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Evaluation of Hip Pain in Young Adults a
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Rachel M. Frank MD , Garth Walker BS , Michael D. Hellman MD , Frank M. McCormick MD & Shane J. Nho MD, MS
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Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL Published online: 28 May 2015.
Click for updates To cite this article: Rachel M. Frank MD, Garth Walker BS, Michael D. Hellman MD, Frank M. McCormick MD & Shane J. Nho MD, MS (2014) Evaluation of Hip Pain in Young Adults, The Physician and Sportsmedicine, 42:2, 38-47 To link to this article: http://dx.doi.org/10.3810/psm.2014.05.2056
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C L I N I C A L F O C U S : P A I N M A N A G E M E N T, O R T H O P E D I C S , A N D S P O R T S I N J U R I E S
Evaluation of Hip Pain in Young Adults
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DOI: 10.3810/psm.2014.05.2056
Rachel M. Frank, MD Garth Walker, BS Michael D. Hellman, MD Frank M. McCormick, MD Shane J. Nho, MD, MS Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL
Abstract: Hip pain is a common complaint in the young, athletic patient population. Primary, intra-articular sources of hip pain are becoming increasingly recognized by primary care providers and sports medicine specialists. Prior to deciding among the various treatment options for the many sources of hip pain in the athletic patient population, the clinician must be able to recognize and accurately diagnose the underlying pathology. Advances in imaging modalities and our understanding of the pathophysiology have improved our ability to accurately understand and diagnose the source of hip pain in this patient population. This review presents a comprehensive strategy for the workup and diagnosis of young, athletic patients presenting with hip pain, and provides the sports medicine specialist with the tools to correlate the patient’s history, physical examination, and imaging findings and to treat these challenging patients. Keywords: athletic patient population; hip pain; imaging modalities; underlying pathology
Introduction
Correspondence: Rachel M. Frank, MD, Department of Orthopaedic Surgery, Rush University Medical Center 1611 West Harrison Street, Suite 300, Chicago, IL 60612. Tel: 312-942-5850 Fax: 312-942-2101 E-mail: [email protected]
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Hip pain is a common complaint in the young, athletic patient population.1–8 Primary, intra-articular sources of hip pain are becoming increasingly recognized by sports medicine specialists. During the past decade, and specifically within the past 5 years, there has been a tremendous increase in the volume of literature available discussing hip pain in this unique patient population.9–19 Although clearly a valuable resource, the substantial number of papers and reviews on the topic of hip pain may cause some confusion for the sports medicine physician, especially given the overlapping symptoms and complaints for patients presenting with a variety of sources of hip pain. Prior to deciding between the various treatment options for the many sources of hip pain in the athletic patient population, the clinician must be able to recognize and accurately diagnose the underlying pathology. Advances in the training and understanding of arthroscopic and open surgical approaches to the hip, as well as innovations in instrumentation and implants have improved our ability to treat a variety of sources of intra-articular hip pain. However, one of the main challenges in the young, athletic patient population is accurately understanding and diagnosing the true source of hip pain. Without an accurate diagnosis, surgical treatment can prove ineffective or even harmful. Thus, in order to guide treatment, it is critical for the clinician to be able to distinguish between different causes of intra-articular hip pain in the athletic patient population.
History and Patient Presentation
A complete history is critical in the evaluation of the athletic patient presenting with hip pain. Young patients especially may not be able to differentiate among groin pain, lateral hip pain, or low back pain, and often it is up to the clinician to tease out the
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Evaluation of Hip Pain in Young Adults
pertinent anatomical and historical details that may help guide the differential diagnosis.9,12,20 Given the proximity of the hip joint to other important anatomical structures, including the lumbosacral spine, reproductive organs, and gastrointestinal tract, referred or radiating pain must be distinguished from primary intra-articular hip pain. Any unexpected symptoms, including the atraumatic, insidious onset of pain associated with weight loss, fevers, night pain, or malaise, must be evaluated in further detail to rule out potential inflammatory, infectious, or malignant etiologies. Similarly, a history of steroid or alcohol use, as well as other systemic illnesses such as sickle cell disease, may predispose young patients to avascular necrosis, and these historical factors should be taken into consideration. In addition, and especially in highly active female athletes, any recent increase in training intensity or duration associated with atraumatic groin pain should prompt the clinician to consider a workup for a femoral neck stress fracture.21 The clinician should ask about both a personal and a family history of similar symptoms. Finally, a recent history of high-energy trauma, such as a motor vehicle accident or a fall from a height, may be indicative of an underlying fracture and should be worked up appropriately with imaging studies. Once trauma and systemic illness have been ruled out, the physician must make a concerted effort to determine the onset and source of the pain, with a focus on determining whether it is intra-articular or extra-articular in origin (Table 1).10,13,14 Extra-articular sources of hip pain, including radiating pain from the lumbosacral spine or from the knee, must be ruled out. It can be helpful to ask the patient about pain as it relates to potential provocative activities or positions, such as prolonged sitting, stair climbing, rising from a seated position, leaning over versus standing straight, or sitting flat on a chair versus crossing one leg over the other to off of the buttock. A summary of painful activities/positions and potential underlying etiologies is provided in Table 2. Patients in this population may be variable with regard to onset (acute, subacute, chronic), duration, and severity of symptoms. Given the athletic nature of this patient population, often symptoms are related to a variety of sports activities. The specific location of the pain should be determined. Often, having the patient point to the exact location of discomfort can aid in the diagnosis. For example, superficial lateral pain may be related to greater trochanteric bursitis or iliotibial band syndrome, whereas posterior hip (or buttock) pain is often referred from the lumbar spine. Anterior hip pain, or groin pain, is most often indicative of an underlying intra-articular etiology. Instead of pointing with a single finger, patients with
Table 1. Sources of Intra-Articular Versus Extra-Articular Primary Hip Pain Intra-articular
Extra-articular
Labral tear Loose body FAI Capsular laxity Ligamentum teres rupture Articular cartilage damage
Iliopsoas tendonitis Gluteus medius/minimus tendinopathy Greater trochanteric bursitis Stress fracture Abductor strain Piriformis syndrome Sacroiliac joint pathology Contusion (hip pointer) Snapping hip syndrome Sports hernia, athletic pubalgia Osteitis pubis
Abbreviation: FAI, femoroacetabular impingement.
intra-articular hip pain may sometimes use their hand to create a C-shape and grasp the lateral aspect of their hip above the greater trochanter with the ends of the C (thumb or fingers) either in the groin or just posterior to the trochanter (C-sign).22 However, intra-articular hip pain sometimes may be difficult to pinpoint, and there are some cases in which hip joint pain may refer to the buttock or to the peritrochanteric area. Often, patients describe mechanical symptoms, including a sensation of popping, locking, catching, or clicking, all of which can be more indicative of intra-articular causes of pain. Further, aggravating or exacerbating symptoms can be helpful in narrowing the differential diagnosis. For example, patients with intra-articular sources of pain are often symptom-free when walking or lying flat, but they describe substantial difficulty with running or with activities that place the affected hip into flexion and internal rotation, such as driving, getting in and out of a car, or leaning forward to tie one’s shoes. A thorough history is important not only for determining what may be the underlying source of hip pain, but also for determining what may not be causing symptoms. For example, if the patient denies groin pain and instead describes lateral hip Table 2. Specific Activities/Positions That Cause Hip Pain Activity/Position
Potential Etiology
Flexion Internal rotation Rising from seated position Leaning forward to tie shoes Putting on socks Getting into or out of vehicle Standing while leaning over Sitting with affected leg crossed over
FAI FAI FAI FAI FAI FAI Spinal stenosis Piriformis syndrome, posterior hip pain Greater trochanteric bursitis Abductor insufficiency
Laying on affected side Single leg stance
Abbreviation: FAI, femoroacetabular impingement.
