A detailed pain history with onset, provocative maneuvers/factors, quality, radiation, site, other associated symptoms, and time course is very useful for an initial evaluation. Pertinent family history such as rheumatological disease and other past medical history could also help narrow down the diagnosis.
Physical examination such as a thorough focused hip exam, gait assessment, pelvis exam and lumbar exam can help narrow down on the differential diagnosis.
Radiographic evaluation such as plain x-rays are generally very useful. MRIs can help substantiate soft tissue injuries such as labral tears and synovitis.
Etiology: Pain in the hip region can be caused by many conditions such as trauma, osteoarthritis, trochanteric bursitis, lumbar radiculopathy, sacroilitis, rheumatoid arthritis, aortoiliac arterial insufficiency, septic arthritis, osteonecrosis, primary or secondary bone tumors, etc.
Location: The region of the maximum tenderness aids in narrowing down the differential diagnosis and condition that could be causing the ongoing symptoms.
Lateral hip pain is more commonly observed in patients with trochanteric bursitis, IT band tightness, gluteal medius tendinitis and L4 radiculitis, etc.
Anterior hip pain is often due to primary hip joint pathology. It is further divided into acute onset secondary to labral injury, proximal hip flexor muscle strain. Chronic insidious onset is usually secondary to osteoarthritis. It is worth noting that pain from avascular necrosis or tumor may present with similar symptoms. A condition known as femoral acetabular impingement syndrome produces anterior hip pain that is often worse when the hip is moved to the ends of its range of movement.
Posterior hip and buttock pain can be referred from the lumbar spine, sacroiliac joint region, piriformis syndrome, proximal hamstring pathology such as ischial bursitis.
Work up: Laboratory testing may be indicated for conditions that raise suspicion after a thorough history and physical examination such as rheumatological disease, septic arthritis etc. Lab testing may include CBC, C-reactive protein, ESR, rheumatoid factor, HLA B 27, antinuclear antibodies etc.
Imaging: Plain radiographs such as x-ray should be performed in acute hip pain to exclude fracture, and moderate to severe chronic hip pain for assessment of hip osteoarthritis. MRI or CT may be necessary when history, physical exam findings and plain radiographs are inconclusive.
Diagnostic procedures: Local anesthetic block can be performed at the greater trochanteric bursa, iliopsoas bursa, intra-articular hip joint region, lateral femoral cutaneous nerve block, SI joint region.
Treatment: A thorough history, physical exam findings, radiographic assessment and interpretation can aid in diagnosis and treatment options for patients suffering with hip pain.
Conservative treatment modalities include rest, physical therapy, ice, over-the-counter anti-inflammatory medications such as ibuprofen, Aleve etc.
Diagnostic and corticosteroid injections can be tried for painful conditions such as trochanteric bursitis, gluteus medius bursitis/tendinitis, sacroiliac joint dysfunction, osteoarthritis, labral tears, ischial bursitis, piriformis syndrome etc.
Surgical treatment includes arthroscopic labral repair and total joint arthroplasties.
