A Review Paper Mastering the Physical Examination of the Athlete’s Hip David P. Trofa, MD, Sophie E. Mayeux, BA, Robert L. Parisien, MD, Christopher S. Ahmad, MD, and T. Sean Lynch, MD pubalgia, osteitis pubis, and femoroacetabular Abstract impingement (FAI) with labral tears. In this review, we describe precise methods for evaluating the athlete’s hip or groin with an emphasis on recognizing the Hip Pathoanatomy most common extra-articular and intra-articular pathologies, The first step in determining the etiology of pain including adductor strains, athletic pubalgia, osteitis pubis, is to establish if there is true pathology of the hip and femoroacetabular impingement with labral tears. joint and surrounding structures, or if the pain is referred from another source. Although a compre- hensive discussion of the plausible causes of hip and groin pain is beyond the scope of this review, ip and groin pain is a it is important to have a general understanding of Take-Home Points common finding among possible diagnoses, as this knowledge lays the athletes of all ages and activ- groundwork for performing the physical examina- ◾ Perform a comprehensive H 3,10 examination to determine ity levels. Such pain most often tion (Table 1). intra-articular patholo- occurs among athletes in sports gy as well as potential such as football, hockey, rugby, Patient History extra-articular sources of soccer, and ballet, which demand The physical examination is guided by the patient’s hip and pelvic pain. frequent cutting, pivoting, and ac- history. Important patient-specific factors to be ◾ Adductor strains can be celeration.1-4 Previously, pain about ascertained include age, sport(s) played, competi- prevented with adequate the hip and groin was attributed to tion level, seasonal timing, and effect of the injury rehabilitation focused on correcting predisposing muscular strains and soft-tissue on performance. Regarding presenting symptoms, factors (ie, adductor contusions, but improvements in attention should be given to pain location, timing weakness or tightness, physical examination skills, imag- (acute vs chronic), onset, nature (clicking, catching, limited range of motion, ing modalities, and disease-spe- instability), and precipitating factors. Acute-onset and core imbalance). cific treatment options have led pain with muscle contraction or stretching, possi- ◾ Athletic pubalgia is diag- to increased recognition of hip bly accompanied by an audible pop, is likely mus- nosed when tenderness can be elicited over the injuries as a significant source of culotendinous in origin. Insidious-onset dull aching pubic tubercle. disability in the athletic popula- pain that worsens with activity more commonly 5,6 ◾ Osteitis pubis is diag- tion. These injuries make up 6% involves intra-articular processes. Most classically, nosed with pain over the or more of all sports injuries, and this pain occurs deep in the groin and is demon- pubic symphysis. the rate is increasing.7-9 strated by the C sign: The patient cups a hand with ◾ FAI and labral injury In this review, we describe its fingers pointing toward the anterior groin at the classically present with a precise methods for evaluating level of the greater trochanter (Figure 1).11 C-sign but can also pres- the athlete’s hip or groin with an A history of burning pain, night pain, pain with ent with lateral hip pain, buttock pain, low back emphasis on recognizing the sitting, weakness, or neurologic symptoms with pain, anterior thigh pain, most common extra-articular radiculopathy suggests a spinal process. and knee pain. and intra-articular pathologies, A comprehensive hip evaluation can be per- including adductor strains, athletic formed with the patient in the standing, seated, Authors’ Disclosure Statement: Dr. Ahmad reports that he is a consultant to Acumed and Arthrex, and receives research support from Arthrex, Stryker, and Zimmer Biomet. The other authors report no actual or potential conflict of interest in relation to this article. 10 The American Journal of Orthopedics ® January/February 2017 www.amjorthopedics.com D. P. Trofa et al Table 1. Differential Diagnoses of Hip and Groin Pain3,10 Intra-Articular Pathology Extra-Articular Pathology Nonmusculoskeletal Pathology Femoroacetabular impingement Athletic pubalgia/sports hernia Intra-abdominal pathology (inguinal or fem- oral hernia, abdominal aortic aneurysm, Labral tears Osteitis pubis appendicitis, diverticulitis, inflammatory Chondral defect Muscular pathology: strains or tendinopa- bowel disease, lymphadenitis) thies Loose bodies Genitourinary pathology (adnexal torsion, Snapping hip (internal or external) Osteoarthritis ectopic pregnancy, nephrolithiasis, orchitis, Ischiofemoral or trochanteric-pelvic pelvic inflammatory