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Frank et al
pain, worse with direct palpation or when lying on the affected side, with improvement in symptoms with nonsteroidal antiinflammatory drugs and ice packs, then the diagnosis of trochanteric bursitis is more likely. In this situation, the diagnosis is essentially confirmed clinically with physical examination, and so even if advanced imaging modalities demonstrate a small labral tear, such findings in this case can be considered incidental, and do not warrant operative intervention. As noted in a systematic review that included evaluation of 1096 asymptomatic hips by Kwee and colleagues,23 labral tears can be found in 19% of asymptomatic hips. An appreciation for knowing which lesions are responsible for symptom generation, and which are simply “innocent bystanders,” is absolutely vital in avoiding unnecessary and potentially harmful surgical intervention. Finally, all patients should be asked about their current and desired level of activity. This information, although not necessarily helpful diagnostically, is extremely useful in determining how symptomatic the patient is, and what the posttreatment expectations might be. Of note, certain aspects of the patient’s history may be more suggestive of arthritis as the underlying cause of intra-articular hip pain, as opposed to labral tears, impingement, or hip dysplasia. In cases of arthritis, patients often describe an insidious, atraumatic onset of their symptoms. Often, patients report morning pain, as well as pain localized to the groin, back, or thigh that is worse with increased activities. The pain typically worsens over time, and may be associated with stiffness, a sensation of weakness (typically due to the pain), and possibly a limp.24
Physical Examination
A thorough physical examination of both hips and nearby potential sources of pain is of utmost importance.9–12,25 The order in which the examination steps are performed can vary, and is often dictated by the patient’s complaints. For example, in the patient described above with lateral hip pain, the examiner may wish to examine the trochanteric bursa last, so as not to cause pain at the beginning of the examination and lead the patient to guard for the remainder of the examination. Regardless of the order, clinicians should develop their own strategy for an efficient examination, and follow that routine for every patient, so as not to miss anything. Martin et al9,12 describe a comprehensive hip examination that can be completed in 21 steps. Their approach enables a complete examination of the “4 layers”—osteochondral, capsulolabral, musculotendinous, and neurovascular—of the hip. The examination places the patient into multiple positions, including standing/walking, seated, supine, prone, and lateral decubitus. 40
For each patient, regardless of the suspected diagnosis, the clinician should always follow a stepwise approach to the examination of both hips, including gait, inspection, palpation, range of motion, sensation, strength, and stability, as well as provocative tests. The joints above (lumbosacral spine, sacroiliac joint) and below (knee) the hip should always be examined in order to search for potential sources of radiating pain. If appropriate, a neurologic examination can be performed to search for lumbar nerve root pathology causing radicular pain radiating to the hip. Examination tests for radicular pain can include a straight-leg-raise assessment (supine and seated) as well as specific evaluation of motor strength, sensation, and reflexes for specific nerve roots. It should be noted that in these cases, examination findings may remain unremarkable, even with a radicular source of symptoms. Further, a concise vascular examination should be performed, with documentation of palpable distal pulses (dorsalis pedis, posterior tibial) as well as of any significant edema or skin changes consistent with vascular disease.
Standing Examination
While standing, the patient should be observed for height symmetry of the iliac crests as well as of the shoulder blades to evaluate leg length discrepancies. With the gait examination, special attention should be paid to pelvic rotation, stance phase, and stride length. Further, the physician should note if the patient has an antalgic gait (shortened stance phase on the affected side), Trendelenburg gait (abductor deficient), or Trendelenburg sign. To assess the Trendelenburg sign, the patient is asked to perform a single-leg stance on the affected leg, and the test is considered positive if the pelvis drops toward the opposite, nonstanding leg, indicating weakness of the hip abductors on the standing leg. Observation of the patient’s posture during the examination can also be useful. For example, patients may slouch to reduce hip flexion or may shift weight to the uninjured side to reduce the load on the affected hip. Similarly, the physician should observe the way in which the patient rises from the seated position, which can sometimes be indicative of which positions of hip flexion/ extension are most painful for the patient. As noted above, in some cases, the patient may lean over the ipsilateral hip to compensate for weak abductors, causing the pelvis to drop toward the contralateral side (Trendelenburg sign).
Supine Examination
The bulk of the physical examination is performed with the patient either seated or lying down (supine or lateral). Again, there is no correct order in which to perform the following
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Evaluation of Hip Pain in Young Adults
tests, but the physician should make an effort to perform every examination maneuver for every patient. Range of motion (Figure 1) evaluation is performed by comparing the affected side to the unaffected side (Table 3). External and internal rotation is performed with the hip flexed to 90 degrees as well as extended. The extension rotation examination is best performed with the patient in the prone position, and is helpful for assessing femoral version. Strength in each of these planes (flexion, extension, abduction, adduction, internal rotation, external rotation) is then assessed, again comparing the affected side to the contralateral hip (Figure 2). Patients with intra-articular sources of hip pain, such as femoroacetabular impingement (FAI) or acetabular dysplasia, likely have difficulty, pain, and decreased range of motion in flexion and internal rotation compared with the opposite side.
Provocative Tests
Multiple pain provocative tests should be performed on the each hip, especially in the patient with potential intra-articular hip pain. These special tests include the impingement test (FADIR: flexion, adduction, internal rotation), the Patrick test (FABER: flexion, abduction, external rotation), the instability/logroll test, the posterior impingement test, the lateral rim impingement test, the trochanteric pain sign assessment, the sub-spine impingement test, and the ischiofemoral impingement test. Of these, the FADIR, FABER, and sub-spine impingement tests are perhaps the most helpful. The test for impingement, the FADIR, is performed with the hip dynamically brought into flexion, adduction, Figure 1. Physical examination of the hip, demonstrating (A) flexion; (B) internal rotation; (C) external rotation; and (D) FABER, often referred to as the Patrick test, which can differentiate sacroiliac joint pathology from primary hip pathology.
Table 3. Normal ROM Values Motion
Value (°)
Flexion Extension Internal rotation External rotation Abduction Adduction
120 30 34 45 45 20
Abbreviation: ROM, range of motion.
and internal rotation; the test is positive if the patient has reproducible groin pain with this movement, and typically signifies the presence of intra-articular pathology. The FABER test can differentiate sacroiliac (SI) joint pathology from primary hip pathology and can also be used to diagnose iliopsoas irritation (Figure 1). This test is performed with the patient supine and with the painful hip flexed and externally rotated, causing the ankle to rest on the opposite knee. If the patient experiences ipsilateral or contralateral posterior low back pain, the SI joint may be affected, whereas if the pain is localized to the groin, posterior FAI may be present. The logroll test can be a sensitive test for intra-articular hip pathology (such as FAI). This test is performed with the patient supine and with the leg extended. The instability test is performed with the legs extended and an externally directed force on the foot and a loss of recoil suggests anterior instability (Figure 3). Posterior impingement is evaluated via the posterior impingement test, which is positive when pain is reproduced with hip extension and external rotation (Figure 4). This test is performed with the patient’s buttock at the end of the examination table with both legs suspended. With the patient’s hip extended, the examiner externally rotates the hip, and the test is positive if this maneuver reproduces pain. The lateral rim impingement test is used to diagnose acetabular overcoverage. This test is performed in the supine position with the patient’s hip passively abducted to provoke pain (Figure 5). Some authors have also described performing instability test with the hip abducted and externally rotated Figure 2. Physical examination of the hip, demonstrating resisted abduction (A) with the knee flexed and (B) with the knee extended.
Abbreviation: FABER, flexion, abduction, external rotation. © The Physician and Sportsmedicine, Volume 42, Issue 2, May 2014, ISSN – 0091-3847 41 ResearchSHARE®: www.research-share.com • Permissions: [email protected] • Reprints: [email protected] Warning: No duplication rights exist for this journal. Only JTE Multimedia, LLC holds rights to this publication. Please contact the publisher directly with any queries.
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Figure 3. Physical examination of the hip, demonstrating logroll in (A) extension and (B) external rotation.
and brought through a wide range of motion from flexion to extension. If the patient experiences a sensation of guarding or apprehension, the test can be considered positive for instability as well.9 (Figure 5). Several subtle findings during range-of-motion testing can be indicative of underlying hip pathology. For example, a positive trochanteric pain sign is positive when the patient experiences posterolateral hip pain with the FABER maneuver (Figure 6). The sub-spine impingement test is positive when the patient experiences anterior groin pain with hip hyperflexion. The ischiofemoral impingement sign is positive when the patient experiences posterior hip pain with extension and internal rotation. When performed as part of a complete assessment of the hip, not only can impingement be diagnosed, but also the specific problematic area of impingement often can be determined. It must be emphasized that several of the above tests may be positive in the setting of osteoarthritis, as opposed to FAI, and thus results must be interpreted cautiously and as part of the comprehensive evaluation of the patient, incorporating history and imaging findings.
Figure 4. Physical examination of the hip, demonstrating assessment of posterior impingement.
Figure 5. Physical examination of the hip, demonstrating assessment of lateral rim impingement.
