Posterior, Lateral, and Anterior Hip Pain Due to Musculoskeletal Origin: A Narrative Literature Review of History, Physical Examination, and Diagnostic Imaging

doi:10.1016/j.jcm.2016.08.004

PMC full text:

J Chiropr Med. 2016 Dec; 15(4): 281–293.

Published online 2016 Oct 21. doi: 10.1016/j.jcm.2016.08.004

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Table 1

Differential Diagnosis, Clinical Features, Orthopedic Testing, and Diagnostic Imaging for an Adult Presenting With Posterior Hip Pain^a

Differential	Clinical Features/Orthopedic Testing	Diagnostic Imaging^b
Femoroacetabular pathology	Under-recognized cause of posterior hip pain Consider especially if posterior pain presents with concomitant anterior hip pain or if posterior pain is exacerbated with hip motion	MRA (labral tear); MRI; R

Spinal or SIJ pathology	Centralization of symptoms with repeated spinal movement favor spinal involvement and should be done to exclude spine referral Composite testing of positive thigh thrust, distraction, compression, sacral thrust, and Gaenslen test favors SIJ origin, especially when symptoms are not reproduced with spinal movement	MRI; R

Proximal hamstring tendinopathy	Previous hamstring injury, pain with activity, and pain while seated Symptoms may mimic sciatica Active, passive, and resisted range of motion tests and tenderness with palpation	MRI; US

Sacral stress fracture	Fatigue fracture: • Common in athletes, especially female athletes with RED-S Insufficiency fracture: • Osteoporotic females most at risk Positive fulcrum, pelvic shear, adductor squeeze, and FABERE tests or pain while standing on the affected limb Tenderness with direct palpation Mimics other hip pathologies including sciatica	MRI; R (specific only); SS

Piriformis syndrome	Tenderness with palpation of the muscle Positive Freiberg sign, Pace sign, Beatty sign, and FADDIR^c test	Primarily used to exclude other sources of hip pain

Obturator internus/gemelli complex tendinopathy	Similar HPE features for piriformis syndrome	Primarily used to exclude other sources of hip pain

Ischiofemoral impingement	Often presents with concomitant anterior hip pain	MRI

Sciatic neuropathy	Typically there is a history of total hip arthroplasty Neurodynamic testing using the straight leg raise	MRI; US

Pudendal neuropathy	Accompanying perineal pain Symptoms elicited with palpation of inferomedial sciatic notch/ischial spine Passive internal and external rotation of the hip and resisted hip abduction and adduction at 90 degrees of hip extension may elicit symptoms	MRI; US

Abbreviations:
CTA = computed tomographic arthrography
FABERE = flexion-abduction-external rotation, extension
FADDIR = flexion-adduction-internal rotation
HPE = history and physical examination
MRA = magnetic resonance arthrography
MRI = magnetic resonance imaging
R = radiography
RED-S = relative energy deficiency in sport
SIJ = sacroiliac joint
SS = skeletal scintigraphy
US = ultrasonography.

^a Myofascial pain syndrome should be considered in each compartment.
^bDiagnostic imaging recommendations discussed in the manuscript are listed in alphabetical order and not in order of utility.