II. Causes: Critical Causes of Hip Pain (not to miss)

III. Causes: Timing in the Elderly (acute versus insidious)

  1. Spontaneous onset without Trauma in elderly
    1. Ask about systemic symptoms
    2. Obtain Hip XRay
    3. Obtain infectious and Arthritis labs (CBC, CRP, ESR, RF)
    4. Consider serious causes
      1. Inflammatory Arthritis (acute synovitis)
      2. Septic Arthritis of the hip (especially if fever, toxic appearance or severe Hip Pain on ambulation or range of motion)
      3. Hip Fracture
      4. Hip Avascular Necrosis
  2. Insidious onset in elderly
    1. See Red Flags above
    2. Osteoarthritis
    3. Hip Avascular Necrosis
    4. Malignancy
    5. Hip Fracture

IV. Causes: Anterior Hip Pain

  1. Anterior thigh pain
    1. Meralgia Paresthetica
  2. Anterior Groin Pain
    1. Sports Hernia (Athletica pubalgia)

V. Causes: Anterolateral Hip Pain or Groin Pain

  1. Precautions
    1. Anterolateral Hip Pain is most associated with intrinsic hip pathology
      1. May present with patient cupping the anterolateral hip between their thumb and index finger (C Sign)
    2. Also consider referred pain
      1. Inguinal Hernia
      2. Lumbar Radiculopathy
      3. Pelvic pathology
        1. Especially if no pain on Hip Range of Motion or on direct pressure
  2. Hip Pain on weight bearing and mechanical symptoms (painful hip locking, catching, clicking)
    1. See Snapping Hip
    2. Hip Labral Tear
    3. Iliopsoas Bursitis (Internal Snapping Hip)
    4. Hip loose body or chondral lesions
  3. Hip Pain on weight bearing without mechanical symptoms
    1. Femoral Neck Fracture or Femoral Stress Fracture
      1. Obtain Hip MRI and Non-weight bearing if suspected despite negative Hip XRay
    2. Hip Impingement (or Femoroacetabular Impingement)
      1. Pain especially on standing after prolonged sitting (e.g. arising from Car Seat)
    3. Hip Osteoarthritis
    4. Hip Avascular Necrosis (Hip Osteonecrosis)
    5. Septic Arthritis
  4. Anterolateral thigh neuropathic pain
    1. Meralgia Paresthetica (typically anterior thigh pain)
    2. Lumbar Radiculopathy
  5. Children with deep referred Hip Pain (especially with weight bearing)
    1. Legg-Calve-Perthes
      1. Children 2 to 12 years old (especially males)
    2. Slipped Capital Femoral Epiphysis
      1. Overweight children 11 to 14 years old
    3. Transient Synovitis
      1. Children ages 3 to 8 years old who refuse to bear weight
      2. Must distinguish from Septic Arthritis
  6. Overuse or sports related Anterior Hip Pain
    1. See Groin Pain or Hip Pain in Athletes
    2. Clicking or Snapping Hip (Thomas Test or Snapping Hip maneuver)
      1. See Hip Pain with mechanical symptoms listed above
    3. Hip Stress Fracture
      1. See above
    4. Resisted muscle testing and local tenderness
      1. Hip flexor Muscle Strain

VI. Causes: Lateral Hip Pain

  1. Background
    1. Pure Lateral Hip Pain is unlikely to be associated with intrinsic hip pathology
    2. Most intrinsic Hip Pain will be anterolateral (see above)
  2. Overuse or sports related
    1. Consider Iliotibial Band Syndrome
    2. External Snapping Hip
  3. Tender over lateral thigh with pain on weight bearing
    1. Femoral Lesion (metastases, Multiple Myeloma, chondrosarcoma)
  4. Tender over greater trochanter
    1. Greater Trochanteric Bursitis
  5. Tender at gluteus medius, hip abductor weakness/pain
    1. Gluteus medius muscle dysfunction

