Hip pain is a common complaint that may be referred to the thigh, back, or groin areas. The anatomic location of the true hip joint is unclear to many patients, who confuse pain generated from this area with symptoms arising from the lumbar spine or soft tissues around the hip. The hip joint and its periarticular structures are relatively inaccessible to evaluation by palpation. Accurate assessment of patients with “hip pain” depends on the identification of specific historical features, appropriate physical examination maneuvers, basic insights into common radiographic findings, and a thorough understanding of the differential diagnosis. The likely cause of hip pain in a given patient often has a high correlation with the patient’s age.
Taking a careful and astute history is the first essential step in identifying the cause of a patient’s hip pain. The history should determine the location of the pain and establish whether the onset of pain was abrupt or gradual. Further, the process of obtaining the history must delineate the circumstances associated with the onset of pain and identify activities that improve or worsen the patient’s symptoms.
Pain located primarily in the groin and associated with weight bearing or range of motion is most typical of intra-articular hip abnormalities. Pain beginning in the low back and radiating down the buttock and back of the leg to the side of the calf and lateral side of the foot is more likely caused by a lumbar radiculopathy than an intra-articular hip abnormality. Pain localized to the side of the hip and exacerbated by lying on the affected side is most likely greater trochanteric bursitis. Hip pain due to infections or malignancy is severe, generalized, constant, and often worse at night.
A traumatic event associated with the acute onset of pain strongly suggests fracture or injury to the soft tissues about the hip. In cases of acute onset pain, the history also should include questions regarding changes in activity, such as new exercise programs or injuries. For example, abnormal mechanics during walking or running, such as injury to the opposite leg or running on oval tracks that lack banks can predispose to trochanteric bursitis. Repetitive loading activities or a sudden increase in the amount of running can result in a femoral stress fracture.
Pain that has been slow and progressive over time is common in arthritic conditions. A person with osteoarthritis of the hip experiences a gradual onset of worsening hip pain and decreasing range of motion. It becomes progressively harder to walk normally, especially going up and down stairs. Hip flexion becomes painful and patients should be asked if they are having trouble tying their shoes.
The age of the patient influences the differential diagnosis of hip pain. Children are susceptible to particular hip problems, such as slipped ...