What is the likely cause of hip pain in a patient with full range of motion and no pain on resistance testing, but experiences pain when hopping on their right leg?

Hip Pain with Hopping but Normal ROM and Resistance Testing

This clinical presentation most likely indicates greater trochanteric pain syndrome (GTPS) with gluteus medius/minimus tendinopathy, which requires plain radiographs initially followed by MRI to definitively diagnose and guide treatment. 1

Clinical Reasoning

The key diagnostic features here create a specific pattern:

• Pain with single-leg hopping indicates a functional loading problem rather than intra-articular pathology 2
• Full passive range of motion effectively rules out most intra-articular causes like femoroacetabular impingement (FAI) syndrome or labral tears, which typically restrict ROM 2
• No pain on resistance testing makes acute muscle strain or tendon rupture less likely 2

This triad points strongly toward periarticular soft tissue pathology, specifically abductor tendon dysfunction that manifests only under dynamic loading conditions 1, 3.

Differential Diagnosis Priority

Most Likely: Greater Trochanteric Pain Syndrome

• Gluteus medius/minimus tendinopathy is the leading diagnosis when lateral hip pain occurs with functional activities but examination findings are otherwise unremarkable 1, 3
• The hopping test creates eccentric loading on the hip abductors, which provokes pain in tendinopathy even when static resistance testing is negative 1
• This condition affects 10-25% of the general population and is particularly common in active adults 4

Important Alternative: L3 Radiculopathy

• Must be excluded because it can present with lateral hip/thigh pain and normal hip examination 5
• Key distinguishing feature: L3 radiculopathy causes dermatomal sensory loss along the medial lower leg, which GTPS does not 5
• Negative FABER and FADIR tests help exclude intra-articular hip pathology and support a neurogenic source 5

Less Likely but Consider:

• Stress fracture (femoral neck or pubic ramus) - would typically show pain with small-arc ROM and percussion tenderness 2, 6
• Intra-articular pathology (labral tear, FAI syndrome) - essentially ruled out by full ROM and negative impingement tests 2, 7

Diagnostic Workup Algorithm

Step 1: Complete Physical Examination

• Palpate the greater trochanter for point tenderness (highly suggestive of GTPS) 1, 3
• Assess sensory distribution along medial lower leg to exclude L3 radiculopathy 5
• Perform FABER and FADIR tests - if negative, intra-articular pathology is unlikely 2, 5
• Examine lumbar spine - referred pain from spine pathology can mimic lateral hip pain 1, 3

Step 2: Initial Imaging

Plain radiographs (AP pelvis and frog-leg lateral hip) are mandatory first-line imaging to exclude osseous pathology, arthritis, or structural abnormalities 2, 1. This follows ACR Appropriateness Criteria recommendations 2.

Step 3: Advanced Imaging if Radiographs Normal

MRI without contrast is the definitive study for suspected gluteus medius/minimus tendinopathy 1:

• Sensitivity 33-100%, specificity 92-100% for detecting tendon tears 1
• ACR explicitly states MRI is "usually appropriate when evaluating for clinically suspected tendon, muscle, or ligament injury" 1
• Can classify location, extent, and chronicity of tendon pathology 1

Critical caveat: Delaying MRI may allow progression from partial to complete tear, worsening functional outcomes 1. If clinical suspicion is high, proceed directly to MRI after plain films.

Step 4: Consider Diagnostic Injection

If diagnosis remains unclear after imaging, ultrasound-guided corticosteroid injection into the peritrochanteric region provides both diagnostic confirmation and therapeutic benefit 1, 3.

Treatment Algorithm

For Tendinopathy Without Tear:

1. Relative rest and activity modification to prevent further damage 1
2. NSAIDs (naproxen 500mg twice daily) for acute pain relief 1
3. Physical therapy focusing on eccentric strengthening and hip stabilizer exercises 1
4. Expected timeline: 80% of patients recover within 3-6 months with conservative treatment 1

If Conservative Treatment Fails (6-12 weeks):

• Ultrasound-guided corticosteroid injection into peritendinous region 1
• Consider orthopedic referral if symptoms persist 1

For Complete Tears or Refractory Symptoms:

• Surgical referral is indicated 1
• Early referral may improve outcomes if tear is identified 1

Common Pitfalls to Avoid

1. Assuming normal ROM excludes all hip pathology - periarticular conditions like GTPS can have completely normal passive ROM 2, 1

2. Relying solely on resistance testing - tendinopathy may not be painful with manual muscle testing but becomes symptomatic under dynamic loading conditions like hopping 2

3. Skipping plain radiographs - imaging should never be used in isolation, but radiographs are essential to exclude osseous pathology before proceeding to MRI 2, 1

4. Forgetting to examine the lumbar spine - referred pain from L3 radiculopathy or other spinal pathology can present identically to lateral hip pain 5, 1, 3

5. Delaying MRI when clinical suspicion is high - progression from partial to complete tear significantly worsens outcomes 1