Evaluation of Hip and Groin Pain

Differential Diagnosis

Most Common

1. Adductor Muscle Strain or Tendinopathy

2. Osteitis Pubis or Pubic Symphysitis

3. Trochanteric Bursitis

4. Obturator Nerve Entrapment

5. Referred pain from the SI joint or Lumbar Spine

6. Symphysis Syndrome

Less Common

1. Iliopsoas Strain

2. Iliopsoas Bursitis

3. Stress Fracture of Neck of Femur or Pubic Ramus

4. Rectus Abdominus Tendinopathy

5. Inguinal Hernias

6. Osteomyelitis

7. Inguinal Lymphadenopathy

8. Hip Joint Pathology: Synovitis, Osteoarthritis, Labral Tear, or Rim Lesion

9. Snapping Hip

10. Nerve Entrapment: Iliolinguinal, Genitofemoral, Lateral Cutaneous Nerve of the Thigh

11. Rectus Femoris Muscle Strains

12. Avulsion Apophysitis or Fracture of the Anterior Superior Iliac Spine

Not to be Missed

1. Slipped Capital Femoral Epiphysis

2. Intra Abdominal Pathology: Appendicitis, Prostatitis, UTI, Gynecological Pathology

3. Ankylosing Spondylitis

4. Avascular Necrosis of the Femoral Head

5. Perthe's Disease

6. Testicular Tumor

History

• Onset of Pain

• Localization of Pain

• Excacerbation by Exercise

• Associated low back or Buttock pain

Examination

Always remember to examine the joint above (Lumbar Spine) and below (Knee)

Inspection

1. From Behind

2. From Each Side

3. Standing and Walking

Palpation

1. Adductor Muscles and Tendons

2. Pubic Symphysis and Ramus

3. Rectus Abdominis

4. Iliopsoas

Motion

Note that range of movement is measured determined actively first, if there is a deficiency, move on to passive range of motion. Any deficits should be measured with a goniometer. Note should be made of discrepence between active and passive movement.

Also check the following passive movements:

1. Hip Quadrant

2. Adductor Muscle Stretch

3. Quadriceps Muscle Stretch

4. Psoas Muscle Stretch

One may also assess the following functional motions:

1. Hopping (may reproduce pain)

2. Sit Ups

3. Lunging

4. Zig-Zag Running

5. Trendelenberg Test

Muscles

Measurement of muscle strength using the Oxford (MRC) Scale.

1. Hip Flexion and Extension

2. Hip Adduction and Abduction

3. Hip Internal and External Rotation

4. Bilateral Hip Adduction (Squeeze Test)

5. Lumbar Spine Movements

6. Abdominal Flexion

7. Iliopsoas Flexion

NeuroVascular

1. Check and Grade reflexes, sensation, and strength of lower limb nerve roots

2. Check Pulse

3. Rectal tone in suspected Cauda Equina Syndrome

Special Tests for Sciatic Nerve Irritation

1. Straight Leg Raise

2. The Prone Knee Bend Test for Femoral Nerve Stretch

3. Slump Test

Special Tests for Sacroiliac Joint Irritation

1. FABER Test

2. Sacroiliac Compression Test

Special Tests for Spondylolisthesis

1. Jackson Hyperextension Test

Special Tests for Inguinal and Femor Hernias

1. Palpation of the Inguinal Canal

2. Cough Test

Investigations

1. Plain Films: Useful for signs of Osteitis Pubis, Hip joint abnormalities, or stress fractures. SI joint problems may also be seen.

2. Bone Scan: For confirmation of Stress Fractures or Osteitis Pubis.

3. MRI: Useful for detection of Labral Tears, Osteitis Pubis, and Stress Fractures.

4. Ultrasound: For Hip Labrum and to rule out hernias.

Appendix

Muscular Anatomy of the Hip Joint

Index

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