motion is initially preserved but can Date. We performed a PubMed search using the keywords greater tro- become limited and painful as the disease progresses.32 chanteric pain syndrome, hip pain physical examination, imaging femoral MRI is valuable in the diagnosis and prognostication of hip stress fractures, imaging hip labral tear, imaging , osteonecrosis of the femoral head.30,33 ischiofemoral impingement syndrome, meralgia paresthetica review, MRI hip labrum, septic arthritis systematic review, and ultrasound hip pain. Search dates: March and April 2011, and August 15, 2013. Differential Diagnosis of Posterior Hip and Buttock Pain The authors thank Kristen Prewitt, DO, (model examiner in the figures) and Grace Trabulsi (model patient) for their assistance. PIRIFORMIS SYNDROME AND ISCHIOFEMORAL IMPINGEMENT The Authors Piriformis syndrome causes buttock pain that is aggra- JOHN J. WILSON, MD, MS, is an assistant professor in the Department of vated by sitting or walking, with or without ipsilateral Family Medicine at the University of Wisconsin School of Medicine and radiation down the posterior thigh from sciatic nerve Public Health in Madison. He is also a team physician for the University of compression.34,35 Pain with the log roll test is the most Wisconsin Intercollegiate Athletics.

January 1, 2014 ◆ Volume 89, Number 1 www.aafp.org/afp American Family Physician 33 Hip Pain

MASARU FURUKAWA, MD, MS, is a postgraduate trainee in the Depart- 21. Egol KA, Koval KJ, Kummer F, et al. Stress fractures of the femoral . ment of Family Medicine at the University of Wisconsin School of Medicine Clin Orthop Relat Res. 1998;(348):72-78. and Public Health. 22. Fullerton LR Jr, Snowdy HA. Femoral neck stress fractures. Am J Sports Med. 1988;16(4):365-377. Address correspondence to John J. Wilson, MD, MS, University of 23. Newberg AH, Newman JS. Imaging the painful hip. Clin Orthop Relat Wisconsin–Madison, 1685 Highland Ave., Madison, WI 53705 (e-mail: Res. 2003;(406):19-28. [email protected]). Reprints are not available from the authors. 24. Margaretten ME, Kohlwes J, Moore D, et al. Does this adult patient have septic arthritis? JAMA. 2007;297(13):1478-1488. REFERENCES 25. Eich GF, Superti-Furga A, Umbricht FS, et al. The painful hip: evalua- tion of criteria for clinical decision-making. Eur J Pediatr. 1999;158(11): 1. Christmas C, Crespo CJ, Franckowiak SC, et al. 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eTable A. Differential Diagnosis of Hip Pain

Diagnosis Pain characteristics History/risk factors Examination findings Additional testing

