What is the appropriate physical assessment for a patient presenting with hip pain, considering their past medical history, age, and potential underlying conditions such as osteoarthritis, osteoporosis, or hip dysplasia?

Physical Assessment for Hip Pain

Begin with plain radiographs (AP pelvis and lateral hip views) as the mandatory first imaging test, followed by a systematic 21-step physical examination that evaluates gait, range of motion, provocative maneuvers, and muscle strength to distinguish intra-articular from extra-articular pathology. 1, 2

Initial Clinical History

Obtain specific details about:

• Pain location: Anterior (suggests intra-articular pathology, hip flexor injury, or referred abdominal/pelvic pain), lateral (suggests greater trochanteric pain syndrome or gluteus medius pathology), or posterior (suggests lumbar spine pathology, deep gluteal syndrome, or hamstring tendinopathy) 3
• Symptom duration and progression: Chronic versus acute onset helps narrow differential diagnosis 1
• Mechanical symptoms: Locking, catching, or snapping sensations suggest labral tears or snapping hip syndrome 1, 3
• Activity modification: What activities exacerbate or relieve pain 1
• Age and activity level: Young/middle-aged active adults versus older adults have different pathology patterns 1

Systematic Physical Examination (21 Core Steps)

Observation and Gait Assessment

• Gait pattern: Observe for antalgic gait, Trendelenburg gait (suggests gluteus medius weakness), or other compensatory patterns 1, 4
• Assistive device use: Documents functional limitation 1

Range of Motion Testing

• Passive and active ROM: Measure flexion, extension, abduction, adduction, internal rotation, and external rotation 4, 5
• Internal rotation limitation: Often the first motion lost in intra-articular pathology 1, 5

Provocative Maneuvers

• FADIR test (Flexion-Adduction-Internal Rotation): Positive test reproduces anterior hip pain and suggests femoroacetabular impingement or labral pathology 1
• FABER test (Flexion-Abduction-External Rotation): Positive test suggests intra-articular pathology; contralateral pain suggests SI joint dysfunction 6
• Impingement testing: Reproduces patient's chief complaint in FAI syndrome 1

Muscle Strength Assessment

• Use objective methods: Handheld dynamometry with external fixation for isometric or eccentric testing to minimize tester variability 1
• Hip flexors, extensors, abductors, and adductors: Weakness patterns help localize pathology 1, 4
• Gluteus medius strength: Critical for lateral hip pain evaluation 1, 3

Functional Performance Testing

• Single-leg squat: Assess depth and quality of movement (people with hip pain demonstrate reduced squat depth) 1
• Single-leg balance: Impaired performance is consistent finding in hip-related pain 1
• Star Excursion Balance Test (SEBT): Demonstrates impairment in hip-related pain populations 1

Screening for Referred Pain

• Lumbar spine examination: Essential as spine pathology commonly refers to hip region 1, 6, 3
• Pelvic examination: Screen for SI joint dysfunction and pelvic pathology 1, 6
• Knee examination: Can refer pain to hip 1

Imaging Algorithm

First-Line Imaging (Mandatory)

• AP pelvis and lateral femoral head-neck radiographs: Rated 9/9 appropriateness, must be obtained before any advanced imaging 1, 2
• Specialized views when indicated: False profile or Dunn view for dysplasia/FAI evaluation 1
• Radiographs evaluate: Osteoarthritis, FAI morphology, dysplasia, fractures, and bone tumors 1, 2

Advanced Imaging (When Radiographs Negative/Equivocal)

For suspected soft tissue pathology:

• MRI hip without IV contrast (rated 9/9): Superior for detecting labral tears, cartilage damage, tendinopathy, bursitis, muscle injuries, and occult fractures 1, 2, 7
• Ultrasound: Useful for evaluating snapping hip, fluid collections, and guiding injections 1, 2

For suspected intra-articular pathology:

• MR arthrography (rated 9/9): Best for labral tears and FAI syndrome when surgery is being considered 2

Diagnostic Injections

• Image-guided intra-articular hip injection (rated 8/9): Anesthetic with or without corticosteroid definitively determines if pain originates from hip joint versus surrounding structures 1, 2
• Trochanteric injection: For suspected greater trochanteric pain syndrome 1
• SI joint injection: When contralateral FABER test is positive 6

Critical Pitfalls to Avoid

• Never diagnose based on imaging alone: Incidental findings are common in asymptomatic individuals; clinical correlation is mandatory 1, 6
• Never skip plain radiographs: All advanced imaging is rated 1/9 as first test; proceeding directly to MRI violates consensus guidelines 1, 2
• Never assume negative radiographs exclude fracture in high-risk patients: Elderly patients with osteopenia, fall history, and inability to ambulate require urgent MRI for occult fracture (up to 10% of hip fractures are radiographically occult initially) 7
• Never ignore referred pain sources: Comprehensive examination must include spine and pelvis screening, as these commonly present as hip pain 1, 6, 3
• Never obtain only ipsilateral hip views: AP pelvis view is essential to evaluate both hips and pelvic alignment 1, 2

Physical Activity Quantification

• Use objective measures: Body-worn accelerometers (e.g., Fitbit) demonstrate adequate accuracy and reliability for measuring activity levels 1
• Combine with self-reported measures: Captures different dimensions including patient response to activity 1
• Document baseline activity and fluctuations: Essential for monitoring treatment response 1