Special Tests
Other important physical examination tests to perform include the straight leg raise, the Thomas test, and assessment of the patient’s full arc of hip motion. The straight leg raise test is performed with the patient supine, and the affected knee is maintained in extension while the hip is flexed. Pain localized to the lumbar spine region is often indicative of lumbar spine pathology with radiculopathy as opposed to intra-articular hip pain (Figure 7). The Thomas test is performed to search for the presence of a hip flexion contracture. In the supine position, the patient grasps 1 knee with both hands and flexes it to the chest as the hip of the contralateral leg is allowed to completely extend. The test result is positive for a hip flexion contracture if the leg is unable to completely extend. To better stabilize the pelvis, this test may be performed with the opposite hip flexed only to 90 degrees instead of in full flexion. The arc of motion is assessed with the patient supine as the hip is brought through a smooth arc of motion. The arc measurements are based on a clock-face scale, and are a helpful way of documenting at which point throughout hip motion the patient’s symptoms worsen and at which point they improve. In cases of FAI, the painful arc may start Figure 6. Physical examination of the hip, demonstrating assessment of the greater trochanter as a source of pain with (A) greater trochanteric pain sign and (B) direct greater trochanter palpation.
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Evaluation of Hip Pain in Young Adults Figure 7. Physical examination of the hip, demonstrating the straight leg raise.
simply to nonspecific physical examination findings. In these cases, further workup with diagnostic imaging is indicated. Diagnostic imaging is also helpful in preoperative planning, as noted below.
Diagnostic Studies
A variety of imaging studies can be helpful in the evaluation of the young athlete with a painful hip.7,19,26,27
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Radiographs
(right hip) from approximately the 9 o’clock position to the 1 o’clock position, and may end from approximately the 12 o’clock position to the 4 o’clock position.
Palpation
A thorough palpatory examination can be helpful in narrowing the location, and thus the etiology, of the patient’s hip complaints. In particular, the pubic symphysis should be palpated both at rest and during a resisted sit-up. The hip flexor musculature, anterior superior iliac spine, adductor musculature, proximal hamstring origin, ischial tuberosity, piriformis, and SI joints should all be palpated. When palpating each muscle group, the physician should pay particular attention to the various hip bursae, which are common sources of pain when they become inflamed, especially the ischial bursa, which causes posterior hip pain. Pain directly over the greater trochanter with palpation is typically indicative of trochanteric bursitis (Figure 7). Other pathologies may be diagnosed on palpation of the trochanter. Specifically, tendinopathy of the gluteus medius may present as pain along the posterior trochanter at the tendon insertion, whereas pain at the anterior aspect of the greater trochanter may be attributed to gluteus minimus pathology. When analyzed together, the information provided by the history and physical examination alone can often lead to the clinical diagnosis. These tests are aimed at determining if the source of the pain is intra-articular (ie, FAI) or extraarticular (ie, trochanter bursitis, referred pain). As mentioned above, intra-articular pain can even be further characterized by the location of the impingement, depending on which provocative physical examination maneuvers reproduce the symptoms. Nevertheless, sometimes the diagnosis is unclear, and may be due to multiple concomitant pathologies, or
Radiographs of the hip, including a standard weight-bearing anteroposterior (AP) view of the pelvis (with or without a separate AP of the hip), and lateral view of the hip, are obtained on all patients.28 Multiple lateral views have been described, including the cross-table lateral, frog-leg lateral, Dunn lateral, and false-profile lateral views.28 The Dunn lateral view is an AP view taken with the patient’s hip in neutral rotation, 45 degrees of flexion (or 90°, depending on the physician’s preference), and 20 degrees of abduction. The false-profile view is taken with the patient standing with the affected hip against the radiographic cassette and the pelvis rotated 65 degrees in relation to the wall stand, with the affected foot (of the leg against the cassette) parallel to the cassette. Although radiographs help to search for unexpected underlying pathology, including occult fractures, tumors, infection, and foreign bodies, they are most helpful in evaluating the overall femoral–acetabular articulation, especially in patients with intra-articular hip pain due to FAI. Multiple important parameters (Table 4) can be measured off of films, including the Tönnis grade (for degenerative changes), the Tönnis angle, the lateral center edge angle (LCEA) of Wiberg, the alpha angle, and the anterior centeredge angle (of Lequesne). The Tönnis grade, Tönnis angle (ie, the acetabular index) and the LCEA (Figure 8) are measured on an AP pelvis view. The alpha angle (Figure 9) is used to quantify head–neck junction deformity, and is best assessed on the Dunn lateral view.28 The anterior center-edge angle of Lequesne quantifies anterior acetabular coverage of the femoral head, and is measured on the false-profile view of the hip. Assessment of pelvic tilt is also important in the radiographic evaluation of patients with hip pain, especially as variations in tilt/inclination can significantly alter several of the previously described radiographic parameters for FAI, including the LCEA and Tönnis angle.3,29,30 Pelvic tilt is assessed on a lateral pelvic radiograph, and is the angle between a vertical line drawn up from the center of the femoral head, and a second line from the center of the
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Frank et al
Table 4. Radiographic Parameters Used in the Evaluation of Young Patients With Hip Pain Radiographic Parameter
Significance
Tönnis grade
Classification scale for hip arthritis • Measured on AP hip/pelvis view • Grade 0: no signs of osteoarthritis • Grade 1: increased sclerosis with slight joint space narrowing • Grade 2: small periarticular cysts with moderate joint space narrowing and moderate loss of femoral head sphericity • Grade 3: large periarticular cysts with severe joint space narrowing and deformity of the femoral head Measures weight-bearing surface angle • Measured on AP hip/pelvis view • Formed by the angle between a horizontal line and a line extending from the medial to lateral edges of the sourcil • Normal: 10° Assesses for excessive acetabular depth/coverage • Measured on AP hip/pelvis view • Formed by the angle between a vertical line through the center of the femoral head and a line extending from the center of the femoral head to the lateral sourcil • Normal: 25–40° Quantifies head–neck junction deformity • Best measured on Dunn lateral view • Formed by the angle between a line drawn from the center of the femoral head through the center of the femoral neck, and a line from the center of the femoral head to the femoral head–neck junction • Normal: , 50–55° Quantifies anterior coverage of femoral head • Measured on false profile view • Formed by the intersection of a vertical line through the center of the femoral head and a line extending through the center of the femoral head to the anterior sourcil (normal 25–50°; , 20° indicates developmental hip dysplasia).
Tönnis angle (acetabular index)
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LCEA of Wiberg
Alpha angle
Anterior center edge angle (of Lequesne)
Abbreviation: AP, anteroposterior; LCEA, lateral center edge angle.
femoral head to the center of the S1 endplate. Increases in pelvic inclination (tilt) may result in increased measures of acetabular coverage (ie, LCEA, Tönnis angle), whereas decreases can lead to reduced measurements. Proper patient positioning and critical interpretation of radiographs is thus crucial for drawing conclusions on the acetabular morphology in this patient population. Other important radiographic parameters31 that can help in the evaluation of the young patient with hip pain include Figure 8. Radiographs of the (A) AP and (B) lateral views of a patient with right hip femoracetabular impingement, demonstrating Tönnis grade 0, lateral center edge angle of 41° (seen on AP view in red), proximal cross over sign (seen on AP view), and alpha angle of 59° (seen on lateral view, in yellow).
Abbreviation: AP, anteroposterior.
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the crossover sign,32 which is a sensitive and specific radiographic finding of acetabular retroversion, and the ischial spine sign.33 The crossover sign occurs when the line representing the anterior acetabular wall crosses the line of the posterior acetabular wall before reaching the lateral edge of the sourcil. The crossover sign is not always reliable, however, and as noted by Zaltz and colleagues,34 it may be present even in the absence of acetabular retroversion, possibly related to variable anteroinferior iliac spine morphology. The ischial spine sign is indicative of acetabular retroversion, and is present if, on an AP pelvis radiograph, the Figure 9. Axial (A) and coronal (B,C) CT images of a patient with right hip FAI, demonstrating evidence of a small bony prominence proximal to the femoral physis, as well as small cysts and herniation pits in the anterior aspect of the femoral neck at the head-neck junction.
Abbreviations: CT, computed tomography; FAI, femoroacetabular impingement.
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Evaluation of Hip Pain in Young Adults
medial prominence of the ischial spine is projected inside the pelvic brim.33 Interestingly, although previously considered useful as a radiographic parameter for pincer-type FAI, as recently noted by Nepple and colleagues,35 the presence of coxa profunda is not enough to support a diagnosis of FAI, and can be considered a normal radiographic finding (at least in female patients).
