What causes hip pain radiating to the groin when walking, but no pain when using stairs?

Hip Pain Radiating to Groin When Walking (No Pain with Stairs)

This presentation most likely represents an intra-articular hip pathology—specifically osteoarthritis, labral tear, or femoroacetabular impingement—rather than extra-articular soft tissue pathology, because pain with level walking but not with stairs suggests the hip joint itself is the pain generator rather than periarticular structures like bursae or tendons.

Clinical Reasoning

The key distinguishing feature here is the activity-specific pain pattern. When patients have pain with walking on level ground but not with stair climbing, this typically indicates:

• Intra-articular pathology is more likely because level walking creates different loading patterns and rotational forces on the hip joint compared to stair climbing 1, 2
• Extra-articular causes (trochanteric bursitis, abductor tendinopathy, iliopsoas bursitis) typically worsen with stairs due to increased muscle activation and tendon loading 1

The groin radiation is particularly telling, as anterior hip/groin pain is the hallmark of intra-articular hip disease 2.

Differential Diagnosis Priority

Most Likely Diagnoses (in order):

1. Hip osteoarthritis - Most common in adults, presents with groin pain exacerbated by activity 1
2. Labral tear with or without femoroacetabular impingement - Common in younger to middle-aged adults, causes mechanical symptoms and groin pain 1, 2
3. Early chondral injury - Can present before radiographic changes are evident 1

Less Likely (but must exclude):

• Iliopsoas tendinopathy/bursitis - Usually worsens with hip flexion activities like stairs, not better 1, 3
• Inguinal hernia with nerve entrapment - Can mimic hip pathology but typically has localized tenderness at inguinal ligament 4
• Referred pain from spine - Should be considered but less likely with isolated groin radiation 1

Diagnostic Workup Algorithm

Step 1: Initial Imaging

Obtain plain radiographs first (AP pelvis and frog-leg lateral hip views) 1, 5

• This is the mandatory first imaging test for all hip pain presentations 1
• Provides information on joint space narrowing, osteophytes, dysplasia, and FAI morphology 1
• For osteoarthritis specifically, physical examination plus radiography may be superior to MRI with reasonable sensitivity and specificity 1

Step 2: If Radiographs Are Negative, Equivocal, or Nondiagnostic

Proceed to MRI without contrast 1

• MRI is highly sensitive and specific for labral tears, chondral injuries, and early degenerative changes 1
• Should be the first advanced imaging after radiographs for suspected intra-articular pathology 1
• Can detect cartilage delamination, labral pathology, and early osteoarthritis not visible on x-rays 1

Consider MR arthrography if labral tear is strongly suspected 1

• Direct MR arthrography with dilute gadolinium is established as reliable for diagnosing acetabular labral tears 1
• However, high-resolution 3T MRI without contrast may be sufficient and less invasive 1

Step 3: Diagnostic Injection (if diagnosis remains unclear)

Ultrasound or fluoroscopy-guided intra-articular hip injection with anesthetic 1, 2

• Relief of pain with intra-articular injection confirms the hip joint as the pain source 1
• Helps differentiate intra-articular from extra-articular causes 2, 3
• Safe and useful diagnostic tool 1

Physical Examination Pearls

Look specifically for:

• Pain with internal rotation of the hip - Classic sign of intra-articular pathology 1
• Absence of pain with small-arc range of motion - May indicate more advanced disease 1
• Antalgic gait pattern - Suggests significant joint pathology 1
• Localized tenderness at inguinal ligament - Would suggest hernia rather than hip joint 4
• Pain reproduction with FADIR test (flexion-adduction-internal rotation) - Suggests FAI or labral tear 2

Common Pitfalls to Avoid

• Do not assume trochanteric bursitis just because of "hip pain" - true lateral hip pain is different from groin pain 1
• Do not skip plain radiographs - they remain the essential first test and guide all subsequent imaging 1
• Do not order MRI as the first test - radiographs may be sufficient for osteoarthritis diagnosis and are needed for comparison 1
• Consider non-visible inguinal hernia in females - can present with groin pain mimicking hip pathology, especially if pain started with sporting activity 4
• Remember referred pain from spine - but this typically doesn't improve with any specific hip position 1

Age-Specific Considerations

• Younger adults (< 50 years): Think labral tears, FAI, chondral injuries first 1, 2
• Middle-aged to older adults: Osteoarthritis becomes increasingly likely 1
• Adolescents: Consider slipped capital femoral epiphysis, apophyseal avulsion 6