From the Division of Sports Medicine, Hip Preservation Program, University of Rochester Medical Center, Department of Orthopaedics & Rehabilitation, Rochester, New York.
The authors have no financial or proprietary interest in the materials presented herein.
Correspondence: Kelly L. Adler, MEd, ATC, 4901 Lac De Ville, Building D, Suite #110, Rochester, NY 14618. E-mail:
Injury assessment of the painful hip in an athletic individual can be a daunting task. Clinical evaluation should first include a thorough history and focused orthopedic examination. The athlete should be queried for any personal or family history of rheumatologic, auto-immune, and connective tissue disorders, because these may accelerate degradation of articular structures and involve periarticular soft tissues.1 By distributing an unregulated cascade of active inflammatory chemical throughout the body, systemic arthropathies can involve joint tissue or adjacent myofascial structures. Important diagnostic clues lie in the onset, location, and duration of an athlete’s symptoms.
Forming an accurate diagnosis can be complex because of the interrelationships between intra-articular joint pathology, periarticular myofascial compensations, and dynamic neuromuscular adaptation. Multiple layers exist within the hip and pelvis; any one of them can be either a primary pain generator or secondary compensatory source of dysfunction (Table 1). Although the location of an athlete’s pain is reflective of the primary pain generator, location alone should not be used to rule out symptomatic pathology arising from adjacent areas. For example, acetabular undercoverage and proximal femoral malalignment may lead to associated structural instability, resulting in increased demand on dynamic stabilizers, most notably the abductors or hip flexors. Snapping of the iliopsoas or iliotibial band may be the only clinical manifestation of a much larger underlying condition. Acetabular dysplasia, in particular, may first present with lateral hip pain due to fatigue overload of the abductor complex, and is often mistakenly diagnosed as trochanteric bursitis. Isolated trochanteric bursitis is uncommon in young athletes, and its apparent involvement should raise suspicion for occult pathology of a structural nature.
Differential Diagnoses of the Young Athletic Hip
Advanced imaging, such as magnetic resonance imaging and computed tomography, has led to improved clinical recognition of intra-articular joint disease. However, the disease context should be well understood because there is a considerable rate of intra-articular pathology and clinically silent femoroacetabular impingement in asymptomatic athletic individuals.2 When the etiology of pain is unclear, confirmation of intra-articular pain source can be identified using an ultrasound-guided intra-articular lidocaine injection, followed by immediate functional testing. A corticosteroid injection may be considered for an in-season athlete to facilitate completion of the season, but is not recommended as a mainstay of treatment.
Recent publications suggest that multi-specialty integrated delivery systems have the potential to optimize value-based health care.3 Within the University of Rochester Medical Center’s Division of Sports Medicine & Hip Preservation, a trusting relationship between the physicians, athletic trainers, and physical therapists, as well as proximity of respective clinics, allows the athletic trainer/physical therapist to conduct a complex patient-specific examination immediately following the injection. In many cases, athletes with subtle hip pain may only experience symptomatic exacerbation with strenuous physical activity. Therefore, the ability of an athletic trainer/physical therapist to conduct a thorough and customized sport-specific functional battery of tests may be necessary to manifest dynamic hip dysfunction.
The athletic trainer/physical therapist guides the athlete through a battery of functional tests to help differentiate which hip tissue might be the source of pain. Post-injection testing includes range of motion assessment, specifically flexion, external rotation, and internal rotation, FABER and FADIR tests, double and single leg squat, and inline jogging. The athlete also performs a simulation of painful activities of daily living (eg, driving, stair climbing, and hill walking), as well as sport-specific and other patient-reported provocative activities. It is recommended that functional testing be completed within 1 hour to maximize diagnostic accuracy and limit confounding variables. This evaluation can be invaluable to the treating physician and help overcome the diagnostic challenges associated with athletic hip pain.