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Advanced Imaging
Advanced imaging with computed tomography and magnetic resonance imaging (MRI) and magnetic resonance arthrography (MRA) is also extremely helpful in the evaluation of young patients with hip pain.26,36–39 Both conventional and 3-dimensional computed tomography scan40–43 (Figures 9 and 10) can be especially helpful in understanding the bony topography of the femoral head and acetabulum, especially in cases of cam and/or pincer FAI. This type of geographical information is helpful in correlating the objective pathology noted on the imaging as well as on physical examination with the patient’s subjective complaints. Both MRI (Figure 11) and MRA38 are helpful in the evaluation of the periarticular soft tissue, including the labrum and capsular tissue. Subtle degenerative articular changes, as well as isolated chondral defects,44 that are not well appreciated on radiographs can also be seen on MRI/MRA. For example, Figure 11 demonstrates an anterosuperior labral tear and a small cyst in the head–neck junction of proximal femur, findings which are not readily appreciable on radiographs. Magnetic resonance arthrography has been shown to have a sensitivity and specificity for detecting chondral wear of 17% and 100%, respectively. Magnetic resonance imaging is especially useful in the evaluation of avascular necrosis, a cause of symptoms, as well as in the evaluation of femoral Figure 10. Coronal CT images of a patient with right hip FAI demonstrating (A) conventional imaging and (B) a 3-dimensional reconstruction, both of which show mixed cam and pincer-type FAI with labral ossification, as well as a bony mild prominence at the femoral head neck junction.
neck stress fractures,21 whereas MRA may be most helpful in the evaluation of labral tears, cam-type lesions, and os acetabula, with a sensitivity and specificity for detecting labral tears of 81% and 51%, respectively.45 It should be noted, however, that for patients for whom the physician has an already high clinical suspicion of labral pathology, MRA has a poor negative predictive value and thus is unhelpful in ruling out labral lesions.46 Imaging findings may be helpful in preoperative planning, especially with regard to determining the need for labral repair and potential femoral head or acetabular microfracture. This is important information to know preoperatively in order to counsel these young patients, as these procedures will ultimately lengthen the postoperative rehabilitation protocol.
Other Diagnostic Modalities
Other diagnostic tools helpful in the evaluation of the young patient with hip pain include diagnostic intra-articular injections and diagnostic arthroscopy. Intra-articular hip injections can be both diagnostic as well as therapeutic. In cases of atypical presentation of hip pain, the anesthetic injection with lidocaine can be useful to differentiate between intra- and extra-articular sources of hip pain. In these cases, injection should provide nearly complete relief of symptoms, at least temporarily. The patients are asked to complete a pain diary to determine how much pain is relieved and the duration of the pain relief. Often, the dye used for MRA can be mixed with local anesthetic, and the patient is able to tell the physician in the clinic if the MRA study itself made the pain better (ie, if the injection used for the MRA helped relieve the symptoms). Arthroscopy16,17,20,22,47–52 (Figure 12) is the “gold standard” with which the majority of imaging studies are compared. Although arthroscopy is not typically used as a diagnostic tool in the hip, when a surgeon chooses arthroscopy as treatment for a patient (ie, with FAI), diagnosis of other intra-articular hip pathologies is made possible as Figure 11. Coronal MRI—(A) T1-weighted, (B) T2-weighted STIR, (C) protondensity fat saturated—of a patient with right hip FAI.
Abbreviation: CT, computed tomography; FAI, femoroacetabular impingement.
Abbreviations: FAI, femoroacetabular impingement; MRI, magnetic resonance imaging; STIR, short-time inversion recovery.
© The Physician and Sportsmedicine, Volume 42, Issue 2, May 2014, ISSN – 0091-3847 45 ResearchSHARE®: www.research-share.com • Permissions: [email protected] • Reprints: [email protected] Warning: No duplication rights exist for this journal. Only JTE Multimedia, LLC holds rights to this publication. Please contact the publisher directly with any queries.
Frank et al Figure 12. Intraoperative photographs of a patient with right hip FAI undergoing right hip arthroscopy for mixed cam- and pincer-type hip FAI: (A) tear at the chondrolabral junction with delamination; (B) refixation of the labral tear; (C) cam lesion; (D) osteoplasty of the cam lesion.
Conflict of Interest Statement
Rachel M. Frank, MD, Garth Walker, BS, Michael D. Hellman, MD, Frank M. McCormick, MD, and Shane J. Nho, MD, MS, have no conflicts of interest to declare.
References
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Abbreviations: FAI, femoroacetabular impingement.
arthroscopy allows for a comprehensive evaluation of the hip joint. Arthroscopy is clearly associated with several risks, as it involves an operative procedure and subjects the patient to anesthesia. Under anesthesia, the affected hip can be taken through a dynamic examination, and specific areas of impingement can be both diagnosed and surgically corrected with osteoplasty.
Conclusion
Hip pain in the young, athletic patient population can present in a variety of ways, and it is important for the clinician to be able to identify and evaluate these patients appropriately. The diagnosis of primary, intra-articular sources of hip pain is on the rise, and both primary care providers and sports medicine specialists are becoming better at recognizing these unique problems in what can be a challenging patient population. Multiple factors in the patient history may lead to the diagnosis, whereas other cases may be more challenging, requiring an appreciation of subtle findings on physical examination. The most challenging of patients are those with nonspecific complaints and with nonspecific physical examination findings, and in these cases diagnostic imaging may reveal the underlying etiology. In patients with multiple concomitant pathologies, it becomes critical for the physician to correlate all of the diagnostic information available, including the history, physical examination, imaging findings, and response to injection, to determine which of the lesions are symptomatic, and which (if any) are simply incidental findings. Overall, a combination of the history, examination, and imaging findings enables the astute clinician to determine the source of hip pain in these patients, and ultimately guide the treatment decision. 46
1. Philippon MJ, Patterson DC, Briggs KK. Hip arthroscopy and femoroacetabular impingement in the pediatric patient. J Pediatr Orthop. 2013;33(Suppl 1):S126–S130. 2. Kocher MS, Tucker R. Pediatric athlete hip disorders. Clin Sports Med. 2006;25(2):241–253, viii. 3. Tibor LM, Leunig M. The pathoanatomy and arthroscopic management of femoroacetabular impingement. Bone Joint Res. 2012;1(10):245–257. 4. Philippon MJ, Weiss DR, Kuppersmith DA, Briggs KK, Hay CJ. Arthroscopic labral repair and treatment of femoroacetabular impingement in professional hockey players. Am J Sports Med. 2010;38(1):99–104. 5. Byrd JW. Femoroacetabular impingement in athletes, part ii: treatment and outcomes. Sports Health. 2010;2(5):403–409. 6. Philippon M, Schenker M, Briggs K, Kuppersmith D. Femoroacetabular impingement in 45 professional athletes: associated pathologies and return to sport following arthroscopic decompression. Knee Surg Sports Traumatol Arthrosc. 2007;15(7):908–914. 7. Scopp JM, Moorman CT 3rd. The assessment of athletic hip injury. Clin Sports Med. 2001;20(4):647–659. 8. Anderson K, Strickland SM, Warren R. Hip and groin injuries in athletes. Am J Sports Med. 2001;29(4):521–533. 9. Martin HD, Palmer IJ. History and physical examination of the hip: the basics. Curr Rev Musculoskel Med. 2013;6(3):219–225. 10. Frank RM, Slabaugh MA, Grumet RC, Bush-Joseph CA, Virkus WW, Nho SJ. Hip pain in active patients: what you may be missing. J Fam Pract. 2012;61(12):736–744. 11. Martin RL, Kelly BT, Leunig M, et al. Reliability of clinical diagnosis in intraarticular hip diseases. Knee Surg Sports Traumatol Arthrosc. 2010;18(5):685–690. 12. Martin HD, Kelly BT, Leunig M, et al. The pattern and technique in the clinical evaluation of the adult hip: the common physical examination tests of hip specialists. Arthroscopy. 2010;26(2):161–172. 13. Grumet RC, Frank RM, Slabaugh MA, Virkus WW, Bush-Joseph CA, Nho SJ. Lateral hip pain in an athletic population: differential diagnosis and treatment options. Sports Health. 2010;2(3):191–196. 14. Frank RM, Slabaugh MA, Grumet RC, Virkus WW, Bush-Joseph CA, Nho SJ. Posterior hip pain in an athletic population: differential diagnosis and treatment options. Sports Health. 2010;2(3):237–246. 15. Bowman KF Jr, Fox J, Sekiya JK. A clinically relevant review of hip biomechanics. Arthroscopy. 2010;26(8):1118–1129. 16. Larson CM, Guanche CA, Kelly BT, Clohisy JC, Ranawat AS. Advanced techniques in hip arthroscopy. Instr Course Lect. 2009;58:423–436. 17. Byrd JW, Jones KS. Prospective analysis of hip arthroscopy with 10-year followup. Clin Orthop Rel Res. 2010;468(3):741–746. 18. Tibor LM, Sekiya JK. Differential diagnosis of pain around the hip joint. Arthroscopy. 2008;24(12):1407–1421. 19. Sierra RJ, Trousdale RT, Ganz R, Leunig M. Hip disease in the young, active patient: evaluation and nonarthroplasty surgical options. J Am Acad Orthop Surg. 2008;16(12):689–703. 20. Larson CM, Stone RM. Current concepts and trends for operative treatment of FAI: hip arthroscopy. Curr Rev Musculoskel Med. 2013;6(3):242–249. 21. Harrast MA, Colonno D. Stress fractures in runners. Clin Sports Med. 2010;29(3):399–416. 22. Byrd JW. Hip arthroscopy: patient assessment and indications. Inst Course Lect. 2003;52:711–719.