disease, prostatitis, Developmental hip dysplasia impingement urinary tract infection) Traumatic femoral head or neck fracture Capsular laxity Dislocation or subluxation Piriformis syndrome Ligamentum teres rupture Iliotibial band friction syndrome Femoral neck stress fracture Bursitis: trochanteric, ischial, psoas Capsular laxity Psoas abscess Avascular necrosis Pubic ramus fracture (traumatic or stress Legg-Calvé-Perthes disease fracture) Slipped capital femoral epiphysis Apophyseal avulsion fracture (anterior- Transient synovitis superior iliac spine, iliac crest, anterior-in- ferior iliac spine, pubis, ischial tuberosity, Septic arthritis greater trochanter, lesser trochanter) Pigmented villonodular synovitis Lumbar spine pathology Referred knee pain Peripheral nerve compression (genitofem- oral, iliohypogastric, ilioinguinal, lateral femoral cutaneous, obturator, or pudendal nerves) supine, lateral, and prone positions, as previously described (Table 2).6,12,13 Now we describe the physical examination for the most common etiolo- gies presenting in athletes. Extra-Articular Hip Pathologies Adductor Strains The adductor muscle group includes the adductor magnus, adductor brevis, gracilis, obturator exter- nus, pectineus, and adductor longus, which is the most commonly strained. Adductor strains are the most common cause of groin pain in athletes, and usually occur in sports that require forceful eccen- tric contraction of the adductors.14 Among profes- sional soccer players, adductor strains represent almost one fourth of all muscle injuries and result in lost playing time averaging 2 weeks and an 18% reinjury rate.15 These injuries are particularly detrimental to performance because the adductor muscles help stabilize the pelvis during closed- chain activities.3 Diagnosis and adequate rehabili- tation focused on correcting predisposing factors (eg, adductor weakness or tightness, loss of hip range of motion, core imbalance) are paramount in reinjury prevention.16,17 Figure 1. C sign—patient cups hand with fingers pointing toward anterior groin at level of greater trochanter—highlights On presentation, athletes complain of aching deep groin pain and signifies intra-articular pathologic process. www.amjorthopedics.com January/February 2017 The American Journal of Orthopedics ® 11 Mastering the Physical Examination of the Athlete’s Hip Table 2. Example of Comprehensive Hip Physical Examination Performed With Patient in 5 Different Positions6,12,13 Patient Position Standing Seated Supine Lateral Prone General: laxity, body Neurologic Passive range of motion Passive and active range Craig test habitus, posture of motion Circulation Palpation: adductor Palpation: ischial tuberosity Gait: swing, stance origin, pubic tubercle, Palpation: greater foot progression, Skin abdominals trochanter Strength testing Trendelenburg gait, Lymphatic Ely test antalgic gait Resisted adduction Ober test Hip internal- and external- Hyperextension Spine: scoliosis, lordosis Resisted sit-up FADIR (flexion, adduction, rotation range of motion internal rotation) Pelvis: shoulder height, Thomas test Lateral compression test iliac crest Straight leg raise Lateral rim impingement Trendelenburg test Anterior and posterior impingement tests Stinchfield test McCarthy hip extension test FABER (flexion, abduction, external rotation) Straight leg raise A B Figure 2. Assessment for adductor strains. (A) Demonstration of tenderness to palpation at or near adductor origin. (B) Pain may also be exacerbated with resisted adduction. groin or medial thigh pain. The examiner should tors requires proper exposure and is most easily assess for swelling or ecchymosis. There typically performed with the patient supine and the lower is tenderness to palpation at or near the origin extremity in a figure-of-4 position (Figure 2A). on the pubic bones, with pain exacerbated with Resisted adduction can also be tested with the resisted adduction and passive stretch into ab- patient supine and the hips and knees brought into duction during examination. Palpation of adduc- flexion. The test is positive if the patient experienc- 12 The American Journal of Orthopedics ® January/February 2017 www.amjorthopedics.com D. P. Trofa et al A B Figure 3. Assessment for athletic pubalgia. (A) Athlete may experience pain with palpation over pubic tubercle, abdominal obliques, and/or rectus ab- dominis insertion. (B) Pain may also be reproduced with resisted sit-ups. es focal pain in the proximal aspect of the adductor 10% of patients.21-23 muscles while trying to bring the legs together On physical examination with the patient supine, against the examiner’s resistance (Figure 2B). tenderness can be elicited over the pubic tubercle, abdominal obliques, and/or rectus abdominis inser-