Right Hip Pain with Positive Ober's Test: Diagnosis and Management
The most likely diagnosis is Greater Trochanteric Pain Syndrome (GTPS), and first-line management should include physical therapy focused on hip abductor strengthening, NSAIDs, and consideration of corticosteroid injection if conservative measures fail. 1, 2
Clinical Reasoning for Diagnosis
The positive Ober's test combined with pain on hip abduction strongly points toward lateral hip pathology rather than intra-articular disease:
Lateral hip pain is the hallmark of GTPS, which encompasses gluteus medius/minimus tendinopathy, trochanteric bursitis, and iliotibial band syndrome—this presentation distinctly differs from intra-articular hip pathology that typically causes anterior groin pain. 1, 3
The Ober's test specifically evaluates iliotibial band tightness and lateral hip structures, making a positive finding highly suggestive of GTPS rather than conditions like FAI syndrome or labral tears. 2, 4
Pain with abduction suggests hip abductor tendon pathology (gluteus medius or minimus), which is a core component of GTPS and often presents with weakness of hip abduction and local tenderness over the greater trochanter. 2, 5
Important Diagnostic Caveat
While GTPS is most likely, you must exclude intra-articular pathology through clinical examination:
- Perform the FADIR test (flexion-adduction-internal rotation)—a negative FADIR helps rule out intra-articular hip pathology, though its clinical utility is limited. 6, 1
- Absence of groin pain further supports GTPS over FAI syndrome or labral tears. 1, 3
- Multiple hip conditions can coexist, so remain vigilant for overlapping pathology. 1
Diagnostic Workup
Obtain AP pelvis and lateral hip radiographs as the initial imaging study to exclude alternative diagnoses such as osteoarthritis, fractures, or hip dysplasia. 7, 1
When to Advance Imaging
Order MRI of the hip without contrast if the patient has a Trendelenburg gait or symptoms are refractory to initial conservative treatment—this evaluates for abductor tendon tears (gluteus medius and minimus). 1
Radiographs showing greater trochanter surface irregularities have poor diagnostic accuracy for GTPS (only 24.7% positive predictive value), so do not rely on this finding. 1
Critical Diagnostic Pitfalls
- Never diagnose based on imaging alone—incidental findings are extremely common in asymptomatic individuals, and clinical correlation is essential. 7, 1
- Imaging must be combined with symptoms and clinical signs when making treatment decisions. 6
- Consider referred pain from the lumbar spine or sacroiliac joint, which can mimic lateral hip pathology. 7, 3
First-Line Management
Initiate physical therapy immediately focused on hip abductor strengthening and correction of faulty pelvic mechanics in the frontal plane:
- GTPS has been linked to loss of pelvic control secondary to hip abductor weakness or pain with hip abductor activation. 4
- The majority of patients with GTPS respond well to conservative management. 2
Prescribe NSAIDs for symptomatic relief during the rehabilitation phase. 7, 2
Consider corticosteroid injection if symptoms persist despite physical therapy and NSAIDs:
- Ultrasound-guided corticosteroid injection into the trochanteric bursa provides both diagnostic confirmation and therapeutic benefit. 2, 3
- This is appropriate for chronic symptoms refractory to initial conservative therapy. 2
Medications to Avoid
- Avoid hyaluronic acid injections—these should NOT be used for hip pathology. 7
- Avoid opioids entirely for chronic hip pain. 7
When to Consider Surgical Referral
Refer for surgical evaluation if symptoms remain refractory to at least 3-6 months of conservative management, including physical therapy, NSAIDs, and corticosteroid injection: