1. Hip and Thigh Pain Arthur Jason De Luigi, DO
Program Director, Sports Medicine Fellowship
Director, Sports Medicine
Director, Interventional Pain
MedStar National Rehabilitation Hospital
MedStar Georgetown University Hospital
Medical Director and Head Team Physician
US Paralympic Alpine Ski Team

2. Disclosures
Nothing to Disclose

3. Overview Epidemiology Hip and Thigh Anatomy Physical Examination
Diagnostic Imaging
Pathology
Treatment

4. Incidence
Hip and Thigh pain are very commonly the chief complaint of office visits
Account for 0.61% of all visits
About 1 in every 164 encounters
Runners report an average yearly hip or pelvic injury rate of 2% to 11%.

5. Incidence
NHANES III
14.3% of patients aged 60 years and older reported significant hip pain on most days over the previous 6 weeks.
18.4% of those who had not participated in leisure time physical activity during the previous month reported severe hip pain
Opposed to 12.6% of those who did engage in physical activity

6. Common Hip Problems by Age
Newborn
Congenital dislocation of hip
Age 2-8
AVN of hip (Legg-Calve-Perthes), synovitis
Age10-14
Slipped Cap Fem Epiphysis
Age 14-25
Stress Fracture
Age 20-40
Labral Tear
Age >40
Osteoarthritis

7. Anatomy
Bones
Pelvis
Ilium
Ischium
Pubis
Sacrum
Femur

8. Anatomy
Ilium - anterior superior iliac spine, anterior inferior iliac spine, Iliac crest, Gluteal Line, Posterior superior iliac spine
Ischium - Ramus of the ischium, Ischial spine, Ischial tuberosity, body weight rest in the sitting position Pubis - superior and inferior rami, Body of pubis, Pubic crest
All three forms acetabulum –articulates with head of femur to form hip joint Three joints – SI, Pubic symphysis, Acetabulum 8

9. Anatomy

10. Anatomy

11. Anatomy

12. Anatomy Anterior Medial Posterolateral Iliopsoas Quadriceps Sartorius
Vastus Medialis
Vastus Intermedius
Vastus Lateralis
Rectus Femoris
Sartorius
Medial
Adductor Magnus
Adductor Longus
Adductor Brevis
Gracilis
Posterolateral
Piriformis
Gluteus Maximus
Gluteus Medius
Gluteus Minimus
Tensor Fascia Lata
Iliotibial Band

13. Physical Examination

14. Anterior Hip Pain Examination Inspection Palpation ROM Special Tests
Walking/Gait
Pelvic position/splinting
Atrophy/ecchymosis/bony deformity
Palpation
ROM
Flexion/extension/internal/external rotation
Strength
Special Tests
FABER
FADIR Thomas test
Snapping Hip Test
Hernia exam

15. Range of Motion Flexion: 110 to 120 degrees
Extension: 10 to 15 degrees

16. Range of Motion
Abduction: 30 to 50 degrees
Adduction: 30 degrees

17. Range of Motion External rotation: 40 to 60 degrees
Internal rotation: 30 to 40 degrees

18. Special Tests
modified Thomas Test
hip flexor and quad flexibility

19. Special Tests
Patrick’s Test (FABER)
hip joint
SI joint

20. Special Tests Labral Injury FADIR:
Flexion, Adduction, Internal Rotation
Axial Loading
pain +/- click

21. Lateral Hip Pain Examination Special Tests Ober Test
Trendelenberg Test

22. Special Tests
Ober Test
iliotibial band flexibility

23. Posterior Hip Pain Examination ROM Leg Length Neurologic Special Tests
Reflex
Strength
Sensory
Special Tests
Piriformis
FABER (Patrick)
Gaenslen’s
Gillet
Fortin
Facet Loading
Straight Leg Raise
Reverse SLR

24. Range of Motion Lumbar Range of Motion Flexion – 80o Extension – 35o
Lat Bend – 40o
Rotation – 3-18o

25. Special Tests Leg length
true leg length discrepancy congenital maldevelopment trauma
functional leg length discrepancy scoliosis

26. Special Tests Leg length Measured from ASIS to medial malleolus
Functionally measured
knees & hips flexed with thumbs on medial malleolus then knees and hips extended

