A Narrative Literature Review of History, Physical Examination, and Diagnostic Imaging
Patrick J. Battaglia, DC, Kevin D’Angelo, DC, and Norman W. Kettner, DC, DACBR
J Chiropr Med 2016;15:281-293
Copyright 2016 National University of Health Sciences
JACO Editorial Reviewer: Casey Okamoto, DC
Published: March 2019
Journal of the Academy of Chiropractic Orthopedists
March 2019, Volume 16, Issue 1
The original article copyright belongs to the original publisher. This review is available from: https://ianmmedicine.org ©2019 Okamoto and the Academy of Chiropractic Orthopedists. This is an Open Access article which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Objective: The purpose of this study was to present a narrative review of the literature of musculoskeletal causes of adult hip pain, with special attention to history, physical examination, and diagnostic imaging.
Methods: A narrative review of the English medical literature was performed by using the search terms “hip pain” AND “anterior,” “lateral,” and “posterior.” Additionally, specific entities of hip pain or pain referral sources to the hip were searched for. We used the PubMed search engine through January 15, 2016.
Results: Musculoskeletal sources of adult hip pain can be divided into posterior, lateral, and anterior categories. For posterior hip pain, select considerations include lumbar spine and femoroacetabular joint referral, sacroiliac joint pathology, piriformis syndrome, and proximal hamstring tendinopathy. Gluteal tendinopathy and iliotibial band thickening are the most common causes of lateral hip pain. Anterior hip pain is further divided into causes that are intra-articular (ie, labral tear, osteoarthritis, osteonecrosis) and extra-articular (ie, snapping hip and inguinal disruption [athletic pubalgia]). Entrapment neuropathies and myofascial pain should also be considered in each compartment. A limited number of historical features and physical examination tests for evaluation of adult hip pain are supported by the literature and are discussed in this article. Depending on the clinical differential, the gamut of diagnostic imaging modalities recommended for accurate diagnosis include plain film radiography, computed tomography, magnetic resonance imaging, skeletal scintigraphy, and ultrasonography.
Conclusions: The evaluation of adult hip pain is challenging. Clinicians should consider posterior, lateral, and anterior sources of pain while keeping in mind that these may overlap.
JACO Editorial Summary:
- The article was written by authors from the Department of Radiology, Logan University, Chesterfield, MO, as well as Canadian Memorial Chiropractic College, North York, ON, Canada.
- The purpose of the study was to present a narrative review of the literature of musculoskeletal causes of adult hip pain and provide differential considerations for posterior, lateral, and anterior hip pain in the adult patient.
- The investigative researchers conducted a PubMed search for randomized controlled trials, cohort and case-control studies, case series, and both systematic and narrative reviews regarding common etiologies of musculoskeletal hip pain in adults. Additional searches were conducted for physical examination and diagnostic imaging of the hip. In total, 116 papers were included in the narrative review.
- Classifying hip pain by region (anterior, posterior, or lateral) can implicate certain sources of nociception while ruling out others, narrowing the differential. Such an approach may improve the diagnostic yield of a physical exam.
- In the case of posterior hip pain, it is recommended that the lumbar spine and sacroiliac joint be ruled out as potential sources of nociception. This can be accomplished with McKenzie assessment and sacroiliac joint cluster testing respectively.
- Osteoarthritis (OA) of the femoroacetabular joint (FAJ) may frequently cause posterior hip pain. This contrasts with the popular belief that OA of the FAJ causes mostly anterior hip pain in a “C” sign distribution.
- Myofascial trigger points in the hip girdle and low back musculature may mimic intraarticular hip pathology by referring to the posterolateral or anterolateral hip, medial thigh, or lateral thigh.
- When the history and exam alone are insufficient to form a diagnosis, imaging may be warranted. The differential formulated by classifying a condition into posterior, lateral, or anterior hip pain will inform the clinician’s choice of imaging.
Summary: Diagnosis of hip pain necessitates a thorough history and physical examination to identify not only intraarticular hip pathology, but also neuropathies, myofascial contributors, and somatic referral from the lumbar spine and sacroiliac joints. Classifying a pain condition according to location (posterior, lateral, or anterior hip) may be useful in narrowing the list of differentials, guiding the physical exam, and informing the selection of imaging technique.