Hip pain

Last updated: February 6, 2025

Summary

Hip pain can be a diagnostic challenge due to its diverse etiologies and potential for significant morbidity. It can manifest acutely or gradually and may be traumatic (e.g., fractures, muscle strains, tendon injuries) or atraumatic (e.g., septic arthritis, osteoarthritis). Clinical assessment should include details of the hip pain (e.g., onset, duration, and exacerbating symptoms) and a focused examination of the hip. Most patients presenting with hip pain should be initially evaluated with x-rays of both hip and pelvis, with additional testing based on clinical suspicion. Management is based on the underlying cause.

Etiology

Traumatic ^[1]^[2]^[3]^[4]

Bone injury
- Hip fracture
- Acetabular fracture
- Iliac crest apophysis avulsion
- Ischial apophysis avulsion
- Stress fracture (e.g., proximal femur, pelvic)
Muscle injury
- Avulsion injury (e.g., of gluteal muscle, hamstring)
- Muscle tear (e.g., of gluteal muscle, hamstring)
- Muscle strain (e.g., of hamstring, adductors, obturator internus)
- Obturator internus irritation or strain
- Sports hernia
Tendon or ligament injury
- Flexor tendon tear or strain
- Proximal hamstring tendinopathy
- Inguinal ligament strain
- Ligamentum teres injury
Joint injury
- Hip dislocation
- Tear of the acetabular labrum
- Osteochondritis dissecans

Atraumatic ^[1]^[2]^[3]^[4]

Hip joint pathology
- Avascular necrosis
- Femoroacetabular impingement
- Osteoarthritis
- Rheumatoid arthritis
- Osteomyelitis
- Septic arthritis
- Chondral lesions or loose bodies
- Ischiofemoral impingement
- Hip joint heterotopic ossification
Muscle or tendon pathology
- External snapping hip
- Iliopsoas tendinitis or bursitis
- Iliotibial band friction
- Myositis ossificans
Malignancy
- Gonadal tumors (e.g., ovarian cancer)
- Sarcoma
- Metastasis to the hip ^[5]
Referred pain
- Intra-abdominal (e.g., psoas abscess, inguinal or femoral hernia)
- Intrapelvic (e.g., prostatitis, endometriosis)
Spinal pathology
- Lumbar spinal stenosis
- Disc herniation
- Disorder of lumbar facets
- Sacroiliac joint dysfunction
Nerve involvement
- Piriformis syndrome
- Meralgia paresthetica
- Other nerve entrapment (e.g., obturator nerve)
Pain syndromes
- Greater trochanteric pain syndrome
- Fibromyalgia
Other
- Claudication
- Inguinal lymphadenopathy
- Pubic symphysis dysfunction
- Metabolic bone disease (e.g., osteoporosis)

Hip pain in children ^[6]^[7]^[8]

Infectious
Inflammatory
Trauma and overuse
- Hip fracture
- Hip dislocation
- Muscle strain (e.g., adductor, hip flexors, hamstrings)
- Stress fracture (e.g., femoral neck, pubic rami) ^[9]
- Apophysitis (e.g., iliac crest, ischial tuberosity, ASIS) ^[10]
Developmental
Neoplastic
Vascular: Osteonecrosis of the femoral head

Clinical evaluation

Focused history ^[1]^[2]

Inciting factor or injury
Onset, location, alleviating or aggravating factors
Other localizing pain (e.g., abdominal, back)
Strenuous activities (e.g., sports)
Constitutional symptoms

Focused physical examination ^[1]^[2]

Examination of the hip (e.g., range of motion, palpation, strength testing, provocation tests)
Examination of gait (e.g., for Trendelenburg gait, antalgic gait)
Examination of the abdomen
Examination of the spine
Neurovascular examination as needed to evaluate for femoral artery or sciatic nerve injury
Pelvic examination or DRE as needed to rule out causes of referred pain

Hip joint range of motion FABER (Patrick) test Hip joint anatomy

Diagnostics

Studies are based on clinical suspicion and may include the following:

Imaging studies ^[2]^[11]^[12]

Hip and pelvis x-rays
- For acute traumatic or chronic hip pain
- Views
  - Standing anteroposterior and lateral views of the symptomatic hip
  - Anteroposterior view of the pelvis
MRI pelvis and hip without contrast: for persistent hip pain with normal x-ray findings
CT pelvis and hip without contrast: for patients with contraindications to MRI (timely study)
Ultrasound hip: for joint effusion, bursitis, and tendon abnormalities; to guide joint aspiration
Additional imaging (e.g., CT abdomen, spinal imaging): if extra-articular or referred pain is suspected.

