Physical Examination for Persistent Thigh Pain After Hip Surgery
Examine the hip through internal rotation to reproduce the patient's pain, assess gait pattern for antalgic features, and palpate the greater trochanter to differentiate intra-articular from extra-articular pathology. 1
Essential Physical Examination Components
Gait Assessment
- Observe for antalgic gait pattern, which indicates pain-related compensation and is a key finding in patients with persistent hip pathology 1
- Document whether the patient requires an assistive device for ambulation 1
- Assess quality of movement during functional tasks like sit-to-stand transitions 2
Hip Range of Motion Testing
- Perform internal rotation of the hip as the primary provocative maneuver - this reproduces the chief complaint in patients with intra-articular pathology 1
- Test small-arc range of motion separately, as pain with internal rotation but not with small-arc motion helps localize the problem 1
- Evaluate for limitations in hip mobility that may indicate prosthetic issues or soft tissue complications 1
Palpation and Inspection
- Palpate the greater trochanter specifically - tenderness here suggests extra-articular causes like trochanteric bursitis rather than prosthetic complications 1
- Inspect the skin over the hip for erythema, which may indicate infection 1
- Check for intact skin without signs of wound complications 1
Additional Examination Elements
- Assess for muscle herniation through the surgical approach, which can present as a palpable bulge and is a correctable cause of thigh pain 3
- Evaluate dynamic balance and single-leg stability, as deficits in these areas commonly persist after hip arthroplasty 2
- Monitor for signs of exercise intolerance including joint effusion or increased local temperature 2
Differential Diagnosis Considerations Based on Physical Findings
Prosthetic-Related Causes
- Femoral stem impingement typically presents with thigh pain reproduced by internal rotation and may show varus stem positioning on imaging 4, 5
- Stem size correlation: larger femoral components are directly associated with increased thigh pain incidence 6
- Loose beads from porous-coated prostheses strongly correlate with persistent thigh pain 5
Extra-Articular Causes
- Pain with greater trochanter palpation but not with internal rotation suggests periarticular soft tissue pathology rather than intra-articular issues 1
- Muscle hernia through the surgical approach presents as a palpable defect and localized pain 3
Clinical Context and Pitfalls
The physical examination findings must be interpreted alongside the temporal pattern of pain. Approximately 27% of patients report pain at 6 months post-operatively, with 14% developing new thigh pain between 2-5 years after surgery 5, 7. Pain that is new or worsening over time requires more aggressive investigation than stable, mild discomfort.
Common pitfall: Failing to distinguish between pain reproduced by internal rotation (suggesting intra-articular pathology) versus pain with greater trochanter palpation (suggesting extra-articular causes) can lead to inappropriate imaging and treatment decisions 1.
The examination should specifically assess whether pain correlates with poor functional scores, as this combination strongly suggests a prosthetic-related problem requiring revision consideration 5.