Posterior, Lateral, and Anterior Hip Pain Due to Musculoskeletal Origin

Approach to evaluation
l Self-reported hip pain is common (14% of the population over the age of 60 years).
l Hip pain is often localized to one of three locations: anterior, lateral, or posterior.
l Clinicians need to consider both local and distant osteoligamentous, tendinous, nervous, and muscular
anatomy when examining patients with complaints related to the posterior, lateral, or anterior hip.
Additionally, myofascial pain syndrome is a common and overlooked cause of pain.

Anterior hip pain

l Patients with anterior hip pain will localize the pain to the anteromedial thigh (inguinal region) with what
is known as the “C” sign at physical examination.
l Differential diagnosis
Differential Clinical feature / orthopedic testing
¨ Anterior or posterior hip pain
¨ Persistent deep groin pain that is worse with activity
¨ Increased pain on flexion and/or internal rotation, and concurrent
Osteoarthritis
morning stiffness lasting 60 minutes.
¨ ROM limitation (capsular pattern).
¨ Trendelenburg sign, resisted hip abduction, and FABERE tests (+).
¨ More prevalent in athletes (eg, hockey, soccer, dance, and golf).
¨ Persistent stiffness and intermittent groin pain during early stages.
Femoroacetabular
¨ Later stages may reveal sharp pain and mechanical symptoms (ie,
impingement
catching, locking, instability).
¨ Flexion adduction internal rotation tests (+).
¨ Different types of tears exist (post-traumatic; associated with FAI; capsular
laxity/hip hypermobility; and degenerative).
¨ Central groin and peritrochanteric pain more common. Unlikely to
Acetabular labral
present with anterior thigh or ischial pain (compare with OA).
tear
¨ Flexion adduction internal rotation tests (+).
¨ If clicking, catching, or locking of the femoroacetabular joint occur during
testing likelihood of labral tear is increased.
¨ It caused by the movement of iliopsoas tendons passing over bone.
¨ Pain when extending the hip from a flexed position.
Internal snapping
¨ Often associated with intermittent catching, snapping, or popping.
¨ The repeated strumming of the tendon can irritate the bursitis.
¨ Trauma or repetitive weight-bearing exercise involved.
¨ Anterior hip or groin pain that is worse with activity.
Fracture ¨ Pain may be present with extremes of motion, active SLR, the log roll test.
¨ Inability to walk on the affected limb and a shortened, externally rotated,
abducted leg while in the supine position.
Lateral hip pain
l Differential diagnosis
Differential Clinical feature / orthopedic testing
¨ Most patients have an atraumatic, insidious onset of symptoms from
repetitive use.
Greater trochanteric ¨ Associated with bursitis, gluteus medius tendinopathy or tears.
pauin syndrome ¨ Burning or deep ache, aggravated by ambulation or other physical
activities, sitting for long periods, and sleeping on the affected hip.
¨ IT band tightness (Ober test, +) and gluteal muscle weakness.
¨ IT band or gluteal maximus muscle rolls over the GT creates a snap
during hip extension.
¨ Pain with direct pressure radiation down lateral thigh, snapping or
External snapping hip popping.
¨ Often easily observable by observing and listening for snap as the
patient actively flexes and extends the hip.
¨ Ober test (+).
¨ Sensory for anterolateral thigh to the knee.
Lateral femoral ¨ Risk factors include: Prior hip or spine surgery, obesity, pregnancy, tight
cutaneous enuropathy fitting clothes or other objects such as police belts, iliacus hematoma
Neurodynamic testing with side-lying hip extension and adduction.

Posterior pain
l Differential diagnosis
¨ Pain aggravated by sitting or walking, with/without ipsilateral radiation
down down the posterior thigh from sciatic nerve compression.
Piriformis syndrome
¨ Tenderness with palpation of the sciatic notch.
¨ FAIR test (+).
¨ Impingement of the quadratus femoris muscle between the lesser
trochanter and the ischium.
Ischiofemoral
¨ Nonspecific buttock pain with radiation to the posterior thigh.
impingement
¨ Ragual onset of deep buttock pain that is worsened with activities
requiring a long stride, such as running.
¨ Centralization of symptoms with repeated spinal movement (McKenzie
assessment) favor spinal involvement and should be done to exclude
Lumbar spine spine referral.
¨ Pain in the low back (above L5) and hip, buttock, history of lumbar spinal
problems.
¨ Composite testing of (+) thigh thrust, distraction, compression, sacral
thrust, and FABER test favors SIJ origin, especially when symptoms are
SI joint dysfunction
not reproduced with spinal movement.
¨ SI joint dysfunction more common in pregnancy.
 ¨ Overuse injury with hip extension activities
¨ Previous hamstring injury, pain with activity, and pain with direct
pressure.
Hamstring injury
¨ Symptoms may mimic sciatica.
¨ Active, passive, and resisted range of motion tests and tenderness with
palpation on ischial tuberosity (+).

Bursitis
Gteater trochanteric pain Iliopectineal bursitis Ischiogluteal burisits
syndrome (GTPS)
Causes - Tight IT band - Tight IT band - Prolonged sitting
- Muscle imbalance (abductor - DJD - Trauma (falling)
/ adductor)
Onset Insidious onset
Site of pain Lateral hip region Groin region Ischial tuberosity
Symptoms - Ascending stairs Morse by activities Pain with walking, climbing,
and signs - Rolling to the involved involving extreme or stairs flexion of the hip &
- Leg crossed repetitive hip extension trunk, and prolonged sitting
Physical - AM: no limitation Full passive extension and Passive flexion and resisted
examination - PMt: abduction, flexion, resisted hip flexion (+) hip extension (+)
adduction and internal
rotation (+)
- RM: abduction, extension,
external rotation

Summary
l The issues with the hip joint require consideration of history, characteristic & location of pain, and
examinations for differential diagnosis, in order to deduce the possible causes.
l Common diease of hip
Problems
Osteo-related Muscle & tendon-related
Pain
Osteoarthritis Internal snapping
FAI
Anterior
Acetabular labral tear
Fracture
Greater trochanteric pain syndrome
Lateral External snapping hip
Lateral femoral cutaneous enuropathy *
Lumbar spine & SI dysfunction Piriformis syndrome *
Posterior Ischiofemoral impingement *
Hamstring injury
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