Imaging may not be required for patients with acute hip pain and a clear clinical diagnosis based on history and physical examination.

Laboratory studies ^[4]^[13]

CBC and ESR: assessment for inflammation or infection
Rheumatoid factor, anti-CCP: evaluation for rheumatoid arthritis
Arthrocentesis and joint fluid analysis: for suspected septic arthritis

Common causes in adults

Provide immediate inpatient care to patients with fractures or infection.

Traumatic hip pain in adults

Common causes of traumatic hip pain in adults
Condition	Characteristic clinical features	Diagnostic findings	Management
Hip fracture ^[1]	Typically occurs in older adults Usually due to fall or trauma Symptoms Anterior hip pain Inability to ambulate with the affected leg Examination findings: leg externally rotated, abducted, and shortened	Imaging (e.g., x-ray, MRI): fracture	Pain management Orthopedics consult for surgery See “Initial management of hip fracture” and “Treatment of hip fracture.”
Labral tear ^[1]^[2]	Typically occurs in younger adults, athletes Usually due to: Traumatic or sport-related injury Repetitive motion Symptoms Onset may be acute or insidious. Sharp or dull anterior or groin pain Painful clicking or catching with activity Examination findings: positive FABER test and FADIR test	MRI hip: labral tear	Surgery is considered in athletes.
Sports hernia ^[2]^[14]	Typically occurs in athletes Usually due to complex sports-related injury Symptoms Gradual onset Diffuse, dull anterior groin pain Examination findings: pain exacerbated by Valsalva maneuver, hip flexion, and/or resisted sit-up	MRI pelvis: detachment or tear of adductor longus or rectus abdominis	Conservative management (e.g., rest, analgesics) Surgery in refractory cases
Adductor strain ^[14]^[15]	Typically occurs in athletes Often due to sports-related injury Symptoms Onset is usually acute Anterior groin pain Examination findings Pain with resisted adduction Tenderness of adductor muscle and/or tendon	Clinical diagnosis	Ice Pain management Early mobilization Physical therapy

$Intertrochanteric femoral fracture$

Atraumatic hip pain in adults

Common causes of atraumatic hip pain in adults
Condition	Characteristic clinical features	Diagnostic findings	Management
Osteoarthritis ^[1]^[2]^[13]	Typically occurs in older adults Symptoms Gradual onset of groin pain Worse with activity, e.g., climbing stairs, walking up slopes Antalgic gait Examination findings Groin pain with passive abduction or adduction Abductor weakness Posterior pain with squatting Decreased range of motion on passive internal rotation or adduction	X-ray hip Narrowing of joint space Osteophytes Subchondral sclerosis Cysts	Conservative management (e.g., analgesics, physical therapy) Surgery if indicated See “Treatment of osteoarthritis of the hip and knee.”
Femoroacetabular impingement ^[2]^[16]	Typically occurs in young athletes Symptoms Gradual onset of anterolateral hip pain Pain is worse when standing up from a seated position or getting in or out of a car. Examination findings: positive FADIR and FABER tests	X-ray hip ^[2] Pincer deformity: excessive coverage of the femoral head by the acetabulum Cam deformity: bony exostosis at the femoral head-neck junction Deep hip socket Retroversion of acetabulum	Physical therapy Surgery if indicated
Osteonecrosis of the femoral head ^[2]^[17]	Typically occurs in patients with comorbidities (e.g., sickle cell disease, HIV) or steroid use Symptoms Slowly progressive pain Deep anterolateral hip and groin pain with weight-bearing Swelling and/or limited range of motion Examination findings: positive log roll maneuver	X-ray hip ^[17]^[18] Cystic and sclerotic changes in the femoral head Subchondral collapse Flattening of the femoral head Crescent sign: curvilinear subchondral line in the proximal femoral head MRI hip ^[19] Visualization of the interface between necrotic and viable bone Bone marrow edema, joint effusion May show asymptomatic osteonecrosis of the contralateral hip	Pain management Avoidance of weight-bearing on the affected side Orthopedics consult for surgery See “Treatment of osteonecrosis of the femoral head.”
Greater trochanteric pain syndrome ^[1]^[2]^[20]	Typically occurs in women aged 40–60 years ^[21] Symptoms: lateral hip pain Examination findings Trendelenburg gait Pain with resisted abduction Tenderness over greater trochanter	Usually clinical diagnosis	Conservative management (e.g., NSAIDs, physical therapy) Glucocorticoid injections Surgery in refractory cases
Septic arthritis ^[2]^[22]^[23]	Typically affects patients with risk factors for septic arthritis Symptoms Acute onset Fever Anterolateral joint pain Restricted range of motion Examination findings: pain with movement of the affected joint, guarding	CBC: elevated WBC Elevated ESR and CRP Arthrocentesis WBC count > 50,000/mm³ ^[22] Positive synovial fluid culture See “Synovial fluid analysis.”	Targeted antimicrobial therapy for adults with septic arthritis Orthopedics consult for surgery (e.g., debridement) See “Treatment of septic arthritis.”
Meralgia paresthetica ^[2]^[4]	Typically occurs in individuals with abdominal obesity or conditions that cause increased intra-abdominal pressure (e.g., pregnancy), or those who wear tight clothing and/or belts Symptoms: paresthesia, dysesthesia, and/or pain over anterior or lateral thigh	Clinical diagnosis	Removal of compressive source Weight loss Supportive care (e.g., NSAIDs)

