What are the potential causes and management strategies for hip joint pain in adults with no specific medical history?

Hip Joint Pain Differential Diagnosis in Adults

Hip pain in adults requires a systematic anatomic approach, first excluding red flags (infection, fracture, tumor), then categorizing by pain location (anterior, lateral, posterior) to guide diagnosis and management.

Immediate Red Flag Exclusions

Before considering common musculoskeletal causes, you must rule out serious pathology:

• Infection presents with acute onset, fever, severe pain at rest, inability to bear weight, and requires immediate evaluation 1
• Stress fractures manifest with insidious onset, night pain, inability to bear weight, focal bone tenderness, and history of recent trauma or repetitive loading 1, 2
• Tumors demonstrate night pain, constitutional symptoms (fever, weight loss), and progressive worsening unrelated to activity 1, 2
• Inflammatory sacroiliitis from axial spondyloarthropathy shows inflammatory back pain characteristics: insidious onset, improvement with exercise, pain at night or early morning, morning stiffness >30 minutes, age of onset <45 years 2

Anatomic Classification of Hip Pain

Anterior Hip Pain (Groin Region)

Intra-articular causes:

• Femoroacetabular impingement (FAI) syndrome is the predominant diagnosis in young to middle-aged active adults, characterized by groin pain with hip flexion, adduction, and internal rotation, associated with cam, pincer, or mixed morphology on imaging 1, 3
• Acetabular labral tears manifest with sharp, catching pain in the groin or medial hip with mechanical symptoms (clicking, locking), often coexisting with FAI or dysplasia 2, 3
• Acetabular dysplasia/hip instability presents with medial groin pain and instability sensation due to misalignment between femoral head and acetabulum causing rim overload 1, 3
• Osteoarthritis is the most common intra-articular cause in middle-aged and older adults, presenting with groin pain, stiffness, and reduced range of motion 1, 4
• Ligamentum teres tears cause deep intra-articular pain without distinct bony morphology 1, 3

Extra-articular causes:

• Hip flexor injuries (iliopsoas tendinopathy) present with anterior hip pain exacerbated by hip flexion activities 4, 5
• Snapping hip syndrome (internal type) involves iliopsoas tendon snapping over iliopectineal eminence 5, 6

Lateral Hip Pain

• Greater trochanteric pain syndrome is the most common cause, encompassing gluteus medius tendinopathy or tear, trochanteric bursitis, and iliotibial band friction 4, 6
• Gluteal tendinopathy has good surgical outcomes when diagnosed early, warranting consideration of advanced imaging and early referral 4

Posterior Hip Pain

• Lumbar spine pathology is a critical competing musculoskeletal source that must be screened in all hip pain evaluations, presenting as sharp lancinating pain radiating down the leg, induced by sitting/standing/walking 1, 2, 7
• Deep gluteal syndrome with sciatic nerve entrapment (piriformis syndrome) causes posterior hip and buttock pain with radiation 4, 6
• Sacroiliac joint dysfunction accounts for 15-30% of chronic mechanical low back pain cases, presenting with posterior pelvic/buttock pain 2
• Ischiofemoral impingement and hamstring tendinopathy cause posterior hip pain with specific provocative maneuvers 4, 5

Diagnostic Algorithm

Step 1: History Assessment

• Determine pain pattern: Inflammatory (improves with exercise, worse at night/morning, stiffness >30 minutes) versus mechanical (worse with activity, improves with rest) 2
• Assess constitutional symptoms: Fever, weight loss, night sweats suggest infection or tumor 2
• Evaluate ability to bear weight: Inability suggests fracture or infection requiring urgent evaluation 2
• Identify pain location: Anterior (groin), lateral (trochanter), or posterior (buttock) guides differential 4, 6

Step 2: Physical Examination

No single physical examination test has adequate diagnostic utility alone; a comprehensive approach combining multiple findings is essential 1, 2:

• FADIR test (flexion-adduction-internal rotation): A negative test helps rule out hip-related pain, though clinical utility is limited and should not be used in isolation 1, 7, 3
• Hip range of motion assessment: Reduced internal rotation and flexion suggest intra-articular pathology 2
• Mandatory lumbar spine screening: Essential in all cases to exclude referred pain, as spine pathology frequently presents as hip pain 1, 2, 7
• Palpation: Focal bone tenderness suggests fracture; trochanteric tenderness suggests greater trochanteric pain syndrome 4, 6

