What are the differential diagnoses for medial hip pain in sports medicine?

Differential Diagnoses for Medial Hip Pain in Sports Medicine

Medial hip pain in athletes requires systematic exclusion of serious pathology first, followed by categorization into intra-articular versus extra-articular causes, with adductor-related pathology and hip joint disease being the primary considerations for true medial-sided symptoms.

Immediate Red Flags to Exclude First

Before considering common sports-related causes, you must rule out serious pathology that can present with medial hip or groin pain 1, 2, 3:

• Stress fractures (femoral neck or pubic ramus): insidious onset, night pain, inability to bear weight, focal tenderness over bone 1, 2
• Tumors: night pain, constitutional symptoms (fever, weight loss), progressive worsening 1, 2
• Infection (septic arthritis, osteomyelitis): acute onset, fever, inability to bear weight, severe pain at rest 1, 3
• Slipped capital femoral epiphysis (SCFE): particularly in adolescents/young adults, can present as medial thigh or knee pain rather than lateral hip pain, with external rotation deformity 2, 3

Primary Differential Diagnoses for Medial Hip Pain

Intra-articular Hip Pathology

Femoroacetabular Impingement (FAI) Syndrome 1:

• Groin pain (often perceived medially) with hip flexion, adduction, and internal rotation
• Positive FADIR (flexion-adduction-internal rotation) test
• Cam or pincer morphology on radiographs
• May coexist with labral tears

Acetabular Labral Tears 1:

• Sharp, catching pain in groin/medial hip
• Mechanical symptoms (clicking, locking)
• Often associated with FAI or dysplasia
• Requires MRI/MRA for diagnosis

Hip Osteoarthritis 1:

• Medial groin and thigh aching discomfort
• Exacerbated by activity, relieved by rest
• Pain with internal rotation, limited range of motion
• Not quickly relieved after variable exercise

Acetabular Dysplasia/Hip Instability 1:

• Medial groin pain with instability sensation
• Misalignment between femoral head and acetabulum
• Apprehension with provocative maneuvers

Extra-articular Causes

Adductor Tendinopathy/Strain 4:

• Pain localized to medial groin/proximal thigh
• Tenderness at adductor origin on pubic bone
• Pain with resisted adduction
• Most common cause of medial-sided athletic groin pain

Athletic Pubalgia (Inguinal Disruption) 4:

• Deep groin pain with exertion
• Tenderness over pubic symphysis or inguinal canal
• Pain with sit-ups or resisted hip flexion

Iliopsoas Tendinopathy 1, 4:

• Anterior/medial groin pain
• Pain with hip flexion against resistance
• Snapping sensation possible

Osteitis Pubis 4:

• Medial groin pain centered at pubic symphysis
• Tenderness over pubic bone bilaterally
• Worsens with running, kicking

Referred Pain Sources

Lumbar Spine Pathology 1, 2:

• Sharp lancinating pain radiating to medial thigh
• Induced by sitting, standing, or walking
• History of back problems
• Critical: Must screen lumbar spine as competing source in all hip pain evaluations

Sacroiliac Joint Dysfunction 1:

• Pain referred to groin/medial hip
• Tenderness over SI joint
• Positive provocative SI joint tests

Diagnostic Algorithm

Step 1: Initial Clinical Assessment

• Exclude red flags through history (night pain, constitutional symptoms, trauma mechanism) 1, 2
• Determine if pain is activity-related or present at rest 1
• Assess gait and weight-bearing ability 5, 6

Step 2: Physical Examination

• FADIR test: flexion-adduction-internal rotation for intra-articular pathology 1
• Adductor squeeze test: resisted adduction for adductor pathology 4
• Hip range of motion: particularly internal rotation for osteoarthritis 7
• Palpation: pubic symphysis, adductor origin, inguinal region 4, 8
• Screen lumbar spine: mandatory in all cases 1, 2

Step 3: Imaging Protocol

• First-line: AP pelvis and lateral femoral head-neck radiographs (Dunn, frog-leg, or cross-table view) 1
• Advanced imaging: MRI or MRA for intra-articular structures (labrum, cartilage, ligamentum teres) when radiographs inconclusive or surgery considered 1
• Ultrasound: useful for superficial structures like adductor tendons 1

Critical Clinical Pitfalls

• Never diagnose based on imaging alone: incidental findings are common in asymptomatic athletes; clinical correlation is mandatory 1
• Don't miss referred pain: hip pathology can present as knee pain, and spine pathology can present as hip pain 7, 2
• Coexisting pathology is common: labral tears often coexist with FAI or dysplasia 1
• Age matters: SCFE must be considered in adolescents and young adults with any hip/groin pain 2, 3