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Anterior Hip Pain. Hilary Suzawa, MD Med/Peds August 2005. Hip Pain. Pt with hip pathology c/o pain may point to lateral aspect of proximal thigh, buttock, or groin Pt with lumbar spine pathology c/o pain may also point to thigh, buttock, lower leg BUT do NOT have groin pain.

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anterior hip pain

Anterior Hip Pain

Hilary Suzawa, MD


August 2005

hip pain
Hip Pain
  • Pt with hip pathology c/o pain may point to lateral aspect of proximal thigh, buttock, or groin
  • Pt with lumbar spine pathology c/o pain may also point to thigh, buttock, lower leg BUT do NOT have groin pain
physical exam
Physical Exam
  • Observation
    • Can affected leg bear weight?
    • Posture? Gait? Ability to transfer from lying down to sitting to standing?
    • Height symmetry of iliac crests?
    • Check for leg length discrepancy—
      • Measure from ASIS to medial malleolus.
      • Difference >2 cm should be tx with heel lifts
  • Palpation
physical exam4
Physical Exam
  • Range of motion
    • Passive and active
  • Strength

Internal rotation




External rotation

  • AP and frog leg views
  • Indications for X-ray
    • Painful gait
    • Inability to bear weight
    • Point tenderness at a site of muscular insertion
    • Marked reduced ROM
pediatric hip pain
Pediatric Hip Pain
  • Transient synovitis
    • Most common cause of hip pain in children
    • Acute onset limp and refusal to bear weight or use affected leg
    • Improves over 2-3 days
  • Legg-Calve-Perthes
    • Males age 4-8 years
  • Septic arthritis
  • JIA (formerly JRA)
adolescent hip pain
Adolescent Hip Pain
  • Slipped capital femoral epiphysis (SCFE)
  • Apophyseal Injury
  • Osteoid Osteoma
slipped capital femoral epiphysis
Slipped capital femoral epiphysis
  • Males > females
  • 11-14 years
  • Rapid growth
  • Obesity
  • Present with hip pain, medial knee pain, limp
  • Pain with passive internal rotation of a flexed hip
  • If dx is missed, increased risk of AVN of femoral head and early degenerative arthritis
  • 30-40% of cases are bilateral so must evaluate contralateral leg
  • No weight-bearing and referral to orthopedics
scfe x ray
SCFE X-ray