Step 3: Initial Imaging

AP pelvis and lateral femoral head-neck radiographs are the first-line imaging to exclude fractures, tumors, assess for radiographic sacroiliitis, and evaluate bony morphology 1, 2:

• Lateral views should include Dunn view, frog-leg (Lauenstein) view, or cross-table view to assess femoral head-neck morphology 1
• Radiographs have 80% sensitivity for axial spondyloarthropathy, so negative films do not exclude inflammatory disease 2

Step 4: Advanced Imaging (When Indicated)

MRI/MRA or CT scan are recommended where three-dimensional morphological assessment is indicated or to evaluate intra-articular structures (labrum, cartilage, ligamentum teres) 1:

• MRI of hip is indicated when intra-articular pathology is suspected based on positive FADIR test, limited hip ROM, or mechanical symptoms 1, 2
• MRI of sacroiliac joints is necessary if inflammatory sacroiliitis is suspected, demonstrating bone marrow edema before radiographic changes 2
• MRI of lumbar spine is required if radicular symptoms or lumbar pathology is suspected 2
• Ultrasound-guided anesthetic injections can aid in diagnosing intra-articular causes of pain 4

Step 5: Laboratory Testing (When Inflammatory Disease Suspected)

• HLA-B27 testing has 90% sensitivity for axial spondyloarthropathy with 32% post-test probability when positive 2
• ESR/CRP has only 50% sensitivity in axial spondyloarthropathy, so normal values do not exclude inflammatory disease 2

Management Principles

Core Treatments for Osteoarthritis (Most Common in Older Adults)

All patients with symptomatic osteoarthritis should receive education, activity/exercise recommendations, and weight loss interventions if overweight 1:

• Provide access to appropriate information to counter misconceptions that osteoarthritis is inevitably progressive and cannot be treated 1
• Recommend local muscle strengthening and general aerobic fitness 1
• Implement weight loss interventions for overweight/obese patients 1

Adjunct Non-Pharmacological Treatments

• Self-management strategies emphasizing exercise and behavioral changes (appropriate footwear, activity pacing) 1
• Manipulation and stretching particularly for hip osteoarthritis 1
• Assistive devices (walking sticks) for those with specific problems in activities of daily living 1
• TENS, local heat/cold applications may provide symptomatic relief 1

Pharmacological Management

Offer paracetamol for pain relief as first-line therapy, with regular dosing as needed 1:

• Consider topical NSAIDs before oral NSAIDs for localized pain 1
• If paracetamol or topical NSAIDs are insufficient, add opioid analgesics or substitute with oral NSAID/COX-2 inhibitor 1
• Use oral NSAIDs or COX-2 inhibitors at the lowest effective dose for the shortest possible period 1
• Prescribe oral NSAIDs/COX-2 inhibitors alongside a proton pump inhibitor, choosing the one with lowest acquisition cost 1
• Consider individual risk factors (age, gastrointestinal, liver, cardiorenal) when selecting agents 1

Surgical Considerations

Femoroacetabular impingement, labral tears, and gluteus medius tendon tears typically have good surgical outcomes, warranting advanced imaging and/or early referral 4

Critical Clinical Pitfalls

• Imaging findings must correlate clinically: Incidental findings are extremely common in asymptomatic individuals, and diagnosis should never be based on imaging alone 1, 7, 3
• Multiple pathologies often coexist: Labral tears with FAI or dysplasia, SI joint dysfunction with lumbar pathology 2, 3
• Hip pathology can present as knee pain: Particularly slipped capital femoral epiphysis in younger patients, though this is less common in typical adults 7, 3
• Spine pathology frequently presents as hip pain: Mandatory lumbar screening prevents missed diagnoses 1, 2, 7
• Acute trauma can unmask inflammatory disease: Maintain high suspicion if inflammatory features develop after trauma 2
• Glucosamine and chondroitin products are not recommended despite marketing claims 1
• Electroacupuncture should not be used; insufficient evidence exists for acupuncture despite some trials 1