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39. Domayer SE, Ziebarth K, Chan J, Bixby S, Mamisch TC, Kim YJ. Femoroacetabular cam-type impingement: diagnostic sensitivity and specificity of radiographic views compared to radial MRI. Eur J Radiol. 2011;80(3):805–810. 40. Alonso-Rasgado T, Jimenez-Cruz D, Bailey CG, Mandal P, Board T. Changes in the stress in the femoral head neck junction after osteochondroplasty for hip impingement: a finite element study. J Orthop Res. 2012;30(12):1999–2006. 41. Chakraverty JK, Sullivan C, Gan C, Narayanaswamy S, Kamath S. Cam and pincer femoroacetabular impingement: CT findings of features resembling femoroacetabular impingement in a young population without symptoms. AJR. 2013;200(2):389–395. 42. Kang RW, Yanke AB, Espinoza Orias AA, Inoue N, Nho SJ. Emerging ideas: Novel 3-D quantification and classification of cam lesions in patients with femoroacetabular impingement. Clin Orthop Rel Res. 2013;471(2):358–362. 43. Masjedi M, Nightingale CL, Azimi DY, Cobb JP. The three-dimensional relationship between acetabular rim morphology and the severity of femoral cam lesions. Bone Joint J. 2013;95-B(3):314–319. 44. Zaltz I, Leunig M. Parafoveal chondral defects associated with femoroacetabular impingement. Clin Orthop Rel Res. 2012;470(12): 3383–3389. 45. Aprato A, Masse A, Faletti C, et al. Magnetic resonance arthrography for femoroacetabular impingement surgery: is it reliable? J Orthop Traumat. 2013;14(3):201–206. 46. Reurink G, Jansen SP, Bisselink JM, Vincken PW, Weir A, Moen MH. Reliability and validity of diagnosing acetabular labral lesions with magnetic resonance arthrography. J Bone Joint Surg. 2012; 94 A(18):1643–1648. 47. Bare AA, Guanche CA. Hip impingement: the role of arthroscopy. Orthopedics. 2005;28(3):266–273. 48. Bedi A, Kelly BT, Khanduja V. Arthroscopic hip preservation surgery: current concepts and perspective. Bone Joint J. 2013;95-B(1):10–19. 49. Griffiths EJ, Khanduja V. Hip arthroscopy: evolution, current practice and future developments. Int Orthop. 2012;36(6):1115–1121. 50. Larson CM. Arthroscopic management of hip pathomorphology. Instr Course Lect. 2012;61:287–293. 51. Robertson WJ, Kadrmas WR, Kelly BT. Arthroscopic management of labral tears in the hip: a systematic review of the literature. Clin Orthop Rel Res. 2007;455:88–92. 52. Shindle MK, Voos JE, Nho SJ, Heyworth BE, Kelly BT. Arthroscopic management of labral tears in the hip. J Bone Joint Surg. 2008; 90 A(Suppl 4):2–19.
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Evaluation of Hip Pain in Young Adults a
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Rachel M. Frank MD , Garth Walker BS , Michael D. Hellman MD , Frank M. McCormick MD & Shane J. Nho MD, MS
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Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL Published online: 28 May 2015.
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C L I N I C A L F O C U S : P A I N M A N A G E M E N T, O R T H O P E D I C S , A N D S P O R T S I N J U R I E S
Evaluation of Hip Pain in Young Adults
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DOI: 10.3810/psm.2014.05.2056
Rachel M. Frank, MD Garth Walker, BS Michael D. Hellman, MD Frank M. McCormick, MD Shane J. Nho, MD, MS Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL
Abstract: Hip pain is a common complaint in the young, athletic patient population. Primary, intra-articular sources of hip pain are becoming increasingly recognized by primary care providers and sports medicine specialists. Prior to deciding among the various treatment options for the many sources of hip pain in the athletic patient population, the clinician must be able to recognize and accurately diagnose the underlying pathology. Advances in imaging modalities and our understanding of the pathophysiology have improved our ability to accurately understand and diagnose the source of hip pain in this patient population. This review presents a comprehensive strategy for the workup and diagnosis of young, athletic patients presenting with hip pain, and provides the sports medicine specialist with the tools to correlate the patient’s history, physical examination, and imaging findings and to treat these challenging patients. Keywords: athletic patient population; hip pain; imaging modalities; underlying pathology
Introduction
Correspondence: Rachel M. Frank, MD, Department of Orthopaedic Surgery, Rush University Medical Center 1611 West Harrison Street, Suite 300, Chicago, IL 60612. Tel: 312-942-5850 Fax: 312-942-2101 E-mail: [email protected]
38
Hip pain is a common complaint in the young, athletic patient population.1–8 Primary, intra-articular sources of hip pain are becoming increasingly recognized by sports medicine specialists. During the past decade, and specifically within the past 5 years, there has been a tremendous increase in the volume of literature available discussing hip pain in this unique patient population.9–19 Although clearly a valuable resource, the substantial number of papers and reviews on the topic of hip pain may cause some confusion for the sports medicine physician, especially given the overlapping symptoms and complaints for patients presenting with a variety of sources of hip pain. Prior to deciding between the various treatment options for the many sources of hip pain in the athletic patient population, the clinician must be able to recognize and accurately diagnose the underlying pathology. Advances in the training and understanding of arthroscopic and open surgical approaches to the hip, as well as innovations in instrumentation and implants have improved our ability to treat a variety of sources of intra-articular hip pain. However, one of the main challenges in the young, athletic patient population is accurately understanding and diagnosing the true source of hip pain. Without an accurate diagnosis, surgical treatment can prove ineffective or even harmful. Thus, in order to guide treatment, it is critical for the clinician to be able to distinguish between different causes of intra-articular hip pain in the athletic patient population.
History and Patient Presentation
A complete history is critical in the evaluation of the athletic patient presenting with hip pain. Young patients especially may not be able to differentiate among groin pain, lateral hip pain, or low back pain, and often it is up to the clinician to tease out the
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Evaluation of Hip Pain in Young Adults
pertinent anatomical and historical details that may help guide the differential diagnosis.9,12,20 Given the proximity of the hip joint to other important anatomical structures, including the lumbosacral spine, reproductive organs, and gastrointestinal tract, referred or radiating pain must be distinguished from primary intra-articular hip pain. Any unexpected symptoms, including the atraumatic, insidious onset of pain associated with weight loss, fevers, night pain, or malaise, must be evaluated in further detail to rule out potential inflammatory, infectious, or malignant etiologies. Similarly, a history of steroid or alcohol use, as well as other systemic illnesses such as sickle cell disease, may predispose young patients to avascular necrosis, and these historical factors should be taken into consideration. In addition, and especially in highly active female athletes, any recent increase in training intensity or duration associated with atraumatic groin pain should prompt the clinician to consider a workup for a femoral neck stress fracture.21 The clinician should ask about both a personal and a family history of similar symptoms. Finally, a recent history of high-energy trauma, such as a motor vehicle accident or a fall from a height, may be indicative of an underlying fracture and should be worked up appropriately with imaging studies. Once trauma and systemic illness have been ruled out, the physician must make a concerted effort to determine the onset and source of the pain, with a focus on determining whether it is intra-articular or extra-articular in origin (Table 1).10,13,14 Extra-articular sources of hip pain, including radiating pain from the lumbosacral spine or from the knee, must be ruled out. It can be helpful to ask the patient about pain as it relates to potential provocative activities or positions, such as prolonged sitting, stair climbing, rising from a seated position, leaning over versus standing straight, or sitting flat on a chair versus crossing one leg over the other to off of the buttock. A summary of painful activities/positions and potential underlying etiologies is provided in Table 2. Patients in this population may be variable with regard to onset (acute, subacute, chronic), duration, and severity of symptoms. Given the athletic nature of this patient population, often symptoms are related to a variety of sports activities. The specific location of the pain should be determined. Often, having the patient point to the exact location of discomfort can aid in the diagnosis. For example, superficial lateral pain may be related to greater trochanteric bursitis or iliotibial band syndrome, whereas posterior hip (or buttock) pain is often referred from the lumbar spine. Anterior hip pain, or groin pain, is most often indicative of an underlying intra-articular etiology. Instead of pointing with a single finger, patients with
Table 1. Sources of Intra-Articular Versus Extra-Articular Primary Hip Pain Intra-articular
Extra-articular
Labral tear Loose body FAI Capsular laxity Ligamentum teres rupture Articular cartilage damage
Iliopsoas tendonitis Gluteus medius/minimus tendinopathy Greater trochanteric bursitis Stress fracture Abductor strain Piriformis syndrome Sacroiliac joint pathology Contusion (hip pointer) Snapping hip syndrome Sports hernia, athletic pubalgia Osteitis pubis
Abbreviation: FAI, femoroacetabular impingement.
