Hip Pain

Aka: Hip Pain, Hip Arthralgia, Hip Injury, Groin Pain, Groin Injury, Groin Injuries in Athletes, Sports-Related Groin Injury

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II. Definitions

  1. Groin
    1. Junction of lower extremity and pelvic floor at either side of the pubic bone

III. Epidemiology

  1. Hip Osteoarthritis affects up to 10% of U.S. adults by age 45 years and a 25% lifetime risk
    1. Up to 5% of U.S. adults will have a hip replacement within their lifetime
  2. Groin Pain in athletes
    1. Incidence: 2 to 20% and varies by sport and activity level

IV. Pathophysiology

  1. The groin is a complex region of genitourinary, gastrointestinal, musculoskeletal and neurovascular structures
  2. Hip Pain and Groin Pain have broad differentials of both localized and referred sources
    1. See Groin Anatomy
  3. Doha Consensus Statement on Groin Pain Categorization (2015)
    1. Groin Pain in the Athlete
      1. Adductor related Groin Pain
      2. Pubic related Groin Pain
      3. Inguinal related Groin Pain
      4. Iliopsoas related Groin Pain
    2. Hip-Related Groin Pain
    3. Miscellaneous Groin Pain

V. Risk Factors: Groin Injury in Athletes

  1. Groin Injury accounts for 2-5% of Sports Injury
  2. Related to chronic, repetitive stress injury
  3. Higher risk sports for Groin Injury
    1. Soccer
      1. Hip and groin injuries represent roughly half of all injuries in non-elite adult soccer athletes
      2. CAM Deformity of the femoral neck or femoral head is commonly found in adult soccer players
    2. Ice hockey
    3. American Football
    4. Australian Football
    5. Fencing
    6. Handball
    7. Cross Country Skiing
    8. Hurdling
    9. High Jumping
  4. Other risk factors
    1. Increased competition level
    2. Decreased relative hip adduction strength (compared with abductors)
      1. Adductor Squeeze Test with decreased strength
      2. Hip internal rotation reduced
    3. Inadequare off-season training or sport specific conditioning
    4. Older age
    5. Low Vitamin D Levels
    6. Prior Groin Injury

VI. Precautions: Risk Factors for serious pathology

  1. Age over 65 years
  2. Pain on Hip Range of Motion (esp. painful hip flexion or hip rotation)
    1. Intrinsic hip pathology
    2. Septic Arthritis of the hip
  3. Inability to bear weight
    1. Hip Stress Fracture
    2. Hip Septic Arthritis
    3. Avascular Necrosis of the Hip
    4. Femoral lesion (e.g. malignancy)
    5. Unstable Slipped Capital Femoral Epiphysis (8-15 years old)
  4. Abdominal Pain
    1. Abominal aortic aneurysm (may present with back pain if retroperitoneal bleeding)
    2. Appendicitis
    3. Renal Calculi
    4. Pelvic tumors
    5. Ectopic Pregnancy
    6. Pelvic Inflammatory Disease
    7. Abdominal Hernia or Inguinal Hernia
  5. History of malignancy (or Night Sweats, weight loss)
  6. Hip Trauma
  7. Alcohol Abuse
  8. Night pain, Constant pain, Weight loss
    1. Malignancy
  9. Fever
    1. Septic Arthritis of the hip
    2. Malignancy
    3. Perirectal Abscess
    4. Appendicitis
  10. Chronic Corticosteroids, Chronic inflammatory conditions or Coagulopathy
    1. Avascular necrosis of the hip
  11. Cardiovascular Risk Factors (e.g. Diabetes Mellitus, Tobacco Abuse, Coronary Artery Disease, Carotid Stenosis)
    1. Aortoilliac Occlusive Disease