27. Neurologic Examination

28. Special Tests
Patrick’s Test (FABER)
hip joint
SI joint

29. Special Tests
Gaenslen’s Sign
Pain at ipsilateral SIJ is positive test

30. Special Tests Piriformis Test Piriformis flexibility or pain
Sciatic Nerve Distribution

31. Special Tests
Popliteal Angle
Hamstring flexibility

32. Diagnostic Imaging

33. Diagnostic Imaging Radiographs Bone scan: stress fxs
Anterior-Posterior view
Frog leg view
STANDING films to r/o early OA
Bone scan: stress fxs
CT: subtle fractures
MRI: soft tissue, stress fx
Arthrogram: labral tears

34. Anterior Hip Pain Differential Dx Osteoarthritis
Inflammatory arthritis
Muscle and tendon strains
Tendonitis
Femoral neck stress fracture
Sports hernia (Occult hernia or tear of oblique aponeurosis)
Obturator or ilioinguinal nerve entrapment
Osteitis pubis
Acetabular labral tears

35. Hip Ultrasound Indications for a hip examination
Include, but are not limited to:
soft tissue injury
tendon pathology
arthritis
soft tissue masses or swelling
nerve entrapment
effusion
bone injury

36. Hip Ultrasound Specifications of a hip examination
Patient’s body habitus
lower frequency transducer may be required
Spatial resolution
decreases with a decrease in the transducer frequency
operator should use the highest possible frequency that provides adequate penetration

37. Hip Ultrasound Anterior approach Patient positioning: Planes:
supine with the hip in mild external rotation
Planes:
Sagittal oblique plane parallel to the long axis of the femoral neck
femoral head, neck, and joint effusion
Sagittal and axial planes
labrum, iliopsoas tendon and bursa, femoral vessels, sartorius and rectus femoris muscles
The above structures are then scanned in the axial plane, perpendicular to the original scan plane

38. —Sonograpthy of normal hip joint
Longitudinal
—Hip joint aspiration using sonographic guidance. Sonography of normal hip joint. Longitudinal sonogram of normal hip joint longitudinal to femoral neck. Acetabulum is to the left, and arrowheads mark femoral head and shaft. No fluid is seen distending joint capsule.
Fessell D P et al. AJR 2000;174:
©2000 by American Roentgen Ray Society

39. Hip Ultrasound Anterior Approach
Dynamic evaluation of snapping hip syndrome
Anterior: iliopsoas tendon as it passes over superior pubic bone
Lateral: iliotibial band crosses the greater trochanter

40. Hip Ultrasound Lateral approach Patient positioning: Planes:
lateral decubitus
Planes:
axial and coronal (longitudinal)
greater trochanter, greater trochanteric bursa, gluteus muscles, and tensor fascia lata
dynamic evaluation of iliotibial band syndrome 

41. Hip Ultrasound Medial approach Patient positioning: Planes:
45-degree knee flexion, external rotation (frog-leg position)
Planes:
Sagittal oblique and axial planes
(adductor muscles, pubic bone and insertion of rectus abdominis)

42. Hip Pathology Snapping Hip Trochanter Athletic Pubalgia
Iliopsoas
Iliotibial Band
Trochanter
Trochanteric Bursitis
Gluteal Tendons
Athletic Pubalgia
Sports Hernia
Direct Hernia
Indirect Hernia
Hip Osteoarthritis
Iliopsoas Bursitis
Iliopectineal Bursitis
Femoroacetabular Impingement
Acetabular Labral Tear
Adductor
Strain
Tear
Quadriceps
Hamstrings
Ischial Bursitis

43. Anterior Hip Pain Differential Dx Osteoarthritis
Inflammatory arthritis
Muscle and tendon strains
Tendonitis
Femoral neck stress fracture
Sports hernia (Occult hernia or tear of oblique aponeurosis)
Obturator or ilioinguinal nerve entrapment
Osteitis pubis
Acetabular labral tears

44. Margo K, et al. Evaluation and management of hip pain: An algorithmic approach J Fam Pract. 2003, 52:8

45. Hip Pathology Snapping Hip Trochanter Femoroacetabular Impingement
Iliopsoas
Iliotibial Band
Trochanter
Trochanteric Bursitis
Gluteal Tendons
Femoroacetabular Impingement
Acetabular Labral Tear

