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 3

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

Differential	Clinical Features/Orthopedic Testing	Diagnostic Imaging^b
Hip OA	Anterior or posterior hip pain Persistent deep groin pain that is worse with activity Increased pain on internal rotation, and concurrent morning stiffness lasting <60 minutes. Hip internal rotation of <15° with a coexisting limitation of flexion less than or equal to 115° Trendelenburg sign, resisted hip abduction, and FABERE tests	MRI; R

FAI	More prevalent in athletes (eg, hockey, soccer, dance, and golf) Persistent stiffness and intermittent groin pain during early stages Later stages may reveal sharp pain and mechanical symptoms (ie, catching, locking, instability) Flexion, adduction, and internal rotation and flexion internal rotation tests have high sensitivity only Thomas test has high sensitivity and specificity for intra-articular pathology	MRA; R

Acetabular labral tear	Different types of tears exist (post-traumatic; associated with FAI; capsular laxity/hip hypermobility; dysplasia; and degenerative) Central groin and peritrochanteric pain more common. Unlikely to present with anterior thigh or ischial pain (compare with OA). Flexion, adduction, and internal rotation and flexion internal rotation tests have high sensitivity only Thomas test has high sensitivity and specificity for intra-articular pathology If clicking, catching, or locking of the femoroacetabular joint occur during testing likelihood of labral tear is increased	CTA; MRA

Internal snapping hip	Reproducible snap with hip flexion and concomitant pain	US

Stress fracture	Both fatigue and insufficiency stress fractures of the femoral neck, pubic rami, or acetabulum may cause anterior hip pain. For all stress fractures, a high index of suspicion is paramount for early detection Femoral neck: • Tension-side femoral neck stress fractures have higher risk of complication • Fatigue-type stress fractures are seen in young, active individuals. • Insufficiency-type stress fractures are seen in older patients with osteoporosis • PPPT and stress fracture (fulcrum) test Pubic rami: • Presents with anteromedial hip pain • Positive fulcrum, pelvic shear, adductor squeeze, and FABERE tests or pain while standing on the affected limb • Tenderness with direct palpation Acetabulum: • Rare compared to femoral neck or pubic rami	MRI; R (specific only); SS

ONFH	Associated conditions (ie, trauma, corticosteroid use, alcoholism), although commonly idiopathic Deep groin pain accentuated with axial loading of the femur Evaluate the contralateral hip in nontraumatic cases	MRI; R

Hip joint laxity	Seen more commonly in female ballet dancers and gymnasts Beighton scale may be appropriate to evaluate global hypermobility Anterior, posterior, lateral hip apprehension tests Often associated with anterior impingement	MRA; MRI

Inguinal disruption (athletic pubalgia)	Anterior hip pain in an athlete not originating from the femoroacetabular joint Male athletes more common Point tenderness over the pubic tubercle and conjoint tendon Pain exacerbated with a resisted curl-up, resisted hip flexion and/or adduction, and the Valsalva maneuver Adductor squeeze test performed in 90° of hip flexion demonstrates high sensitivity but low specificity for pubic aponeurosis and adductor pathology Exclude inguinal hernia	CTA; MRI; US

Femoral, obturator, ilioinguinal, and genitofemoral neuropathy	Consider if prior hip replacement or inguinal hernia surgery Neurodynamic testing with the femoral nerve tension test	MRI; US

Abbreviations:
CTA = computed tomographic arthrography
FABERE = flexion-abduction-external rotation, extension
FAI = femoroacetabular impingement
MRA = magnetic resonance arthrography
MRI = magnetic resonance imaging
OA = osteoarthritis
ONFH = osteonecrosis of the femoral head
PPPT = patellar-pubic percussion test
R = radiography
SS = skeletal scintigraphy
US = ultrasonography.

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