intra-articular hip pain may sometimes use their hand to create a C-shape and grasp the lateral aspect of their hip above the greater trochanter with the ends of the C (thumb or fingers) either in the groin or just posterior to the trochanter (C-sign).22 However, intra-articular hip pain sometimes may be difficult to pinpoint, and there are some cases in which hip joint pain may refer to the buttock or to the peritrochanteric area. Often, patients describe mechanical symptoms, including a sensation of popping, locking, catching, or clicking, all of which can be more indicative of intra-articular causes of pain. Further, aggravating or exacerbating symptoms can be helpful in narrowing the differential diagnosis. For example, patients with intra-articular sources of pain are often symptom-free when walking or lying flat, but they describe substantial difficulty with running or with activities that place the affected hip into flexion and internal rotation, such as driving, getting in and out of a car, or leaning forward to tie one’s shoes. A thorough history is important not only for determining what may be the underlying source of hip pain, but also for determining what may not be causing symptoms. For example, if the patient denies groin pain and instead describes lateral hip Table 2. Specific Activities/Positions That Cause Hip Pain Activity/Position
Potential Etiology
Flexion Internal rotation Rising from seated position Leaning forward to tie shoes Putting on socks Getting into or out of vehicle Standing while leaning over Sitting with affected leg crossed over
FAI FAI FAI FAI FAI FAI Spinal stenosis Piriformis syndrome, posterior hip pain Greater trochanteric bursitis Abductor insufficiency
Laying on affected side Single leg stance
Abbreviation: FAI, femoroacetabular impingement.
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Frank et al
pain, worse with direct palpation or when lying on the affected side, with improvement in symptoms with nonsteroidal antiinflammatory drugs and ice packs, then the diagnosis of trochanteric bursitis is more likely. In this situation, the diagnosis is essentially confirmed clinically with physical examination, and so even if advanced imaging modalities demonstrate a small labral tear, such findings in this case can be considered incidental, and do not warrant operative intervention. As noted in a systematic review that included evaluation of 1096 asymptomatic hips by Kwee and colleagues,23 labral tears can be found in 19% of asymptomatic hips. An appreciation for knowing which lesions are responsible for symptom generation, and which are simply “innocent bystanders,” is absolutely vital in avoiding unnecessary and potentially harmful surgical intervention. Finally, all patients should be asked about their current and desired level of activity. This information, although not necessarily helpful diagnostically, is extremely useful in determining how symptomatic the patient is, and what the posttreatment expectations might be. Of note, certain aspects of the patient’s history may be more suggestive of arthritis as the underlying cause of intra-articular hip pain, as opposed to labral tears, impingement, or hip dysplasia. In cases of arthritis, patients often describe an insidious, atraumatic onset of their symptoms. Often, patients report morning pain, as well as pain localized to the groin, back, or thigh that is worse with increased activities. The pain typically worsens over time, and may be associated with stiffness, a sensation of weakness (typically due to the pain), and possibly a limp.24
Physical Examination
A thorough physical examination of both hips and nearby potential sources of pain is of utmost importance.9–12,25 The order in which the examination steps are performed can vary, and is often dictated by the patient’s complaints. For example, in the patient described above with lateral hip pain, the examiner may wish to examine the trochanteric bursa last, so as not to cause pain at the beginning of the examination and lead the patient to guard for the remainder of the examination. Regardless of the order, clinicians should develop their own strategy for an efficient examination, and follow that routine for every patient, so as not to miss anything. Martin et al9,12 describe a comprehensive hip examination that can be completed in 21 steps. Their approach enables a complete examination of the “4 layers”—osteochondral, capsulolabral, musculotendinous, and neurovascular—of the hip. The examination places the patient into multiple positions, including standing/walking, seated, supine, prone, and lateral decubitus. 40
For each patient, regardless of the suspected diagnosis, the clinician should always follow a stepwise approach to the examination of both hips, including gait, inspection, palpation, range of motion, sensation, strength, and stability, as well as provocative tests. The joints above (lumbosacral spine, sacroiliac joint) and below (knee) the hip should always be examined in order to search for potential sources of radiating pain. If appropriate, a neurologic examination can be performed to search for lumbar nerve root pathology causing radicular pain radiating to the hip. Examination tests for radicular pain can include a straight-leg-raise assessment (supine and seated) as well as specific evaluation of motor strength, sensation, and reflexes for specific nerve roots. It should be noted that in these cases, examination findings may remain unremarkable, even with a radicular source of symptoms. Further, a concise vascular examination should be performed, with documentation of palpable distal pulses (dorsalis pedis, posterior tibial) as well as of any significant edema or skin changes consistent with vascular disease.
Standing Examination
While standing, the patient should be observed for height symmetry of the iliac crests as well as of the shoulder blades to evaluate leg length discrepancies. With the gait examination, special attention should be paid to pelvic rotation, stance phase, and stride length. Further, the physician should note if the patient has an antalgic gait (shortened stance phase on the affected side), Trendelenburg gait (abductor deficient), or Trendelenburg sign. To assess the Trendelenburg sign, the patient is asked to perform a single-leg stance on the affected leg, and the test is considered positive if the pelvis drops toward the opposite, nonstanding leg, indicating weakness of the hip abductors on the standing leg. Observation of the patient’s posture during the examination can also be useful. For example, patients may slouch to reduce hip flexion or may shift weight to the uninjured side to reduce the load on the affected hip. Similarly, the physician should observe the way in which the patient rises from the seated position, which can sometimes be indicative of which positions of hip flexion/ extension are most painful for the patient. As noted above, in some cases, the patient may lean over the ipsilateral hip to compensate for weak abductors, causing the pelvis to drop toward the contralateral side (Trendelenburg sign).
Supine Examination
The bulk of the physical examination is performed with the patient either seated or lying down (supine or lateral). Again, there is no correct order in which to perform the following
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Evaluation of Hip Pain in Young Adults
tests, but the physician should make an effort to perform every examination maneuver for every patient. Range of motion (Figure 1) evaluation is performed by comparing the affected side to the unaffected side (Table 3). External and internal rotation is performed with the hip flexed to 90 degrees as well as extended. The extension rotation examination is best performed with the patient in the prone position, and is helpful for assessing femoral version. Strength in each of these planes (flexion, extension, abduction, adduction, internal rotation, external rotation) is then assessed, again comparing the affected side to the contralateral hip (Figure 2). Patients with intra-articular sources of hip pain, such as femoroacetabular impingement (FAI) or acetabular dysplasia, likely have difficulty, pain, and decreased range of motion in flexion and internal rotation compared with the opposite side.
Provocative Tests
Multiple pain provocative tests should be performed on the each hip, especially in the patient with potential intra-articular hip pain. These special tests include the impingement test (FADIR: flexion, adduction, internal rotation), the Patrick test (FABER: flexion, abduction, external rotation), the instability/logroll test, the posterior impingement test, the lateral rim impingement test, the trochanteric pain sign assessment, the sub-spine impingement test, and the ischiofemoral impingement test. Of these, the FADIR, FABER, and sub-spine impingement tests are perhaps the most helpful. The test for impingement, the FADIR, is performed with the hip dynamically brought into flexion, adduction, Figure 1. Physical examination of the hip, demonstrating (A) flexion; (B) internal rotation; (C) external rotation; and (D) FABER, often referred to as the Patrick test, which can differentiate sacroiliac joint pathology from primary hip pathology.