VII. Causes

  1. See Hip Pain Causes
  2. See Rheumatologic Conditions affecting the Hip

VIII. History

  1. Sporting activity
    1. Frequency, duration and intensity
    2. Injury mechanism
      1. Stopping, cutting or kicking
  2. Pain characteristics
    1. Location, timing, region, radiation, palliative and provocative
  3. Associated symptoms
    1. Swelling
    2. Ecchymosis
    3. Locking or catching (labral tear or other intraarticular cause)
    4. Popping or clicking (labral tear or other intraarticular cause)
    5. Instability
    6. Altered Sensation, Paresthesias or weakness (nerve entrapment)
  4. Past History
    1. Developmental Dysplasia of the Hip (Congenital Hip Dysplasia)
    2. Slipped Capital Femoral Epiphysis (SCFE)
    3. Sports participation (see high risk sports above)
    4. Family History of hip disorders
  5. Referred pain sources
    1. Spine (radiculopathy)
    2. Abdomen and Pelvis
    3. Genitourinary tract
    4. Skin (e.g. Shingles)

IX. Exam

  1. See Hip Exam
  2. See Hip Anatomy
  3. Observe for groin Ecchymosis (avulsion, Muscle tear, abdominal wall Hematoma)
  4. Observe for bulge in the abdominal and inguinal region (Hernia)
    1. Also palpate the Superficial Inguinal Ring with valsalva or cough
  5. Examine in frog-leg position (leg abducted with hip and knee flexed)
    1. Palpate the lower Abdomen
    2. Palpate pupic symphysis and adjacent pubic bone
    3. Palpate adductor insertions (pubic tubercle, medial inferior pubic ramus, ischial tuberosity)
    4. Palpate iliopsoas Muscle
      1. Region lateral to the rectus abdominis Muscle and inferior to the inguinal ligament
      2. Examiner should feel the Muscle tense and engage when patient actively lifts their leg
    5. Palpate abdominal Muscles when relaxed and when tensed
      1. Relaxed Abdomen with knees flexed to Palate intraabdominal sources of pain
      2. Tensed Abdomen with knees extended to palpate abdominal musculature
    6. Palpate anterior superior iliac spine (ASIS, sartorius and tensor fasciae latae insertion)
    7. Palpate anterior inferior iliac spine (AIIS, rectus femoris insertion)
    8. Palpate anterior hip
  6. Perform active range of motion and passive range of motion
    1. See Hip Range of Motion
    2. Adductor Stretch and resistance
      1. Patient lies supine on exam table with feet pointed upwards
      2. Examiner stands between the patient's feet and grasps each ankle/lower leg
      3. Examiner passively abducts affected hip (moving leg laterally) until pain or endpoint reached
      4. Patient then attempts adduction against resistance, with examiner assessing for pain and weakness
    3. Iliopsoas stretch and resistance
      1. Patient starts in a modified Thomas Test Position
        1. Patient lies supine with buttocks resting against the end of the exam table
        2. Patient maximally flexes the unaffected hip and knee, with examiner hold this knee in position
      2. Examiner passively extends the affected hip and leg (pushing down) and assesses for pain
      3. Examiner resists patient's active hip flexion against resistance and assesses for pain and weakness
    4. Abdominal Muscle Resistance
      1. Patient supine and performs a partial sit-up against resistance
      2. Examiner applies downward pressure on patient's arms and knees
      3. Pain on resistance may indicate inguinal related Groin Pain
  7. Specific Tests
    1. Hip Adduction Test
      1. Also includes Single Hip Adductor Test, Bilateral Hip Adductor Test
    2. FABER Test
      1. Flexion ABduction External Rotation
      2. Also known as Patrick's Test or Figure of Four Test
    3. FADIR Test
      1. Flexion ADduction Internal Rotation
    4. Hip Scour Test (Hip Quadrant Test)
      1. Hip Flexed to 90 degrees and examiner applies axial load
      2. Internally rotate and externally rotate hip
  8. Other examination
    1. Perform an abdominal exam and back exam on all Hip Pain patients
      1. See Abdominal Pain Exam
      2. See Low Back Exam
    2. Neurologic Exam
      1. Sensory Exam
      2. Motor Exam
    3. Vascular Exam
      1. Lower extremity Arterial Pulses (femoral and pedal pulses)
    4. Gait Exam
      1. Antalgic Gait
      2. Trendelenburg Gait
  9. Findings most suggestive of hip intra-articular cause
    1. Pain on external and internal hip rotation
    2. Pain on hip axial loading (force applied at foot or knee towards hip)