VII. Causes: Posterolateral or Posterior Hip Pain

  1. Approach
    1. Posterior Hip Pain is rarely due to intra-articular cause
    2. Most commonly due to SI Joint Dysfunction, Piriformis Syndrome or Lumbar Radiculopathy
  2. Pain reproduced with direct pressure
    1. Gluteal muscle tear
      1. Pain radiates down lateral thigh and buttock
    2. Gluteus medius Tendinopathy
      1. Gluteus medius is hip abductor, weaker than quadriceps, predisposing it to Tendinopathy
    3. Iliac Crest apophysis avulsion
      1. History of direct Trauma in age under 25 years
    4. Hamstring Muscle Strain or avulsion
    5. Ischial apophysis avulsion
      1. History or cutting, kicking or jumping in age under 25 years
  3. Thigh or buttock neuropathic pain (especially Paresthesias and hypoesthesia)
    1. Ischiofemoral Impingement
      1. Impingement of quadratus femoris muscle between the femoral lesser trochanter and the ischium
    2. Sacroiliac Joint Dysfunction
    3. Sacroilitis
    4. Piriformis Syndrome (deep pain worse with sitting)
    5. Lumbosacral Radiculopathy
    6. Discitis

VIII. Causes: Groin Pain or Hip Pain in Athletes

  1. Idiopathic in 30% of cases
  2. Adductor Strain or Adductor Tendinitis (Groin Pull)
  3. Pubic Instability
  4. Osteitis Pubis
  5. Myositis Ossificans
  6. Sports Hernia (athletic pubalgia)
  7. Groin Disruption
  8. Iliopsoas Strain or Iliopsoas Bursitis
  9. Snapping Hip syndrome
  10. Femoral Neck Stress Fracture
  11. Pubic Ramus Stress Fracture
  12. Avulsion Fracture (Adolescent Athletes)
    1. Anterior Superior Iliac Spine Avulsion Fracture
      1. Rapid sartorius contraction in jumping sport
      2. Responds to non-operative conservative therapy
    2. Anterior Inferior Iliac Spine Avulsion Fracture
      1. Strong rectus femoris contraction in kicking sport
      2. Responds to non-operative conservative therapy
    3. Ischial Tuberosity Avulsion Fracture
      1. Rapid hamstring contraction in sprinting, hurdling
      2. Fragments >1-2 cm may require ORIF
  13. Nerve entrapment
    1. Genitofemoral nerve entrapment
    2. Lateral Femoral Cutaneous Nerve Entrapment
    3. Ilioinguinal Nerve Entrapment
    4. Obturator Nerve Entrapment

IX. Causes: Hip Pain in Pregnancy

  1. Common, benign causes
    1. Lumbosacral strain
    2. Sciatica
    3. Pelvic structure compression
  2. Specific to pregnancy
    1. Femoral head Osteoporosis
    2. Femoral head Fracture
    3. Transient Osteoporosis of the hip
      1. Common in second and third trimester as well as early postpartum
      2. Disability out of proportion to physical findings
      3. Osteopenia on XRay
      4. Exclude Hip Avascular Necrosis and Femoral Neck Fracture
  3. Other causes not to miss
    1. Septic Arthritis
    2. Hip Stress Fracture
    3. Hip Avascular Necrosis
    4. Deep Vein Thrombosis
    5. Urinary Tract Infection

X. Causes: Hip Joint disorders with groin or Hip Pain by age

  1. Pediatric Causes (under age 8-12 years)
    1. See Pediatric Limp
    2. Legg-Calve-Perthes Disease
    3. Septic Joint
    4. Toxic Synovitis
  2. Adolescent causes
    1. Slipped Capital Femoral Epiphysis (SCFE)
    2. Hip Avulsion Fracture
  3. Adult causes (See causes below)
    1. Osteoarthritis of femoral head (especially over age 50 years)
    2. Avascular Necrosis of the Femoral Head
    3. Acetabular Labral Tear

XI. Causes: Musculoskeletal causes of groin or Hip Pain

  1. Bone Causes
    1. Hip Fracture
    2. Femoral head avascular necrosis
    3. Cancer (primary site or metastases)
  2. Joint Causes
    1. Hip Osteoarthritis
    2. Septic Arthritis
    3. Gouty Arthritis
    4. Osteoid Osteoma
    5. Osteitis Pubis
  3. Muscle or tendon Causes
    1. Iliotibial Band Syndrome
    2. Trochanteric Bursitis
    3. Iliopsoas Bursitis
    4. Piriformis Syndrome
    5. Myositis Ossificans
  4. Neurologic Causes
    1. Lumbar Disc Disease
    2. Lumbar Spinal Stenosis
    3. Coccygodynia
    4. Meralgia Paresthetica (see nerve entrapment above)

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