46. Hip Pathology AIIS Avulsion Quadriceps Adductor Athletic Pubalgia
Strain
Tear
Adductor
Athletic Pubalgia
Sports Hernia
Direct Hernia
Indirect Hernia

47. Hip Anterior Recess Anterior and posterior layers
Fibrous tissue + minute layer of synovium
Hyperechoic
Each 2-4 mm thick
Radiology 1999; 210: 499

48. Hip Effusion Separation of anterior and posterior layers (1)
Capsule distention at femoral neck > 7 mm or difference of 1 mm from opposite side (2)
Extension & abduction improves visualization (3)
Avoid Internal Rotation of hip during assessment: capsule thickens
(1) Radiology 1999; 210: 499
(2) Scand J Rheum 1989; 18:113
(3) Acta Rad 1997; 38: 867

49. -Hip joint longitudinal -Hypoechoic hip effusion
—Hip joint aspiration using sonographic guidance. 42-year-old male IV drug abuser in whom septic hip joint was clinically suspected. Longitudinal sonogram obtained as illustrated in A shows hypoechoic hip effusion between arrowheads marking femoral cortex and corresponding arrows marking joint capsule. Culture of aspirate grew Staphylococcus aureus.
Fessell D P et al. AJR 2000;174:
©2000 by American Roentgen Ray Society

50. Hip Joint

51. Hip Joint: Effusion Cannot predict infection by ultrasound
Negative power color Doppler does not exclude infection*
Guided aspiration
AJR 1998; 206: 731

52. Transient Hip Synovitis
Anterior
Longitudinal

54. Acute Transient (“Toxic”) Synovitis
inflammatory process of hip w/ chronic irritation and excess secretion of synovial fluid within the capsule; ? cause
Most common dx in limping child <10, but it’s a Dx of exclusion;
r/o septic arthritis, SCFE, stress fx, etc.
Xrays normal; MRI helpful ruling out other causes
Labs: normal CBC, CRP
S/Sx: pain w/ walking, low-grade fever
Tx: relative rest, analgesics

57. Iliopsoas Bursitis Located anterior to the hip
Can be visualized in transverse plane at the level of femoral head
Immediately medial to iliopsoas tendon
Communicates with hip joint in up to 15%
Number is increased with abnormal hip joint
Bursa may be distended with simple fluid, complex fluid or synovitis
Ranges from anechoic to hyperechoic
May distend into abdomen
Should not be confused with intra-abdominal or psoas abscess
Bursitis: presence of pain with transducer pressure
Increased flow on color/power Doppler
Distention out of proportion to hip joint recess

58. Iliopsoas bursitis Cause: overuse of hip flexors S/Sx:
anterior hip pain, +/- snap
preferred position of hip in flex/ER,
TTP to deep palpation anteriorly,
pain with passive hip extension
Tx: relative rest, ice, brief NSAID, stretching of iliopsoas,
+/- steroid injection (preferably w/ guidance)

60. Iliopsoas Bursitis

61. Iliopsoas Tendon

62. Osteitis Pubis Repetitive trauma to pubic symphysis due to overuse
Running/cutting, esp soccer, football, basketball
Signs & Symptoms
insidious onset dull anterior groin pain; may radiate
TTP over Pubic Symphysis
+/- pain w/ resisted Adduction or passive Abduction
Treatment
relative rest, brief NSAID, cross-training
stretching/strength rehab
consider steroid injection

63. Osteitis Pubis
Radiographs

64. Athletic Pubalgia Sports “hernia”
TTP lower abd wall
No palpable hernias
Co-incident injuries
Adductor tendinopathy
Osteitis pubis
Imaging: consider MRI to r/o other conditions
Dynamic US helpful?
Tx: relative rest, flexibility, strength  surgery if refractory

68. Muscle strains
Adductors, gluteals, quads, hamstring tears usually from overstretching during eccentric contraction, esp when muscle fatigued
Risk factors
Early in season
Muscle imbalance, inflexibility, inadequate warmup
S/Sx: localized pain and TTP, +/- swelling or ecchymosis , rarely palpable muscle defect, and decreased ROM
Graded I, II, III similar to sprains
Xrays to r/o avulsion fxs if near muscle origins; MRI if suspected complete tear
Tx: PRICEMM, Rehab (ROMstrengthcardiosport-specific tng)

