Hip pain

Hip pain is a common complaint encountered in clinical practice and can result from a wide range of musculoskeletal, neurological, and systemic conditions. Proper evaluation is essential to identify the underlying cause and guide appropriate management.

Anatomy of the Hip Joint

Bones and Bony Landmarks

The hip joint is formed by the articulation of the femur and the pelvis. Key bony structures include:

• Femur: Head, neck, greater trochanter, lesser trochanter
• Pelvis: Acetabulum, ilium, ischium, pubis

Articulations

The hip is a ball-and-socket joint, allowing a wide range of motion while providing stability. The acetabular labrum deepens the socket and enhances joint congruence.

Ligaments and Capsule

The hip joint is reinforced by strong ligaments and a fibrous capsule:

• Iliofemoral ligament: Limits hyperextension
• Pubofemoral ligament: Restricts excessive abduction
• Ischiofemoral ligament: Limits internal rotation
• Joint capsule: Encloses the joint and maintains stability

Muscles and Tendons

Muscles surrounding the hip contribute to movement and joint stability:

• Flexors: Iliopsoas, rectus femoris
• Extensors: Gluteus maximus, hamstrings
• Abductors: Gluteus medius, gluteus minimus
• Adductors: Adductor longus, adductor brevis, adductor magnus
• Rotators: Piriformis, obturator internus, gemelli

Nerves and Blood Supply

The hip joint receives innervation and blood supply essential for function and healing:

• Nerves: Sciatic nerve, femoral nerve, obturator nerve
• Arterial supply: Medial and lateral circumflex femoral arteries, obturator artery

Etiology of Hip Pain

Traumatic Causes

• Fractures: Femoral neck fracture, acetabular fracture
• Dislocations: Posterior or anterior hip dislocation
• Muscle or tendon injuries: Strains, tears of hip flexors or abductors

Degenerative Causes

• Osteoarthritis: Cartilage degeneration leading to joint space narrowing
• Avascular necrosis: Loss of blood supply to the femoral head
• Labral tears: Damage to the acetabular labrum causing pain and instability

Inflammatory Causes

• Rheumatoid arthritis: Autoimmune inflammation of the hip joint
• Ankylosing spondylitis: Chronic inflammatory disease affecting the sacroiliac and hip joints
• Septic arthritis: Infection-induced joint inflammation

Infectious Causes

• Osteomyelitis: Bone infection involving the femur or pelvis
• Abscesses: Localized collections of pus around the hip joint

Referred Pain

• Lumbar spine pathology: Herniated disc or spinal stenosis causing radiating hip pain
• Sacroiliac joint disorders: Pain referred from the SI joint
• Intra-abdominal or pelvic sources: Kidney stones, gynecologic conditions

Clinical Presentation

History

A detailed patient history is essential in evaluating hip pain. Key aspects include:

• Onset: Acute versus gradual development of pain
• Duration: How long the pain has been present
• Character: Sharp, dull, aching, or stabbing
• Radiation: Pain radiating to the thigh, knee, or groin
• Aggravating factors: Walking, climbing stairs, weight-bearing activities
• Relieving factors: Rest, medication, positional changes
• Associated systemic symptoms: Fever, weight loss, night sweats, or fatigue

Physical Examination

Physical examination helps localize the source of hip pain and assess functional limitations:

• Inspection: Look for swelling, deformity, muscle atrophy, or asymmetry
• Palpation: Assess tenderness, warmth, or crepitus over the joint and surrounding structures
• Range of motion: Evaluate flexion, extension, abduction, adduction, internal and external rotation
• Special tests:
  • FABER test: Detects hip or sacroiliac joint pathology
  • Trendelenburg test: Assesses hip abductor strength and stability
  • Impingement tests: Identify femoroacetabular impingement or labral pathology

Diagnostic Evaluation

Laboratory Tests

Laboratory investigations can help identify inflammatory or infectious causes:

• Complete blood count (CBC) to detect infection or anemia
• Erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) to assess inflammation
• Rheumatologic markers such as rheumatoid factor and anti-CCP antibodies

Imaging Studies

Imaging is crucial for visualizing structural abnormalities and guiding treatment:

• X-ray: Evaluates joint space narrowing, osteophytes, fractures, and dislocations
• MRI: Detects soft tissue injuries, labral tears, avascular necrosis, and early osteoarthritis
• CT scan: Detailed assessment of fractures and complex bony anatomy
• Ultrasound: Identifies effusions, bursitis, or tendon abnormalities

Other Diagnostic Procedures

• Joint aspiration: Helps diagnose septic arthritis or crystal-induced arthritis
• Diagnostic injections: Local anesthetic injections can confirm the source of pain

Management of Hip Pain

Conservative Management

Initial treatment of hip pain often focuses on non-surgical approaches to relieve pain and improve function:

• Rest and activity modification: Avoid activities that exacerbate pain while maintaining gentle mobility
• Physical therapy: Exercises to strengthen hip muscles, improve flexibility, and correct gait abnormalities
• Pharmacologic therapy: Nonsteroidal anti-inflammatory drugs (NSAIDs), acetaminophen, or short-term analgesics
• Assistive devices: Canes, walkers, or braces to reduce weight-bearing stress on the hip

Interventional Management

For patients who do not respond to conservative measures, minimally invasive procedures may be considered:

• Corticosteroid injections: Reduce inflammation and provide short-term pain relief
• Hyaluronic acid injections: Lubricate the joint and improve mobility in degenerative conditions
• Nerve blocks: Targeted injections to reduce pain transmission from specific nerves

Surgical Management

Surgery is indicated for severe structural damage or refractory pain despite conservative treatment:

• Hip arthroscopy: Labral repair, removal of loose bodies, or treatment of femoroacetabular impingement
• Total hip arthroplasty: Replacement of the hip joint for advanced arthritis or avascular necrosis
• Osteotomy: Realignment of bone to improve joint mechanics
• Fracture fixation: Stabilization of traumatic fractures to restore hip function

Complications and Prognosis

Hip pain can lead to various complications if not properly managed:

• Chronic pain and reduced quality of life
• Decreased mobility and muscle weakness
• Joint instability or deformity in untreated fractures or degenerative disease
• Post-surgical complications such as infection, prosthesis loosening, or dislocation

The prognosis depends on the underlying cause, severity, and timeliness of treatment. Early diagnosis and tailored management typically result in better functional outcomes and pain relief.

Prevention and Lifestyle Modifications

Preventing hip pain involves strategies to reduce joint stress, maintain muscle strength, and minimize risk factors for injury and degeneration.

• Weight management: Maintaining a healthy body weight reduces load on the hip joint and lowers the risk of osteoarthritis.
• Strengthening exercises: Regular exercises targeting hip abductors, extensors, and core muscles improve stability and reduce injury risk.
• Ergonomic and activity modifications: Proper posture, avoiding high-impact activities, and using supportive footwear can prevent excessive strain on the hip.
• Early recognition of risk factors: Addressing underlying conditions such as osteoporosis, arthritis, or prior hip injuries helps prevent progression of pain.

References

1. Netter FH. Atlas of Human Anatomy. 7th ed. Philadelphia: Elsevier; 2019.
2. Standring S. Gray’s Anatomy: The Anatomical Basis of Clinical Practice. 42nd ed. London: Elsevier; 2020.
3. Braddom RL. Physical Medicine and Rehabilitation. 5th ed. Philadelphia: Elsevier; 2016.
4. Heckmann N, Bhatt S. Evaluation and management of hip pain in adults. Am Fam Physician. 2018;98(3):165-174.
5. Lieberman JR, Berry DJ. Hip Disorders and Surgical Management. In: Rockwood and Green’s Fractures in Adults. 9th ed. Philadelphia: Wolters Kluwer; 2020.
6. Harris WH. Etiology and management of osteoarthritis of the hip. J Bone Joint Surg Am. 2017;99(12):1101-1110.
7. Katz JN, Wright EA. Epidemiology and diagnosis of hip disorders. N Engl J Med. 2018;379(7):657-665.
8. Fitzgerald GK, Piva SR. Nonoperative management of hip osteoarthritis. Clin Geriatr Med. 2017;33(1):113-124.
9. Galanis I, Tzurbakis M. Hip joint injections and minimally invasive interventions. Orthop Clin North Am. 2019;50(2):145-156.
10. Charnley J. Total hip replacement by low-friction arthroplasty. Clin Orthop Relat Res. 2017;471:3-8.