X. Differential Diagnosis

  1. See Hip Pain Causes
  2. See Rheumatologic Conditions affecting the Hip
  3. Exclude serious hip causes
    1. Septic Arthritis of the Hip
    2. Hip Fracture or Hip Stress Fracture
    3. Hip Dislocation
    4. Hip Avascular Necrosis
    5. Slipped Capital Femoral Epiphysis (SCFE, peri-Puberty)
  4. Exclude serious external Hip Pain Causes
    1. Peripheral Arterial Disease (Aortoilliac Occlusive Disease, Abdominal Aortic Aneurysm)
    2. Peritonitis (or other surgical Abdomen)
    3. Malignancy involving hip or Pelvis (bony metastases, Multiple Myeloma, Chondrosarcoma)

XI. Imaging: Hip

  1. Hip XRay
    1. Obtain Anteroposterior View (AP View) and Frog-Leg Lateral View
    2. Indications
      1. First-line study in hip Pain Evaluation
      2. Evaluate for bony lesions (e.g. malignancy)
      3. Femoral Neck Stress Fracture
      4. Hip Avulsion Fracture
      5. Slipped Capital Femoral Epiphysis
      6. Avascular Necrosis of the Femoral Head
      7. Osteoarthritis
      8. Hip Joint lesions (e.g. pincer lesion, cam lesion)
      9. Osteitis Pubis
    3. Low yield for Osteoarthritis (36% Test Sensitivity)
      1. Kim (2015) BMJ 351:h5983 +PMID:26631296 [PubMed]
    4. Hip XRay may miss non-displaced Femoral Fractures
      1. Consider MRI or CT for negative XRay with higher index of suspicion
      2. Parker (1992) Arch Emerg Med 9(1): 23-7 [PubMed]
      3. Hakkarinen (2012) J Emerg Med 43(20: 303-7 +PMID:22459594 [PubMed]
  2. Pelvis MRI Indications
    1. Pubic or Adductor related Groin Pain in athletes refractory to initial conservative therapy
    2. Inguinal related Groin Pain when dynamic Ultrasound nondiagnostic and refractory symptoms
  3. Hip MRI (or Hip CT if MRI unavailable) Indications
    1. Hip Pain with non-diagnostic XRay
    2. Muscle tears and Tendon Strains
    3. Avulsion Fractures
    4. Hip Avascular Necrosis
    5. Hip Labral Tear
    6. Hip cartilage defects
  4. Hip MRI with arthrography Indications
    1. Suspected Hip Labral Tear (Test Sensitivity 90% contrasted with 36% for standard MRI)
  5. Dynamic Pelvic Ultrasound Indications
    1. Inguinal Inguinal related Groin Pain (e.g. Sports Hernia)
  6. Hip Ultrasound
    1. Long axis view detects hip effusion and can direct hip needle aspiration if septic hip is suspected
    2. Also indicated in Functional Evaluation of hip
    3. Test Sensitivity approaches 80-85% for identifying hip effusion in children
      1. Vieira (2010) Ann Emerg Med 55(3): 284-9 +PMID:19695738 [PubMed]
  7. Bone Scan (Scintigraphy) Indications
    1. Stress Fracture
    2. Osteomyelitis
    3. Sacroiliitis
    4. Osteitis Pubis

XII. Diagnostics

  1. Electromyography (EMG) or Nerve Conduction Study
    1. Consider for undifferentiated pain with suspected neuropathic origin
  2. Diagnostic Herniography
    1. Contrast injected within the peritoneum
    2. Patient performs Valsalva Maneuver
    3. Imaging demonstrates abnormal contour of contrast