Complete symptomatic resolution during functional testing is highly suggestive of an intra-articular pain source, usually due to chondral, labral, or synovial pathology. A positive response to a diagnostic injection also predicts a favorable prognostic outlook for arthroscopic hip surgery.4 Equivocal or no improvement following an injection indicates that the primary pain generator may be extra-articular, most frequently due to myofascial compensatory overload, or lumbosacral involvement. When the injection does not resolve pain, the physician may consider restructuring the athlete’s conservative treatment program and giving further consideration to alternative pain generators within adjacent segments of the kinetic chain. Surgical procedures are less likely to provide durable symptomatic improvement in the absence of a positive diagnostic injection test.5
Regardless of injection results, in our practice, advanced imaging modalities such as magnetic resonance imaging are still routinely obtained to rule out rare but severe joint pathology such as malignancy, stress fracture, or avascular necrosis. However, for routine diagnostic imaging and real-time dynamic feedback, musculoskeletal ultrasound can supplant more expensive imaging modalities. The addition of a targeted injection at the time of diagnostic ultrasound can provide several diagnostic and therapeutic advantages as described above.
As selection for surgical candidates continues to be optimized through the use of diagnostic lidocaine injections, patient satisfaction and surgical outcomes should improve commensurately. Providing patients with short-term relief allows them to develop realistic expectations regarding the ability of an arthroscopic procedure to correct symptoms and dysfunction.
- Bernstein EJ, Mandl LA. Changing incidence of orthopedic surgery in rheumatic disease: contributing factors. Curr Rheumatol Rep. 2013;15:365. doi:10.1007/s11926-013-0365-8 [CrossRef]
- Gerhardt MB, Romero AA, Silvers HJ, Harris DJ, Watanabe D, Mandelbaum BR. The prevalence of radiographic hip abnormalities in elite soccer players. Am J Sports Med. 2012;40:584–588. doi:10.1177/0363546511432711 [CrossRef]
- Porter ME. Value-based health care delivery. Ann Surg. 2008;248:503–509.
- Byrd JT, Jones KS. Diagnostic accuracy of clinical assessment, magnetic resonance imaging, magnetic resonance arthrography, and intra-articular injection in hip arthroscopy patients. Am J Sports Med. 2004;32:1668–1674. doi:10.1177/0363546504266480 [CrossRef]
- Yoong P, Guirguis R, Darrah R, Wijeratna M, Porteous MJ. Evaluation of ultrasound-guided diagnostic local anaesthetic hip joint injection for osteoarthritis. Skeletal Radiol. 2012;41:981–985. doi:10.1007/s00256-011-1290-4 [CrossRef]
Differential Diagnoses of the Young Athletic Hip
|LOCATION OF PAIN||CLINICAL EXAMINATION||DIFFERENTIAL DIAGNOSIS|
|Anterior hip||Pain with palpation AIIS, ASIS, pelvic brim||AIIS, ASIS, or iliac crest apophysitis, AIIS or ASIS avulsion, AIIS/ subspine impingement|
|Pain with active and/or resisted hip flexion||Muscle strain, IP or proximal rectus tenosynovitis, pain inhibition weakness|
|Positive impingement signs||Groin pain with FADIR/FABER test, FAI (anterior, lateral, posterior), chondrolabral injury, synovitis, IP snapping/impingement|
|Reproducible anterior snapping||IP tenosynovitis and contracture, atraumatic instability, structural malalignment (femoral anteversion, acetabular dysplasia)|
|Loose capsular endpoints||Atraumatic instability, capsular attenuation, physiological laxity, hypermobility condition|
|Tenderness through course of IP or at adductor tubercle||Iliopsoas or adductor tenosynovitis|
|Pain with coughing, sneezing, core activation||Athletic pubalgia/central core dysfunction, inguinal hernia, muscle strain (adductor longus/brevis, pectineus)|
|Lateral hip||Secondary to intra-articular joint pathology||Fatigue overload/tendonitis due to compensation|
|Discomfort with palpation||Trochanteric bursal irritation, abductor overload/tendinopathy, structural insufficiency|
|Positive Ober’s or reproducible lateral snapping||Iliotibial band contracture, gluteus maximus contracture|
|Posterior hip/buttock||Localized sacroiliac joint pain||SI joint dysfunction, secondary pelvic ring dysfunction due to FAI|
|Complaints of deep muscular pain/tightness||Piriformis/short external rotator syndrome, deep gluteal pain syndrome, sciatic entrapment neuritis, ischiofemoral impingement|
|Thigh, lower leg, or foot tingling/numbness||Lumbosacral spinal pathology|