Anterior thigh pain Meralgia Paresthesia, hypesthesia Obesity, pregnancy, tight pants or belt, Anterior thigh hypesthesia, dysesthesia None paresthetica conditions with increased intra- abdominal pressure Anterior groin pain Athletic pubalgia Dull, diffuse pain radiating to Soccer, rugby, football, hockey players No hernia, tenderness of the inguinal Radiography: No bony involvement (sports hernia) inner thigh; pain with direct canal or pubic tubercle, adductor MRI: Can show tear or detachment of the rectus pressure, sneezing, sit-ups, origin, pain with resisted sit-up or hip abdominis or adductor longus kicking, Valsalva maneuver flexion Anterolateral hip and groin pain (C sign) Femoral neck Deep, referred pain; pain with Females (especially with female athlete Painful ROM, pain on palpation of Radiography: Cortical disruption fracture/stress weight bearing triad), endurance athletes, low greater trochanter MRI: Early bony edema fracture aerobic fitness, steroid use, smokers Femoroacetabular Deep, referred pain; pain with Pain with getting in and out of a car FADIR and FABER tests are sensitive Radiography: Cam or pincer deformity, acetabular impingement standing after prolonged retroversion, coxa profunda sitting Hip labral tear Dull or sharp, referred pain; Mechanical symptoms, such as Trendelenburg or antalgic gait, loss of MRI: Can show a labral tear pain with weight bearing catching or painful clicking; history internal rotation, positive FADIR and Magnetic resonance arthrography: offers added of hip dislocation FABER tests sensitivity and specificity Iliopsoas bursitis Deep, referred pain; Ballet dancers, runners Snap with FABER to extension, Radiography: No bony involvement (internal snapping intermittent catching, adduction, and internal rotation; MRI: Bursitis and edema of the iliotibial band hip) snapping, or popping reproduction of snapping with Ultrasonography: , bursitis, fluid around extension of hip from flexed position tendon Dynamic ultrasonography: Snapping of iliopsoas or iliotibial band over greater trochanter Legg-Calvé-Perthes Deep, referred pain; pain with 2 to 12 years of age, male Antalgic gait, limited ROM or stiffness Radiography: Early small femoral epiphysis, sclerosis disease weight bearing predominance and flattening of the femoral head Loose bodies and Deep, referred pain; painful Mechanical symptoms, history of hip Limited ROM, catching and grinding Radiography: Can show ossified or osteochondral chondral lesions clicking dislocation or low-energy trauma, with provocative maneuvers, positive loose bodies history of Legg-Calvé-Perthes disease FADIR and FABER tests MRI: Can detect chondral and fibrous loose bodies Osteoarthritis Deep, aching pain and Older than 50 years, pain with activity Internal rotation < 15 degrees, flexion Radiography: Presence of osteophytes at the of the hip stiffness; pain with weight that is relieved with rest < 115 degrees acetabular joint margin, asymmetrical joint-space bearing narrowing, subchondral sclerosis and cyst formation continued - FABER = flexion, abduction, external rotation; FADIR = flexion, adduction, internal rotation; MRI = magnetic resonance imaging; ROM = range of motion. 34B commercial use of one individual user of the website. All other rights reserved. Contact [email protected] for copyright questions and/or permission requests. permission and/or questions copyright for [email protected] Contact reserved. rights other All website. the of user individual one of use commercial Downloaded from the American Family Physician website at www.aafp.org/afp. Copyright © 2013 American Academy of Family Physicians. For the private, non private, the For Physicians. Family of Academy ©2013 American Copyright www.aafp.org/afp. at website Physician Family American the from Downloaded (continued) American FamilyAmerican Physician eTable A. Differential Diagnosis of Hip Pain

Diagnosis Pain characteristics History/risk factors Examination findings Additional testing

Anterolateral hip and groin pain (C sign) (continued) Osteonecrosis Deep, referred pain; pain with Adults: Lupus, sickle cell disease, Pain on ambulation, positive log roll test, Radiography: Femoral head lucency and subchondral of the hip weight bearing human immunodeficiency virus gradual limitation of ROM sclerosis, subchondral collapse (i.e., crescent sign), infection, corticosteroid use, smoking, flattening of the femoral head and alcohol use; insidious onset, but MRI: Bony edema, subchondral collapse can be acute with history of trauma Slipped capital Deep, referred pain; pain with 11 to 14 years of age, overweight Antalgic gait with externally rotated Radiography: Widened epiphysis early, slippage of femoral epiphysis weight bearing (80th to 100th percentile) on occasion, positive log roll and femur under epiphysis later straight leg raise against resistance tests, pain with hip internal rotation relieved with external rotation Septic arthritis Refusal to bear weight, pain Children: 3 to 8 years of age, fever, ill Guarding against any ROM; pain with Hip aspiration guided by fluoroscopy, computed with leg movement appearance passive ROM tomography, or ultrasonography; Gram stain and

www.aafp.org/afp Adults: Older than 80 years, diabetes culture of joint aspirate mellitus, rheumatoid arthritis, recent MRI: Useful for differentiating septic arthritis from joint surgery, hip or knee prostheses transient synovitis Transient synovitis Refusal to bear weight Children: 3 to 8 years of age, Pain with extremes of ROM sometimes fever and ill appearance Lateral pain