Table 3. Normal ROM Values Motion
Value (°)
Flexion Extension Internal rotation External rotation Abduction Adduction
120 30 34 45 45 20
Abbreviation: ROM, range of motion.
and internal rotation; the test is positive if the patient has reproducible groin pain with this movement, and typically signifies the presence of intra-articular pathology. The FABER test can differentiate sacroiliac (SI) joint pathology from primary hip pathology and can also be used to diagnose iliopsoas irritation (Figure 1). This test is performed with the patient supine and with the painful hip flexed and externally rotated, causing the ankle to rest on the opposite knee. If the patient experiences ipsilateral or contralateral posterior low back pain, the SI joint may be affected, whereas if the pain is localized to the groin, posterior FAI may be present. The logroll test can be a sensitive test for intra-articular hip pathology (such as FAI). This test is performed with the patient supine and with the leg extended. The instability test is performed with the legs extended and an externally directed force on the foot and a loss of recoil suggests anterior instability (Figure 3). Posterior impingement is evaluated via the posterior impingement test, which is positive when pain is reproduced with hip extension and external rotation (Figure 4). This test is performed with the patient’s buttock at the end of the examination table with both legs suspended. With the patient’s hip extended, the examiner externally rotates the hip, and the test is positive if this maneuver reproduces pain. The lateral rim impingement test is used to diagnose acetabular overcoverage. This test is performed in the supine position with the patient’s hip passively abducted to provoke pain (Figure 5). Some authors have also described performing instability test with the hip abducted and externally rotated Figure 2. Physical examination of the hip, demonstrating resisted abduction (A) with the knee flexed and (B) with the knee extended.
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Figure 3. Physical examination of the hip, demonstrating logroll in (A) extension and (B) external rotation.
and brought through a wide range of motion from flexion to extension. If the patient experiences a sensation of guarding or apprehension, the test can be considered positive for instability as well.9 (Figure 5). Several subtle findings during range-of-motion testing can be indicative of underlying hip pathology. For example, a positive trochanteric pain sign is positive when the patient experiences posterolateral hip pain with the FABER maneuver (Figure 6). The sub-spine impingement test is positive when the patient experiences anterior groin pain with hip hyperflexion. The ischiofemoral impingement sign is positive when the patient experiences posterior hip pain with extension and internal rotation. When performed as part of a complete assessment of the hip, not only can impingement be diagnosed, but also the specific problematic area of impingement often can be determined. It must be emphasized that several of the above tests may be positive in the setting of osteoarthritis, as opposed to FAI, and thus results must be interpreted cautiously and as part of the comprehensive evaluation of the patient, incorporating history and imaging findings.
Figure 4. Physical examination of the hip, demonstrating assessment of posterior impingement.
Figure 5. Physical examination of the hip, demonstrating assessment of lateral rim impingement.
Special Tests
Other important physical examination tests to perform include the straight leg raise, the Thomas test, and assessment of the patient’s full arc of hip motion. The straight leg raise test is performed with the patient supine, and the affected knee is maintained in extension while the hip is flexed. Pain localized to the lumbar spine region is often indicative of lumbar spine pathology with radiculopathy as opposed to intra-articular hip pain (Figure 7). The Thomas test is performed to search for the presence of a hip flexion contracture. In the supine position, the patient grasps 1 knee with both hands and flexes it to the chest as the hip of the contralateral leg is allowed to completely extend. The test result is positive for a hip flexion contracture if the leg is unable to completely extend. To better stabilize the pelvis, this test may be performed with the opposite hip flexed only to 90 degrees instead of in full flexion. The arc of motion is assessed with the patient supine as the hip is brought through a smooth arc of motion. The arc measurements are based on a clock-face scale, and are a helpful way of documenting at which point throughout hip motion the patient’s symptoms worsen and at which point they improve. In cases of FAI, the painful arc may start Figure 6. Physical examination of the hip, demonstrating assessment of the greater trochanter as a source of pain with (A) greater trochanteric pain sign and (B) direct greater trochanter palpation.
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Evaluation of Hip Pain in Young Adults Figure 7. Physical examination of the hip, demonstrating the straight leg raise.
simply to nonspecific physical examination findings. In these cases, further workup with diagnostic imaging is indicated. Diagnostic imaging is also helpful in preoperative planning, as noted below.
Diagnostic Studies
A variety of imaging studies can be helpful in the evaluation of the young athlete with a painful hip.7,19,26,27
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Radiographs
(right hip) from approximately the 9 o’clock position to the 1 o’clock position, and may end from approximately the 12 o’clock position to the 4 o’clock position.
Palpation
A thorough palpatory examination can be helpful in narrowing the location, and thus the etiology, of the patient’s hip complaints. In particular, the pubic symphysis should be palpated both at rest and during a resisted sit-up. The hip flexor musculature, anterior superior iliac spine, adductor musculature, proximal hamstring origin, ischial tuberosity, piriformis, and SI joints should all be palpated. When palpating each muscle group, the physician should pay particular attention to the various hip bursae, which are common sources of pain when they become inflamed, especially the ischial bursa, which causes posterior hip pain. Pain directly over the greater trochanter with palpation is typically indicative of trochanteric bursitis (Figure 7). Other pathologies may be diagnosed on palpation of the trochanter. Specifically, tendinopathy of the gluteus medius may present as pain along the posterior trochanter at the tendon insertion, whereas pain at the anterior aspect of the greater trochanter may be attributed to gluteus minimus pathology. When analyzed together, the information provided by the history and physical examination alone can often lead to the clinical diagnosis. These tests are aimed at determining if the source of the pain is intra-articular (ie, FAI) or extraarticular (ie, trochanter bursitis, referred pain). As mentioned above, intra-articular pain can even be further characterized by the location of the impingement, depending on which provocative physical examination maneuvers reproduce the symptoms. Nevertheless, sometimes the diagnosis is unclear, and may be due to multiple concomitant pathologies, or
Radiographs of the hip, including a standard weight-bearing anteroposterior (AP) view of the pelvis (with or without a separate AP of the hip), and lateral view of the hip, are obtained on all patients.28 Multiple lateral views have been described, including the cross-table lateral, frog-leg lateral, Dunn lateral, and false-profile lateral views.28 The Dunn lateral view is an AP view taken with the patient’s hip in neutral rotation, 45 degrees of flexion (or 90°, depending on the physician’s preference), and 20 degrees of abduction. The false-profile view is taken with the patient standing with the affected hip against the radiographic cassette and the pelvis rotated 65 degrees in relation to the wall stand, with the affected foot (of the leg against the cassette) parallel to the cassette. Although radiographs help to search for unexpected underlying pathology, including occult fractures, tumors, infection, and foreign bodies, they are most helpful in evaluating the overall femoral–acetabular articulation, especially in patients with intra-articular hip pain due to FAI. Multiple important parameters (Table 4) can be measured off of films, including the Tönnis grade (for degenerative changes), the Tönnis angle, the lateral center edge angle (LCEA) of Wiberg, the alpha angle, and the anterior centeredge angle (of Lequesne). The Tönnis grade, Tönnis angle (ie, the acetabular index) and the LCEA (Figure 8) are measured on an AP pelvis view. The alpha angle (Figure 9) is used to quantify head–neck junction deformity, and is best assessed on the Dunn lateral view.28 The anterior center-edge angle of Lequesne quantifies anterior acetabular coverage of the femoral head, and is measured on the false-profile view of the hip. Assessment of pelvic tilt is also important in the radiographic evaluation of patients with hip pain, especially as variations in tilt/inclination can significantly alter several of the previously described radiographic parameters for FAI, including the LCEA and Tönnis angle.3,29,30 Pelvic tilt is assessed on a lateral pelvic radiograph, and is the angle between a vertical line drawn up from the center of the femoral head, and a second line from the center of the
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Frank et al
Table 4. Radiographic Parameters Used in the Evaluation of Young Patients With Hip Pain Radiographic Parameter
Significance
Tönnis grade
Classification scale for hip arthritis • Measured on AP hip/pelvis view • Grade 0: no signs of osteoarthritis • Grade 1: increased sclerosis with slight joint space narrowing • Grade 2: small periarticular cysts with moderate joint space narrowing and moderate loss of femoral head sphericity • Grade 3: large periarticular cysts with severe joint space narrowing and deformity of the femoral head Measures weight-bearing surface angle • Measured on AP hip/pelvis view • Formed by the angle between a horizontal line and a line extending from the medial to lateral edges of the sourcil • Normal: 10° Assesses for excessive acetabular depth/coverage • Measured on AP hip/pelvis view • Formed by the angle between a vertical line through the center of the femoral head and a line extending from the center of the femoral head to the lateral sourcil • Normal: 25–40° Quantifies head–neck junction deformity • Best measured on Dunn lateral view • Formed by the angle between a line drawn from the center of the femoral head through the center of the femoral neck, and a line from the center of the femoral head to the femoral head–neck junction • Normal: , 50–55° Quantifies anterior coverage of femoral head • Measured on false profile view • Formed by the intersection of a vertical line through the center of the femoral head and a line extending through the center of the femoral head to the anterior sourcil (normal 25–50°; , 20° indicates developmental hip dysplasia).
