History
Taking an appropriate history from a patient with hip pain is of paramount importance. The first focus should be on the patient’s account of the pain. If the pain was of an acute onset after an injury, the incident should be thoroughly described. Was there a snap or pop? Did it occur during acute acceleration or deceleration? What was the exact motion occurring during the injury (ie, foot planter, how was he/she hit, etc)? Was the athlete able to bear weight after the injury? Could he or she continue playing? These injuries often occur with a pop or snap, with a resultant sudden, severe, well-localized pain and immediate disability.
If the pain has been more long term, a review of the athlete's training methods, distances, and activity level should be explored. Does the pain start during the activity, or only afterward? Is there night pain? Is the pain better the next day or worse? Is the pain occurring earlier in the activity? Do any specific activities or movements increase the pain?
Ask the patient about a previous history of similar problems. Has there been any previous diagnostic testing or treatment?
To rule out more dangerous pathologies, always ask about night sweats, fevers, weight loss, or anorexia. Is there any history of stress fractures, menstrual irregularities, or amenorrhea?
To rule out abdominal sources of the hip pain, ask about nausea, vomiting, diarrhea, changes in stools, or the presence of blood in stools.
To help rule out spinal causes, ask about lower back pain; radiation of pain down the leg into the calf, foot, or toes; and numbness, tingling, or weakness in the leg or foot.
Physical Examination
It is important to do a thorough examination of the hip in order to establish any limitations or deficits that the patient may have. Along with a hip examination, an examination of the knee and lumbosacral spine is important to establish if the patient's hip pain is referred pain from these sites. A systematic approach of observation, palpation, checking range of motion (ROM), and strength testing is important.
Observation
Observe the patient from the front, back, and sides. Note any asymmetry, as well as how the patient’s clothing rests on the waist and hips. Then, observe the patient walking to see if one side is favored over the other. These observations can be helpful clues in focusing the examination, as well as in detecting signs of a leg-length discrepancy. Swelling and ecchymosis can be present with more severe strains, but these findings are often absent because the injured structures are deep in the hip.
Palpation
Along with bony palpation (see below), it is important to appreciate the patient's muscle tone as this may be an indicator of muscle strain or guarding against underlying pathology. Acute or chronic injuries lead to tenderness of the muscle and tendon. Spasm after an acute injury is common. Passive stretching and active contraction of the muscle is often difficult but can help to pinpoint the exact anatomic injury.
It is important to establish and palpate the following landmarks:
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Boney landmarks
Anterior superior iliac spine (ASIS) – Sartorius and tensor fasciae latae
Iliac crest – Gluteal muscle attachment
Anterior inferior iliac spine (AIIS) – Rectus femoris attachment
Greater trochanter – Vastus lateralis and gluteal muscles
Posterior superior iliac spine (PSIS)
Ischial tuberosity – Hamstring muscles
Pubic ramus – Adductors
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Muscle landmarks
Anterior – Quadriceps muscles
Posterior – Gluteal muscles and hamstring muscles
Medial – Adductor muscles
Lateral – Iliotibial band and gluteal muscles
ROM
It is important to check both active and passive ROM of the hip to assess and establish limitations and barriers. Actual measurements will help to the clinician to monitor the patient’s progress over time.
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Rotation
Hip rotation is evaluated by having the patient seated with the knee flexed at 90° and moving the foot from the midline. Internal foot movement equates to external hip rotation (60°) and external foot movement results in internal hip rotation (30°).
Another way of measuring hip rotation is to have the patient lying on his or her back. Flex the hip 90º and internally and externally rotate the hip. Limitations of internal rotation occur most often with hip osteoarthritis, femoral head osteonecrosis, and stress fractures of the femoral neck.
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Flexion/Extension
Hip flexion (120°) is assessed with the knee flexed, and hip extension (15°) is examined with the patient lying in the prone position with the leg kept straight and elevated.
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Abduction/Adduction
Abduction (45-50°) and adduction (20-30°) are performed with the patient lying supine and using the ankle to move away (abduction) or toward the midline (adduction). Follow the ROM examination with strength testing, which is performed by applying resistance to the ROM discussed above.
Pain and resistance to quadriceps stretching indicates injury at the proximal rectus femoris, such as a myotendinous strain or avulsion. An injury at the origin of the hamstrings will cause similar findings with a seated or lying straight-leg raise.
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Sensory
The sciatic (motor and sensory) and the lateral femoral cutaneous (sensory) nerves are commonly responsible for pain or numbness around the hip. Sciatic nerve pain and numbness can occur in the posterior hip and thigh with or without radiation. The lateral femoral cutaneous nerve provides sensory enervation to the anterolateral thigh and can be compressed as it passes under the inguinal ligament, especially in obese individuals, leading to a condition known as paresthetica meralgia.
Special Tests
Leg-length testing: With the patient supine, take linear measurements from the ASIS to the medial malleolus on each extremity. Then, have the patient flex his or her knees, and observe if one knee is higher (longer tibia) or if it is more prominent (longer femur).
Trendelenburg test: Have the patient stand on one foot; the examiner then observes for a pelvic tilt toward the side of the raised foot. This is an indication of weak abductors on the opposite hip.
A study by Allison et al found that patients with gluteal tendinopathy use different frontal plane kinematics of the hip and pelvis during single leg loading. [26]
Thomas test: With the patient supine, the examiner places one hand under the patient's lumbar spine, and the patient flexes one hip toward the body. When the spine touches the examiner's hand, the pelvis is stabilized and further flexion now occurs solely from the hip. Flexion of the contralateral leg during further flexion of the ipsilateral hip or arching the back during extension may be a sign of a flexion contracture.
Hop Test: Pain in the ipsilateral groin region when the patient hops on one leg may be a sign of a femoral neck stress fracture.
FABER (flexion, abduction, external rotation) or Patrick test: This test is frequently used to differentiate lumbar spinal problems from primary hip pathology. This comprehensive maneuver elicits anterior hip or groin pain. If there is significant loss of ROM from a mechanical means (ie, not pain-inhibited), consider an intra-articular problem, such as hip arthritis or avascular necrosis. If groin pain is elicited and yet the range of motion is relatively normal, suspect iliopsoas tendinitis. If the FABER/Patrick test produces posterior hip pain, consider a disorder of the sacroiliac (SI) joint. To perform this test, the patient's affected hip is moved into flexion, abduction, and external rotation while he or she lies supine with one ankle placed over the opposite knee ("figure 4" position). If pain is elicited when the examiner presses down on the flexed knee, this test may indicate an SI joint pathology or adductor muscle and tendon pain.
Ober test: With the patient lying on the unaffected side, passively abduct the upper leg and flex the knee to 90º. Slightly extend the hip, and observe if the hip drops into the adducted position. Decreased adduction is a sign of tightness in the tensor fasciae latae and/or the iliotibial band.
The cause of many overuse injuries of the hip can be traced to biomechanical problems farther down the kinetic chain. One should exam the knees to determine valgus or varus alignment. The alignment of the hindfoot, pronation of the ankle, and cavus or planus foot type should be determined.