XIII. Evaluation: Sports-Related Groin Injury

  1. Adductor related Groin Pain
    1. See Adductor Strain (Adductor Tendinitis, Groin Pull)
    2. Findings
      1. Pain on adductor longus palpation, resisted hip adduction and passive hip abduction
    3. Pelvic MRI Imaging (if not responding to conservative therapy)
      1. High False Positive Rate (correlate MRI with related findings in a symptomatic athlete)
      2. Pubic body subchondral Bone Marrow edema
      3. Rectus abdominis and Adductor Aponeurosis or capsule tear
      4. Soft tissue edema
    4. Management
      1. Initial Conservative Management
        1. Physical Therapy (Holmich Protocol)
        2. Manual Therapy
      2. Specialty referral Indications
        1. No improvement after 8-12 weeks of physical therapy
      3. Other measures in refractory cases
        1. Dextrose Prolotherapy
        2. Adductor tendon release
  2. Pubic related Groin Pain
    1. See Osteitis Pubis
    2. See Pubic Apophysitis (children and young adult athletes)
    3. Findings
      1. Pain with palpation of Pubic Symphysis and adjacent pubic bone
      2. Differentiate from Adductor related Groin Pain (see above)
    4. Pelvic MRI Imaging (if not responding to conservative therapy)
      1. Pubic Symphysis joint degeneration and Bone Marrow edema
    5. Management
      1. Initial Conservative Management
        1. Physical therapy directed at pelvic stability and core Muscle Strength
      2. Specialty referral Indications
        1. No improvement after >12 weeks of physical therapy
      3. Other measures in refractory cases
        1. Pubic Symphysis curettage
        2. Pubic Symphysis Arthrodesis (symphysiodesis)
  3. Inguinal related Groin Pain
    1. See Sports Hernia (Athletic Pubalgia)
    2. Findings
      1. Pain on history and exam of the Inguinal Canal
      2. Pain with abdominal Muscle resistance testing (see above)
      3. Inguinal Canal palpation during valsalva may exacerbate pain
    3. Imaging
      1. Dynamic Ultrasound (preferred first-line in most cases)
        1. May demonstrate Hernia or posterior canal weakness
      2. MRI Pelvis
        1. Indicated for non-diagnostic Ultrasound and refractory to conservative therapy
    4. Management
      1. Surgery Referral Indications (for Hernia Repair)
        1. Hernia identified on imaging
        2. Non-diagnostic imaging AND refractory to conservative management >8-12 weeks
      2. Initial Conservative Management (if Hernia absent on imaging)
        1. Physical therapy directed at core Muscle Strength and neuromuscular rehabilitation
  4. Iliopsoas related Groin Pain
    1. See Iliopsoas Strain or Iliopsoas Bursitis
    2. See Snapping Hip syndrome
    3. Findings
      1. Pain on iliopsoas pain, resisted hip flexion and passive hip extension
    4. Imaging
      1. Hip XRay (consider Hip MRI)
        1. Comorbid hip pathology is common
      2. Dynamic Hip Ultrasound Indications
        1. Iliopsoas Bursitis
        2. Snapping Hip syndrome
    5. Management
      1. Initial Conservative Management
        1. Physical therapy directed at Iliopsoas strengthening and functional deficits
      2. Specialty referral Indications
        1. No improvement after >8-12 weeks of physical therapy
      3. Other measures in refractory cases
        1. Iliopsoas bursa Corticosteroid Injection

XIV. Management

  1. Treat specific conditions
    1. See Hip Pain Causes

XV. References

  1. Fields (1997) Lecture: AAFP Sports Medicine, Dallas
  2. Ruane (1998) Physician SportsMed 26(4):78-103
  3. Schleihauf (2019) Crit Dec Emerg Med 33(5): 19-28
  4. Shahideh (2013) Crit Dec Emerg Med 27(9):10-18
  5. Braly (2006) Clin Sports Med 199-210 [PubMed]
  6. Brunner (2003) Am Fam Physician 67(3):537-42 [PubMed]
  7. Chamberlain (2021) Am Fam Physician 103(2): 81-9 [PubMed]
  8. Fricker (1997) Br J Sports Med 31:97-101 [PubMed]
  9. Lynch (1999) Sports Med 28:137-44 [PubMed]
  10. Maloy (2025) Am Fam Physician 111(4): 337-43 [PubMed]
  11. Morelli (2001) Am Fam Physician 64(8):1405-14 [PubMed]
  12. Wilson (2014) Am Fam Physician 90(1): 27-34 [PubMed]

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