Hip pain is a common complaint which patients may describe in the thigh, back, or groin areas. Pain in these areas may be due to pathology in or about the hip joint or may be referred, which commonly occurs with spinal stenosis. The hip joint and its periarticular structures are relatively inaccessible to evaluation by palpation for possible tenderness. Therefore, accurate evaluation of patients with “hip” pain depends on the identification of specific historical features of the symptoms, the determination of the exact cause of the pain (through careful medical history and appropriate physical examination), a basic understanding of common radiographic findings, and a thorough understanding of the potential differential diagnosis. The particular cause of hip pain often correlates with the age of the patient.
The history should (1) determine the location of the pain within the hip area, (2) distinguish between acute and chronic pain, (3) establish whether the onset of pain was abrupt or gradual, (4) delineate the circumstances associated with the onset of pain, and (5) identify activities that exacerbate or ameliorate the pain.
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 to be due to a lumbar radiculopathy than to 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 running, such as the feet crossing the midline (increased adduction), wide pelvis and genu valgum, or running on oval tracks that lack banks can predispose to trochanteric bursitis. Repetitive loading activities 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 slowly worsening hip pain and decreasing range of motion. It becomes progressively harder to walk normally, especially going up and down stairs.
The age of the patient influences the differential diagnosis of hip pain. Children are susceptible to particular hip problems, such as slipped capital femoral epiphysis and Legg-Calvé-Perthes disease. Adolescents and young adults commonly have avascular necrosis, hip dysplasia, labral tears, or femoroacetabular impingement. Middle-aged and older patients often have hip arthritis, low back pain, or trochanteric bursitis.