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Approach to the Hip Region Exam

Hip pain is really common. Sometimes the pain is
coming from the hip joint. Other times, pain may be
coming from other surrounding causes. Here, we'll
review all causes of pain in the hip region and show
you the exam to diagnose each one.

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Introduction
Pain in the Hip Region

Before we can review the exam of the hip, it's important to know the possible diagnoses. That way
you're going through each exam maneuver unique to each specific diagnosis. To aid in the process,
it's helpful to organize your diagnoses into three locations: anterior, lateral and posterior.
Differential Diagnoses of Regional Hip Pain
Anterior

Hip Joint Disease, including:

Osteoarthritis
Neck Fracture
Septic Arthritis
Femoral-Acetabular Syndrome
Avascular Necrosis
Meralgia Paresthetica (can be anterior and/or lateral)

Lateral

Greater Trochanteric Bursitis

External Snapping Hip

Posterior

Radiculopathy (visit Low Back Exam page)

Sacroiliitis or Sacraliliac Joint Pain
Piriformis Syndrome
Approach to Hip Region Pain Physical Exam - Stanford Medicine 25

Hip Joint Disease

Anterior Region

Pain coming from the hip joint usually presents in the anterior region. As noted above, there are a
number of problems that could arise in the hip joint (e.g. osteoarthritis, neck fracture, septic arthritis
femoral-acetabular syndrome and avascular necrosis). Together with the exam noted below, once
you are able to localize the pain to the hip joint, you can use other data (e.g. vitals, labs and imaging)
to help with the specific diagnosis.

Below are the number of exam manuevers used to localize pain to the hip joint.

Click this link to jump to the section on anterior hip pain in the video.

Log Rolling Test

The log rolling test can be helpful if you suspect a hip fracture. It is done by simply rolling the leg side-
to-side while the patient is supine.
Compression Test at the Foot
The compression test is done by hitting the balls of the feet to transmit pressure towards the hip
while the leg is lifted. Again, this can be very painful in a hip fracture.

Compression Test at the Knee (and Lateral Hip)

The compression test can also be done by tapping at the knee, again transmitting pressure towards
the hip. Finally, you can also by tap lateral to the hip (see video for demonstration). All compression
tests can be positive in hip pain but especially with a fracture. If positive, hip x-rays (and possibly
more imaging) should be ordered.
Range of Motion of Hip Joint
Video demonstration to test range of motion.

Tests for range of motion look for pain in the hip joint as the ball-and-socket joint of the hip is
activated. The most common cause of pain with range of motion is osteoarthritis (or degenerative
joint disease) of the hip but again any of the problems of the hip listed above will likey cause pain
during range of motion and/or limitation in range of movement.

Some of these motions include:

Flexing both hip and knee at 90 degress, then rotating back-and-forth both interally and
externally to approx 45 degrees.
Flexing the hip and knee beyond 90 degress to the extremes of range of motion and rotating
from side-to-side

Range of motion at 90 degrees hip and knee flexion.

Extreme range of motion beyond 90 degrees hip and knee flexion.

Meralgia Paresthetica
 Anterior/Lateral Region

If your patient complains of anterior (sometimes anterior and lateral) thigh pain, the diagnoses may
be meralgia paresthetica. This diagnosis is usually caused by entrapment of the lateral femoral
cutaneous nerve as it passes under the inguinal ligament and supplies the sensory distribution of the
anterior/lateral thigh.

The pain is often described as burning. There may be an associated paresthesia (numbness and/or
tingling) and sometimes a decrease in sensation. Therefore, a sensory exam should be performed in
the region. Meralgia paresthetica is more common in diabetics.

Click this link to jump to the section in the video.

Crediit
 Greater Trochanteric Bursitis
Lateral Region

Greater trochanteric bursitis consists of pain over the lateral side of the hip. The diagnosis of greater
trochanteric bursitis is diagnosed by asking the patient to lay on the side (painful side up) and
palpating over the burse of the greater trochanter. Tenderness should be appreciated. Pain is often
self-limiting but can also be treated with NSAIDs.

External Snapping Hip

Lateral Region

Greater trochanteric bursitis has more recently been thought to be part of a greater trochanteric pain
syndrome that includes the tendons that insert and cross over the greater trochanter such as the
iliotibial band which traverses the lateral hip and if inflammed could cause a "snap" during
movement as the hip flexes and extends.

To test for an external stapping hip, with the patient on their side (painful side up), you will grab the
whole leg then flex and extend the leg while palpating the iliotibal tendon (near the greater
trochanter) and feeling for a popping or snapping that may be associated with pain. Link to video
demonstrating this.
 Lumber Radiculopathy
Posterior Region

A very common cause of posterior pain near the buttocks is caused by radiculopathy as the nerves
exit the lumber spine. That topic is covered in our page on the Approach to Low Back Pain here.

Sacroiliitis / Sacraliliac Joint Pain

Posterior Region

Pain at the sacroiliac joint is often in the posterior or buttocks region. Pain in the sacroiliac joint can
be elicited with the FAbER Test. FAbER stands for Flexion, Abduction and External Rotation. Once the
leg is flexed, abducted and externally rotated (as noted in image below), you will apply a downward
pressure at the knee. The presence of pain in the posterior (or buttocks) region suggests pain from
the sacroiliac joint.

Link to video demonstrating this.

 Piriformis Syndrome
Posterior Region

Piriformis syndrome occurs when the piriformis muscle compresses the sciatic nerve. Tests
for piriformis sydrome are attempting to move the leg so that the piriformis muscle pushes against
the sciatic nerve leading to pain and thus a positive test.

Link to video demonstrating this.

In the first manuver, keeping the leg straight, flex the hip up to 90 degrees, looking for pain in
the posterior/buttocks region.

In the second manuver, keeping the hip flexed, flex the knee and adduct the knee accross the
body of the patient, again looking for pain in the the posterior/buttocks region.

Consult the Expert on Regional Hip Pain

Baldeep Singh
Dr. Baldeep Singh is a Clinical Professor at Stanford University and the Vice Chair for Academic
Affairs for the Division of Primary Care and Population Health. He is involved in a number of
clinical teaching roles at Stanford's School of Medicine and an active member of the Stanford
Medicine 25 team with a special expertise in the exam of the lower back and regional hip pain.

Clinical Pearl

As you see from this page, most of what we refer to as "hip pain", doesn't
involve the hip joint. Remember, if the pain is lateral or posterior (near
buttocks), look for the other causes of pain that don't involve the hip joint.”
 Key Learning Points 
Learn the approach to regional hip pain that includes:

Knowing the differential diagnoses

Knowing each unique exam that will confirm or exclude each diagnosis

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