69. Quadriceps Contusions
Direct blow to muscle causes tissue damage
S/Sx: localized TTP, +/-ecchymosis
Grade I: knee flexion >90
Grade II: knee flexion 45-90
Grade III: knee flexion <45
Tx: PRICE; avoid NSAID 48 hrs
Max knee flexion, wrap in place 24 hrs
Crutches, gradual WB, rehab (ROMstrength)
RTP when FROM, 90%+ strength, activity w/o pain
Complications:
Compartment syndrome (acute)
Myositis ossificans (chronic)
Slowly enlarging mass, redness, increasing pain
Xrays weeks, BS/US sooner

77. Stress Fractures Caused by repetitive overuse stresses
RF’s: training errors, females, inadequate footwear, intrinsic factors
Pelvic, femoral neck, femoral shaft
S/Sx: insidious pain w/ activity; +/- local TTP or pain w/ hop test, +/- decreased ROM
Xrays first, MRI or BS if neg but suspected Tx
Femoral: immediate NWB, Ortho referral
Tension sidesurgery
Pelvic/femoral shaft: painless relative rest; graduated WB, strength/stretching rehab, address other RF’s

78. Hip fractures
Most common through femoral neck, various traumatic causes
S/Sx: pain, swelling, and loss of function
Involved leg shortened and externally rotated
Tx: Ortho referral, surgery

79. Hip Dislocation Femoral head usually goes posteriorly
common mechanism: knee to dashboard during traffic collision
S/Sx: extreme pain, obvious deformity, unwilling to move the extremity; position typically flexion, adduction, and internal rotation (FAdIR)
Tx: emergent reduction in ER under sedation (Ortho STAT!)

80. AVN of Femoral Head Causes:
Trauma: fxs, hip dislocation, surgery
Medical conditions (numerous)
S/Sx: nonspecific hip pain, may radiate to knee; exam may be relatively unremarkable, with decr IR/ER as dz advances
Xrays usually diagnostic >3mo duration; MRI or BS if normal
Tx: make pt NWB and refer to Ortho
Conservative tx vs hip replacement depending on severity

81. Pelvic Apophysitis
THE PHYSICIAN AND SPORTSMEDICINE - VOL 29 - NO. 1 - JANUARY 2001

82. Pelvic Apophysitis Cause: overuse at tendinous insertion at apophysis
Iliac crest > ASIS, AIIS, lesser troch, greater troch, ischial tuberosity
S/Sx: localized pain, TTP, pain w/ passive stretch of attached muscle
Xrays to r/o avulsion fxs
Tx: relative rest (rare crutches), ice, brief NSAID?, cross training, strength rehab, flexibility

83. Pelvic Avulsion Fractures
Caused by violent contraction of the attaching muscle in skeletally immature athlete
Sprint, jump, soccer, gymnast, dancer, football
Ischial tuberosity > AIIS > ASIS > iliac crest, lesser troch, greater troch
S/Sx: sudden pain +/- pop, poor ROM, local pain and TTP +/- muscle bulging away from the attachment
Xrays needed to eval size/displacement
Tx: PRICEMM, progressive rehab
Ortho referral if displacement >2 cm

84. Slipped Capital Femoral Epiphysis (SCFE)
Slippage of femoral epiphysis laterally off femoral head
Most prevalent ages 9-15, esp overweight
Bilateral up to 50%
S/Sx: insidious poorly localized hip/groin pain +/- radiation to knee, worse w/ activ
May have limited IR
Xrays usually diagnostic; MRI early if neg but dz suspected
Tx: immed NWB, Ortho referral, surgery

85. Kline’s Line: tangent to superior femoral neck on AP view
Abnormal: Less or no transsection of physis
Normal transsection of physis

88. Legg-Calve-Perthes Avascular necrosis of proximal femoral epiphysis
Most prevalent ages 4-9, males 4:1
Develops slowly
S/Sx: intermittent deep hip pain worse w/ activity, +/- radiating to groin, ant/med thigh, knee;
limping, decreased ROM, and hip flexor tightness may be noted
Xrays usually diagnostic: MRI or BS early if xray neg but AVN suspected
Tx: Ortho referral; crutches, pain meds

