What are the steps for a comprehensive hip exam and potential treatment options for hip pain?

Comprehensive Hip Examination

Begin with plain radiographs (AP pelvis and hip views) as your first imaging test, then proceed to a systematic physical examination that includes 18-21 core maneuvers focusing on range of motion, provocative tests, and gait assessment. 1, 2, 3

Initial Clinical Assessment

A targeted history and physical examination, including provocative maneuvers, range of motion, gait abnormalities, locking or snapping, duration of symptoms, and pain patterns (e.g., worse at night and relieved by activity) are essential for narrowing the differential diagnosis. 1 Attention must also be paid to the knees and spine as potential sources of referred pain. 1

Physical Examination Components

The hip examination should evaluate four anatomical layers: osseous, capsulolabral, musculotendinous, and neurovascular, plus the kinematic chain linking upper and lower body. 2

Standing Position Tests (3 tests)

• Gait assessment (performed 86% of the time by hip specialists) 3
• Single-leg stance phase test (performed 77% of the time) 3
• Femoral anteversion test (performed 58% of the time in prone position) 3

Supine Position Tests (11 tests)

• Flexion range of motion (performed 98% of the time) 3
• Flexion with internal rotation ROM (performed 98% of the time) 3
• Flexion with external rotation ROM (performed 86% of the time) 3
• Passive supine rotation test (performed 76% of the time) 3
• FADIR test (Flexion/Adduction/Internal Rotation) (performed 70% of the time) 3
• Straight leg raise against resistance (performed 61% of the time) 3
• FABER test (Flexion/Abduction/External Rotation) (performed 52% of the time) 3

Lateral Position Tests (3 tests)

These assess abductor strength and trochanteric pathology. 3

Imaging Algorithm

First-Line Imaging

X-ray pelvis (rating 9/9) and X-ray hip (rating 9/9) are complementary and both should be obtained as the initial imaging studies. 1 Radiographs screen for common disorders such as arthritis, fractures, and bone tumors, and may be the only imaging necessary for conditions like osteoarthritis or advanced osteonecrosis. 1

Second-Line Imaging Based on Clinical Suspicion

If radiographs are negative/equivocal and you suspect extra-articular soft tissue abnormality (tendonitis, bursitis):

• MRI hip without IV contrast (rating 9/9) 1, 4
• Ultrasound hip (rating 7/9) as an alternative 1, 4

If radiographs are negative/equivocal and you suspect labral tear or femoroacetabular impingement:

• MR arthrography hip (rating 9/9) 1, 4
• CT arthrography hip (rating 7/9) as an alternative 1

If evaluating articular cartilage after radiographs:

• MRI hip without IV contrast (rating 9/9) or MR arthrography hip (rating 9/9) 1
• CT arthrography hip (rating 8/9) 1

For hip pain radiating down the leg with numbness and normal radiographs:

• MRI hip without IV contrast is the next appropriate study 4
• Consider lumbar spine imaging if clinical suspicion exists for referred pain from spine pathology 4

Diagnostic Injections

Image-guided anesthetic and corticosteroid injection into the hip joint (rating 8/9) can determine if pain originates from the hip joint itself versus surrounding structures or referred sources, particularly when concurrent low back, pelvic, or knee pathology exists. 4 This procedure can be performed simultaneously with MR or CT arthrography and provides both diagnostic information and therapeutic benefit. 1, 4

Critical Pitfalls to Avoid

• Never proceed directly to advanced imaging without obtaining plain radiographs first (all advanced imaging rated 1/9 as first test). 1, 4
• Failing to obtain both pelvis and hip views may miss important pathology. 4
• Do not use nuclear medicine bone scan, PET imaging, or CT without contrast for soft tissue pathology causing numbness (all rated 1/9 for appropriateness). 4
• Occult femoral neck fractures can present with normal initial radiographs—MRI is required for diagnosis, and delaying MRI when pain worsens or persists beyond 2-3 days may indicate an occult fracture requiring urgent surgical intervention. 4
• Peripheral nerve blocks of the obturator nerve for chronic pain are experimental/investigational due to insufficient evidence. 4

Treatment Considerations

When arthrography is performed, simultaneous intra-articular injection of anesthetic and steroid can provide diagnostic information and be therapeutic. 1 For painful total hip replacement, the temporal onset, duration, severity, site, and character of pain provide important clues, and physical examination should focus on tests and maneuvers that reproduce the patient's symptoms. 5