Illustration of right hip radiograph in osteoarthritis Bilateral hip osteoarthritis Bilateral femoral head avascular necrosis Bilateral avascular osteonecrosis of the femoral head

Common causes in children

Common causes of hip pain in children ^[6]^[7]^[8]
Disease	Characteristic clinical features	Distinguishing diagnostic findings	Management
Transient synovitis	3–8 years of age ^[24] Sex: ♂ > ♀ (2:1) URI in recent weeks Typically no fever Transient hip pain	Normal x-ray Effusion on ultrasound that should improve over several days	Conservative therapy only (self-limiting) Pain management in children Rest See “Transient synovitis.”
Septic arthritis	Any age Acute onset of pain and fever Fever > 38.5°C Child may refuse to bear weight.	↑ CRP/ESR WBC > 50,000/mm³ on synovial fluid analysis Effusion on ultrasound Widened joint space on x-ray (but unremarkable in early stages) See “Diagnosis of septic arthritis.”	Empiric antibiotics for children with septic arthritis Therapeutic arthrocentesis Urgent orthopedics consult See “Acute management checklist for septic arthritis.”
SCFE	10–16 years of age ^[25] Acute on chronic dull pain with antalgic gait No fever Vague hip and knee pain See “Clinical features of SCFE.”	X-ray: displacement of the femoral head See “Diagnosis of SCFE.”	Non-weight-bearing Pain management in children Urgent orthopedics referral for surgical stabilization See “Treatment of SCFE.”
LCPD	4–10 years of age ^[7] Insidious onset No fever Vague hip and knee pain (may fluctuate with activity) Can cause the child to limp See “Clinical features of LCPD.”	Early x-ray findings: often normal Late x-ray findings: increased lucency of the femoral head and widened joint spaces See “Diagnosis of LCPD.”	Conservative therapy: limited weight bearing, physical therapy, bracing Surgery (e.g., femoral osteotomy) See “Treatment of LCPD.”
DDH	Asymptomatic during infancy Inability to abduct the hip, hip pain, and limp develop later if uncorrected. See “Clinical features of DDH.”	Ultrasound before 4 months and x-ray after 4 months are diagnostic. See “Diagnosis of DDH.”	Abduction brace (e.g., Pavlik harness, von Rosen harness) Surgical repair See “Treatment of DDH.”

Pediatric hip pathologies often present as referred pain in the knee. Children or adolescents presenting with nonspecific knee pain and no findings suggestive of knee pathology require prompt assessment of the hip.

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Hip pain

Summary

Etiology

Traumatic [1][2][3][4]

Atraumatic [1][2][3][4]

Hip pain in children [6][7][8]