89. Lateral Hip Pain Differential Dx Greater trochanteric pain syndrome
Iliotibial band syndrome
Meralgia paresthetica

91. Hip Pointer Contusion to the iliac crest
S/Sx: pain, swelling, and ecchymosis
severe limit to motion
+/- palpable hematoma
Xrays to r/o fractures
TX: rest, ice, compression, ?benefit from steroid/lido inj after acute phase, progressive ROM, strength rehab
RTP: padding over area

92. Trochanteric Bursitis
Located in posterolateral aspect of greater trochanter
Located over the posterior and lateral facets of GT
Deep to the gluteus maximus and Iliotibial tract
Abnormal bursal distention of trochanteric bursa in lateral hip

93. Trochanteric bursitis
Causes:
friction between IT band, glut medius/minimus/max and greater trochanter; common in running w/ improper biomechanics and overtraining
direct blows
S/Sx:
local pain, tenderness over the greater trochanter
Eval for leg length discrep, adductor/abductor muscle imbalance, hyperpronation
Tx: relative rest, ice, brief NSAID, ITB stretching, +/- steroid injection
Address biomechanical defects above

94. Trochanteric Bursitis
Trochanteric fluid seen posterolateral to GT and deep to Gluteus Maximus
Best visualized if distended
Distention does not indicate inflammation
However is suggestive
Pain with probe pressure & increased flow on color/power Doppler
Increases likelihood of inflammation->Bursitis

97. Greater Trochanter Gluteus Medius and Minimus

98. Trochanteric Bursa Coronal Axial

101. Posterior Hip Pain Posterior Hip
Expand Differential to include Back Pain
Evaluate for “red flags”

102. Posterior Hip Pain Differential Dx Lumbar spine disease
Degenerative disc disease
Facet arthropathy
Spinal stenosis
Sacroiliac joint disorders
Hip extensor and external rotator muscle pathology
Piriformis Syndrome
Aortoiliac vascular occlusive disease (rare)

105. Piriformis Syndrome
Pain due to sciatic nerve compression at piriformis
Cause: trauma, prolonged sitting, overuse; anomalies in 15-20%
S/Sx:
dull buttock pain +/- radiation into leg
TTP over mid-buttock
Pain worse with passive IR or resisted ER
-Tx: relative rest, ER stretching, +/- steroid injection

106. Hip Pathology Hamstrings Ischial Bursitis Iliopsoas Bursitis Strain
Tear
Ischial Bursitis
Iliopsoas Bursitis

107. Ischial bursitis
Cause: excessive friction over ischial tuberosity, or direct blow (hematoma, scarring)
S/Sx: pain with sitting, TTP over ischial tuberosity, pain w/ passive hip flexion and active/resistive hip extension
Xray to r/o fractures in traumatic hx
Tx:
Ice, padding, brief NSAID
Prolonged: steroid injection
Refractory: surgical excision

108. Lumbar and Sacroiliac Pathology
Significant Cause of Pathology referring to posterior hip and thigh
Lumbar Pathology
Lumbar Discogenic Pain
Lumbar Facet Arthropathy
Lumbar Radicular Pain
Lumbar Stenosis
Lumbar Spondylosis
Sacroiliac Pain
Sacroilitis

109. References
Birrer R. and O’Connor F. Sports Medicine for the Primary Care Physician. Boca Raton: CRC Press, 2004.
Greene W. Essentials of Musculoskeletal Care. Rosemont: American Academy of Orthopaedic Surgeons, 2001.
Hoppenfeld S. Physical Examination of the Spine and Extremities. East Norwalk: Appleton-Century-Crofts, 1976;59-74.
Lillegard W. Evaluation of Knee Injuries. In W Lillegard (ed), Handbook of Sports Medicine. Boston: Butterworth-Heinemann, 1999:
Netter F. Atlas of Human Anatomy. West Caldwell: CIBA-Geigy, 1989.
Tandeter H. et al. Acute Knee Injuries: Use of Decision Rules for Selective Radiograph Ordering. American Family Physician. Dec 1999; 60: (For Radiograph Images)

110. References
ACR practice guidelines for the performance of the musculoskeletal ultrasound examination
Nazarian et al.