Basics
Description
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Bones:
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Pelvis and femur bone
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The acetabulum is the socket
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Muscles:
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Flexors: Iliopsoas, sartorius, rectus femoris
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Extensors: Gluteus maximus, hamstring muscles
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Abductors: Gluteus medius, gluteus minimus
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Adductors: Gracilis, pectineus, adductor longus, adductor brevis, adductor magnus
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Nerves:
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Femoral: Hip flexors
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Obturator: Adductors
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Superior gluteal: Abductors
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Ligaments:
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Sacroiliac: Sacrum to ilium
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Sacrotuberous: Sacrum to ischial tuberosity
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Sacrospinous: Sacrum to ischial spine
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Diagnosis
Signs and Symptoms
History
Thorough history of the mechanism of injury and nature of pain
Physical Exam
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Initial procedures:
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Have the patient disrobe.
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Examine the lumbar spine.
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Examine the knee.
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Check the neurovascular status.
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Standing inspection:
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Compare the height of the iliac crests in the horizontal plane. (Asymmetry suggests leg-length discrepancy.)
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Look for muscle atrophy and correlate with gait inspection, if possible.
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Gait inspection:
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Observe for asymmetry between left and right.
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Antalgic gait: Shortened stride and decreased stance phase on the affected leg
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Make note of pain and endurance.
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Trendelenburg limp:
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Evaluate for pelvic tilt during the stance phase of gait.
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Positive finding occurs when the patient leans to the affected side, placing the center of gravity over the hip and effectively unloading the abductor muscles.
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Supine examination:
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Look for leg-length discrepancy (measure from the inferior edge of the anterior superior iliac spine to the inferior edge of the medial malleolus on both sides).
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Compare active and passive ROM.
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Hip flexion: 110-120°
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Hip extension: 10-15°
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Abduction: 45-50°
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Adduction: 20-30°
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Internal rotation: 15-45°
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External rotation: 40-65°
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Extension: 30°
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Note guarding, pain, and spasm.
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Antalgic gait may be caused by hip, back, or other lower limb problems.
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Weakness, muscle atrophy, decreased sensation, and asymmetric deep tendon reflexes suggest spine abnormality.
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Osteoarthritis of the hip:
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Typically presents with start-up pain, morning stiffness, and deep groin pain
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Hip flexion with simultaneous internal rotation reproduces groin pain.
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Presents with decreased active and passive ROM:
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Hip flexion contracture is common
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Radiographs: Joint space narrowing and osteophyte formation
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Greater trochanteric bursitis:
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Typically presents as lateral hip pain
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Patients are exquisitely tender to palpation of greater trochanter.
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Resisted hip abduction reproduces lateral hip pain.
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Buttock and posterior hip pain:
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Indicates lumbar spine abnormality until proven otherwise
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Radicular pain produced by deep palpation of the sciatic nerve differentiates sciatica from intra-articular abnormality.
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With the patient in the lateral decubitus position, flex the hip and knee to 90°.
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Palpate the nerve midway between the greater trochanter and the ischium.
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Labral tears/femoroacetabular impingement:
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Young athletic patients
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Typically presents as groin pain during or after activity
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Hip flexion with simultaneous internal rotation reproduces groin pain.
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Radiographs may be normal.
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MRI can confirm diagnosis.
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Examine for and rule out inguinal hernia.
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Tests
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Trendelenburg test (to evaluate strength of the gluteus medius muscle):
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Have the patient perform a single-leg stand on the affected side and try to maintain the pelvis level with the floor.
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If the pelvis tilts to maintain the single-leg stand, it is a sign of abductor weakness or hip joint pain, and the test is positive.
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Thomas test (to evaluate flexion contracture):
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With the patient supine, place your hand under the lumbar spine and bring 1 leg up into full flexion.
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Have the patient hold it there by grasping the knee with both hands.
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Bring the other leg into full extension.
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Any loss of extension is a flexion contracture.
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Miscellaneous
FAQ
Q: What is the most common cause of lateral hip pain?
A: Greater trochanteric bursitis.
Q: Arthritis of the hip joint usually presents with complaints of pain in which area of the hip?
A: The groin.