Tönnis angle (acetabular index)
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LCEA of Wiberg
Alpha angle
Anterior center edge angle (of Lequesne)
Abbreviation: AP, anteroposterior; LCEA, lateral center edge angle.
femoral head to the center of the S1 endplate. Increases in pelvic inclination (tilt) may result in increased measures of acetabular coverage (ie, LCEA, Tönnis angle), whereas decreases can lead to reduced measurements. Proper patient positioning and critical interpretation of radiographs is thus crucial for drawing conclusions on the acetabular morphology in this patient population. Other important radiographic parameters31 that can help in the evaluation of the young patient with hip pain include Figure 8. Radiographs of the (A) AP and (B) lateral views of a patient with right hip femoracetabular impingement, demonstrating Tönnis grade 0, lateral center edge angle of 41° (seen on AP view in red), proximal cross over sign (seen on AP view), and alpha angle of 59° (seen on lateral view, in yellow).
Abbreviation: AP, anteroposterior.
44
the crossover sign,32 which is a sensitive and specific radiographic finding of acetabular retroversion, and the ischial spine sign.33 The crossover sign occurs when the line representing the anterior acetabular wall crosses the line of the posterior acetabular wall before reaching the lateral edge of the sourcil. The crossover sign is not always reliable, however, and as noted by Zaltz and colleagues,34 it may be present even in the absence of acetabular retroversion, possibly related to variable anteroinferior iliac spine morphology. The ischial spine sign is indicative of acetabular retroversion, and is present if, on an AP pelvis radiograph, the Figure 9. Axial (A) and coronal (B,C) CT images of a patient with right hip FAI, demonstrating evidence of a small bony prominence proximal to the femoral physis, as well as small cysts and herniation pits in the anterior aspect of the femoral neck at the head-neck junction.
Abbreviations: CT, computed tomography; FAI, femoroacetabular impingement.
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Evaluation of Hip Pain in Young Adults
medial prominence of the ischial spine is projected inside the pelvic brim.33 Interestingly, although previously considered useful as a radiographic parameter for pincer-type FAI, as recently noted by Nepple and colleagues,35 the presence of coxa profunda is not enough to support a diagnosis of FAI, and can be considered a normal radiographic finding (at least in female patients).
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Advanced Imaging
Advanced imaging with computed tomography and magnetic resonance imaging (MRI) and magnetic resonance arthrography (MRA) is also extremely helpful in the evaluation of young patients with hip pain.26,36–39 Both conventional and 3-dimensional computed tomography scan40–43 (Figures 9 and 10) can be especially helpful in understanding the bony topography of the femoral head and acetabulum, especially in cases of cam and/or pincer FAI. This type of geographical information is helpful in correlating the objective pathology noted on the imaging as well as on physical examination with the patient’s subjective complaints. Both MRI (Figure 11) and MRA38 are helpful in the evaluation of the periarticular soft tissue, including the labrum and capsular tissue. Subtle degenerative articular changes, as well as isolated chondral defects,44 that are not well appreciated on radiographs can also be seen on MRI/MRA. For example, Figure 11 demonstrates an anterosuperior labral tear and a small cyst in the head–neck junction of proximal femur, findings which are not readily appreciable on radiographs. Magnetic resonance arthrography has been shown to have a sensitivity and specificity for detecting chondral wear of 17% and 100%, respectively. Magnetic resonance imaging is especially useful in the evaluation of avascular necrosis, a cause of symptoms, as well as in the evaluation of femoral Figure 10. Coronal CT images of a patient with right hip FAI demonstrating (A) conventional imaging and (B) a 3-dimensional reconstruction, both of which show mixed cam and pincer-type FAI with labral ossification, as well as a bony mild prominence at the femoral head neck junction.
neck stress fractures,21 whereas MRA may be most helpful in the evaluation of labral tears, cam-type lesions, and os acetabula, with a sensitivity and specificity for detecting labral tears of 81% and 51%, respectively.45 It should be noted, however, that for patients for whom the physician has an already high clinical suspicion of labral pathology, MRA has a poor negative predictive value and thus is unhelpful in ruling out labral lesions.46 Imaging findings may be helpful in preoperative planning, especially with regard to determining the need for labral repair and potential femoral head or acetabular microfracture. This is important information to know preoperatively in order to counsel these young patients, as these procedures will ultimately lengthen the postoperative rehabilitation protocol.
Other Diagnostic Modalities
Other diagnostic tools helpful in the evaluation of the young patient with hip pain include diagnostic intra-articular injections and diagnostic arthroscopy. Intra-articular hip injections can be both diagnostic as well as therapeutic. In cases of atypical presentation of hip pain, the anesthetic injection with lidocaine can be useful to differentiate between intra- and extra-articular sources of hip pain. In these cases, injection should provide nearly complete relief of symptoms, at least temporarily. The patients are asked to complete a pain diary to determine how much pain is relieved and the duration of the pain relief. Often, the dye used for MRA can be mixed with local anesthetic, and the patient is able to tell the physician in the clinic if the MRA study itself made the pain better (ie, if the injection used for the MRA helped relieve the symptoms). Arthroscopy16,17,20,22,47–52 (Figure 12) is the “gold standard” with which the majority of imaging studies are compared. Although arthroscopy is not typically used as a diagnostic tool in the hip, when a surgeon chooses arthroscopy as treatment for a patient (ie, with FAI), diagnosis of other intra-articular hip pathologies is made possible as Figure 11. Coronal MRI—(A) T1-weighted, (B) T2-weighted STIR, (C) protondensity fat saturated—of a patient with right hip FAI.
Abbreviation: CT, computed tomography; FAI, femoroacetabular impingement.
Abbreviations: FAI, femoroacetabular impingement; MRI, magnetic resonance imaging; STIR, short-time inversion recovery.
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Frank et al Figure 12. Intraoperative photographs of a patient with right hip FAI undergoing right hip arthroscopy for mixed cam- and pincer-type hip FAI: (A) tear at the chondrolabral junction with delamination; (B) refixation of the labral tear; (C) cam lesion; (D) osteoplasty of the cam lesion.
Conflict of Interest Statement
Rachel M. Frank, MD, Garth Walker, BS, Michael D. Hellman, MD, Frank M. McCormick, MD, and Shane J. Nho, MD, MS, have no conflicts of interest to declare.
References
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Abbreviations: FAI, femoroacetabular impingement.
arthroscopy allows for a comprehensive evaluation of the hip joint. Arthroscopy is clearly associated with several risks, as it involves an operative procedure and subjects the patient to anesthesia. Under anesthesia, the affected hip can be taken through a dynamic examination, and specific areas of impingement can be both diagnosed and surgically corrected with osteoplasty.
Conclusion
Hip pain in the young, athletic patient population can present in a variety of ways, and it is important for the clinician to be able to identify and evaluate these patients appropriately. The diagnosis of primary, intra-articular sources of hip pain is on the rise, and both primary care providers and sports medicine specialists are becoming better at recognizing these unique problems in what can be a challenging patient population. Multiple factors in the patient history may lead to the diagnosis, whereas other cases may be more challenging, requiring an appreciation of subtle findings on physical examination. The most challenging of patients are those with nonspecific complaints and with nonspecific physical examination findings, and in these cases diagnostic imaging may reveal the underlying etiology. In patients with multiple concomitant pathologies, it becomes critical for the physician to correlate all of the diagnostic information available, including the history, physical examination, imaging findings, and response to injection, to determine which of the lesions are symptomatic, and which (if any) are simply incidental findings. Overall, a combination of the history, examination, and imaging findings enables the astute clinician to determine the source of hip pain in these patients, and ultimately guide the treatment decision. 46
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