apophyseal injury
Apophyseal Injury
  • Acute muscle contraction can lead to avulsion of an apophysis (ossification center at the attachment of tendon to bone)
  • Overuse in adults leads to tendonitis but in adolescents leads to apophysitis
  • Localized pain and swelling, weakness, decreased ROM
  • X-ray to check if there is fracture and displacement
apophyseal injury treatment
Apophyseal Injury Treatment
  • Rest, ice
  • Crutches for up to 3 weeks
  • For pain may benefit from heat, electrical stimulation, U/S
  • Rehabilitation—progressive resistance training
  • Limited sports participation 4-8 weeks after injury
  • Competitive sports 8-10 weeks after injury as long as X-ray improved, good strength and ROM, no pain
osteoid osteoma
Osteoid osteoma
  • Benign bone tumor
  • May be dx incidentally on x-ray
  • Bone pain that is characteristically relieved by aspirin
  • Surgical excision for severe refractory cases
adult anterior hip pain
Adult Anterior Hip Pain
  • Disease of the hip
    • Stress Fracture
    • Strains and Tendonitis
    • Osteoarthritis and Inflammatory Arthritis
    • Bursitis
    • Nerve compression
    • Osteitis pubis
    • Acetabular tear
  • Disease of the back that radiates to the hip
  • Male or female GU disease
  • GI disease
  • Vascular structures
stress fracture
Stress Fracture
  • From chronic repetitive forces
  • Absorption of bone > metabolic repair during bone remodeling
  • Stress fractures of the pubic ramus, femoral neck, or proximal femur can cause anterior hip pain
  • Most common in distance runners, jumpers, ballet and aerobic dancers, triathletes
femoral stress fracture
Femoral Stress Fracture
  • Possibility of progression to displacement and osteonecrosis of femoral head
  • Progression of hip pain: occurs late in activity  limits activity  occurs with any weight-bearing or at rest
  • Limited internal rotation of the hip and pain when the pt hops on the affected leg
  • X-ray may show fracture line, or area of lucency, or increased sclerosis
  • Compared with bone scan, MRI has similar sensitivity and improved specificity for stress fractures
femoral stress fracture16
Femoral Stress Fracture
  • Treatment
    • If there is displacement  urgent ORIF
    • If no displacement tx depends on the side of the femoral neck with the fracture
    • Percutaneous fixation is recommended if
      • Fracture line involves >50% of femoral neck OR
      • Fracture involves superior or lateral side of the femoral neck
strains and tendonitis
Strains and Tendonitis
  • Strain=acute injury to a muscle or tendon
    • Violent muscle contraction or stretch leads to pain, swelling, ecchymosis
  • Tendonitis=acute inflammatory tendon changes secondary to overuse
    • Insidious onset of increasing activity intolerance
    • Iliopsoas tendonitis (“internal snapping hip”)—snap or clunk heard as hip moves from flexion to extension b/c of iliopsoas tendon moving medially to laterally across the femoral head
strains and tendonitis18
Strains and Tendonitis
  • Treatment
    • Rest
    • Ice
    • Compression
    • Avoid painful activity
    • Surgery is NOT recommended because muscle tissue not amenable to repair
  • Osteoarthritis is the most common cause of anterior hip pain in patients >50 yrs
  • Fairly steady pain, progressively worse with activity
  • Painful, limping gait
  • Pain worse with full internal rotation and extension of the hip
  • X-ray shows joint space narrowing
    • Normal space is ~4 mm with less than 1 mm difference between sides
  • Treatment
    • Analgesics
    • Exercise
      • Aerobic exercise
      • Flexibility
      • Resistance training
      • Joint ROM
    • Total joint arthroplasty
inflammatory arthritis
Inflammatory Arthritis
  • Seronegative spondyloarthropathies
    • Ankylosing spondylitis, Reiter’s Syndrome, Psoriatic arthropathy, enteropathic arthropathy
  • Crystalline arthropathies
    • Gout, pseudogout
  • Rheumatoid arthritis
  • Septic arthritis
  • Viral arthritis
inflammatory arthritis22
Inflammatory Arthritis
  • Pain worse in the AM and improves with activity
  • Enthesopathy (pain and inflammation at site of muscle insertion)
  • Systemic symptoms (fever, weight loss)
  • Skin or eye symptoms
  • X-ray—absence of osteophytes
  • Elevated ESR or CRP
  • Joint fluid with WBC 2,500-5,000/mm3
  • Tx NSAIDS, exercise, may need anti-rheumatic meds
  • Trochanteric Bursitis
    • Most commonly injured bursa in the hip
    • Caused by falls onto the lateral hip, overuse injuries esp in runners and dancers
  • Bursa over the ischial tuberosity
    • Caused by a fall on the buttock
  • Iliopsoas (iliopectineal bursa)
    • Anterior groin pain that is worse with resisted hip flexion
nerve compression
Nerve Compression
  • Sciatic nerve
    • L4-5, S1-S3
    • Compression by the piriformis muscle
    • Dull ache in the buttock that may radiate down posterior thigh
    • Females >males
    • Spine X-rays to differentiate from nerve root compression in the lumbosacral spine
nerve compression25
Nerve Compression
  • Lateral femoral cutaneous nerve
    • Compressed as it passes under the inguinal ligament, esp in obese patients
    • Meralgia paresthetica
    • Numbness or pain over the anterolateral thigh
osteitis pubis
Osteitis Pubis
  • Pain and bony erosion of the symphysis pubis
  • More common in soccer, rubgy, tennis and ice-hockey players
  • Males > females
  • Pain over the pubic area that radiates laterally across the anterior hip
  • Aggravated by striding, kicking, pivoting
osteitis pubis27
Osteitis Pubis
  • X-rays may show symphysis widening, cystic changes, sclerosis; check “flamingo view”
  • Tx is hip adductor and rotator stretching exercises
acetabular labral tears
Acetabular Labral Tears
  • Activity-related sharp groin and anterior thigh pain that is worse with extension
  • Deep clicking sensation
  • Feel that the hip is “giving way”
  • Sx for >6 months
  • May have clicking palpated on Thomas test
  • Imaging may not be helpful
  • Hip arthroscopy is gold standard
clinical case 1
Clinical Case 1
  • 37 yo WF w/ no PMH presents c/o pain over her left hip and left lateral thigh down to the knee
  • Pain is worse when she gets up from a seated position but then feels better after she takes a few steps
  • However, pain can recur after she has been walking for ~20 minutes
  • Pt likes to run and do yoga
clinical case 130
Clinical Case 1
  • On PE VS are normal
  • Pt’s hip exam shows tenderness over the left lateral greater trochanter
  • Pt also has discomfort with external rotation on the left
clinical case 131
Clinical Case 1
  • What is your leading dx?
  • What tests would you like to order?
    • +/-X-ray
  • What tx would you give?
    • NSAIDS
    • Iliotibial band stretching program
    • Corticosteroid injection into greater trochanteric bursa
clinical case 2
Clinical Case 2
  • 45 yo WF with h/o HTN and DM presents c/o gradual onset of pain in the right thigh and groin area over the past 6 mths.
  • Initially pain was only with walking but now pain occurs at rest.
  • Pt c/o 10 minutes of stiffness when she awakes
clinical case 233
Clinical Case 2
  • VS are normal except pt’s weight is 167 lbs and BMI is 32
  • Pt has an antalgic gait
  • Pt has good strength and reflexes
  • Straight leg raise is negative B
  • ROM of right hip is intact except for loss of internal rotation compared to the left
clinical case 234
Clinical Case 2
  • What is your leading dx?
    • Osteoarthritis
  • What tests would you order?
clinical case 235
Clinical Case 2
  • What treatment would you give?
    • Physical Therapy for exercises and to evaluate need for walking device
    • Acetaminophen or NSAID
    • Total hip replacement
  • O’Kane, J. Anterior Hip Pain. American Family Physician 1999; 60 (6).
  • Adkins, S and Figler, R. Hip Pain in Athletes. American Family Physician 2000; 61 (7).
  • Snider, Robert. Essentials of Musculoskeletal Care 1997.