External snapping Pain with direct pressure, All age groups, audible snap with Positive Ober test, snap with Ober test, Radiography: No bony involvement hip* radiation down lateral ambulation pain over greater trochanter MRI: Bursitis and edema of the iliotibial band thigh, snapping or popping Ultrasonography: Tendinopathy, bursitis, fluid around Greater trochanteric Pain with direct pressure, Runners, middle-aged women Pain over greater trochanter tendon bursitis* radiation down lateral thigh Dynamic ultrasonography: Snapping of iliopsoas or Greater trochanteric Pain with direct pressure, Associated with knee osteoarthritis, Proximal iliotibial band tenderness, iliotibial band over greater trochanter

Volume 89, Number 1 Volume 89, Number pain syndrome radiation down lateral thigh increased body mass index, low back Trendelenburg gait is sensitive and pain; female predominance specific Posterolateral pain Gluteal muscle tear Pain with direct pressure, Middle-aged women Weak hip abduction, pain with resisted MRI: Gluteal muscle edema or tears or avulsion* radiation down lateral thigh external rotation, Trendelenburg gait is and buttock sensitive and specific Iliac crest apophysis Tenderness to direct History of direct trauma, skeletal Iliac crest tenderness and/or ecchymosis Radiography: Apophysis widening, soft tissue swelling

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avulsion palpation immaturity (younger than 25 years) around iliac crest January 1, 2014January continued

FABER = flexion, abduction, external rotation; FADIR = flexion, adduction, internal rotation; MRI = magnetic resonance imaging; ROM = range of motion. *—Conditions associated with greater trochanteric pain syndrome. - Hip Pain attachment ischium to muscle surrounding edema hypertrophy, or atrophy muscle the sciatic nerve sclerotic changes of the sacroiliac joint space Additional testing Additional Radiography: Avulsion or strain of hamstring MRI: Hamstring edema and retraction MRI: Soft tissue edema around quadratus femoris MRI: Lumbar spine has no disk herniation, piriformis Radiography: and narrowing Possibly findings, no ecchymosis, weakness to leg flexion, hamstring palpable in gap sciatic notch to the sacroiliac joint, sacroiliac joint tenderness line Examination findingsExamination tuberosity tenderness,Ischial None established Positive log roll test, tenderness over the FABER test elicits posterior pain localized (continued) flexed and leg extended leg and flexed contraction (cutting, kicking, jumping) distallyradiate or pain with sitting, weakness and numbness are rare compared with symptoms radicular lumbar pregnancy, history of minor trauma History/risk factors Eccentric muscle contraction while hip Skeletal immaturity, eccentric muscle Groin and/or buttock pain that may History of direct trauma to buttock Female predominance, common in pressure pressure posterior thigh radiation, sciatica symptoms thigh radiation, sciatica symptoms buttock, and groin Pain characteristics Buttock pain, pain with direct Buttock pain, pain with direct Buttock or back pain with Buttock pain with posterior Pain radiates to lumbar back,

strain or avulsion avulsion impingement dysfunction eTable A. DifferentialeTable Diagnosis of Hip Pain Diagnosis pain Posterior Hamstring muscle Ischial apophysis Ischiofemoral Piriformis syndrome Sacroiliac joint FABER = flexion, abduction, external rotation;FADIR = flexion, adduction,internal rotation; MRI = magnetic resonance imaging; ROM = range ofmotion. *—Conditions associated greater with trochanteric pain syndrome.

DownloadedJanuary 1, from2014 the ◆ VolumeAmerican 89, Family Number Physician 1 website at www.aafp.org/afp.www.aafp.org/afp Copyright © 2013 American Academy of FamilyAmerican Physicians. Family For the Physician private, non -34C commercial use of one individual user of the website. All other rights reserved. Contact [email protected] for copyright questions and/or permission requests. Hip Pain

Posterior and buttock

Lateral Lateral

Anterior and groin ILLUSTRATIONS TODD BY BUCK eFigure A. Localization of hip pain. (A) Posterior view. (B) Anterior view.

A B C 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 on the patient’s 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 are rotated back toward the table, with the hip in flexion and knee in extension.

34DDownloaded American from Family the American Physician Family Physician website at www.aafp.org/afp.www.aafp.org/afp Copyright © 2013 American AcademyVolume of Family89, Number Physicians. 1 ◆For January the private, 1, 2014 non- commercial use of one individual user of the website. All other rights reserved. Contact [email protected] for copyright questions and/or permission requests.