Hip pain affects patients of all ages and increases with time. In fact, up to one in seven older adults will report “significant hip pain on most days.” (1) Regardless of age, hip pain can lead to difficulties with basic activities like sitting and standing, negatively affecting functional capabilities and reducing quality of life. Fortunately, evidence-based chiropractors are proficient in managing most of these patients... provided we accurately diagnose the problem.

This week's blog and video will dive into the crucial aspects of hip evaluation, featuring a comprehensive hip physical exam tutorial to help you elevate your diagnostic skills to the next level! In the next few minutes, you’ll review:

The top tests for differentiating hip vs. lumbar pain
A complete hip exam tutorial video
When to image a painful hip

Watch this micro-webinar on performing a hip physical exam.

What Are The Most Common Hip Diagnoses?

According to the 2021 ChiroUp Network Dataset Analysis of 631,970 clinical diagnoses collected from more than 2,200 evidence-based chiropractic providers, the top three most common hip diagnoses in chiropractic offices were:

Hip abductor weakness
Piriformis syndrome
Gluteal tendinopathy / Greater trochanteric pain syndrome

Providers must consider various other potential diagnoses that can affect the region's bones, joints, cartilage, ligaments, tendons, muscles, and nerves.

Essential Questions To Ask In A Hip Exam

Like most other musculoskeletal complaints, a comprehensive patient history is the primary source of diagnostic information for hip-related issues. Key history questions during a hip pain physical exam include:

Onset - Traumatic onsets can indicate sprains, labral tears, or fractures. Conversely, non-traumatic hip pain emerges slowly and often signals myofascial, degenerative, or systemic conditions. Overuse conditions, notably tendinopathies and neuropathies, frequently stem from a consistent pattern of repetitive microtrauma.
Symptom location and character - Pain location can provide diagnostic clues; however, several etiologies generate a similar pattern of discomfort involving the anterior and lateral hip.

In addition to the standard OPPQRST inquiry, other essential questions include:

Significant stiffness - Hip osteoarthritis patients commonly report morning stiffness. However, if this stiffness exceeds 30 minutes, it may raise suspicion of inflammatory arthropathy. Download the ChiroUp Inflammatory Arthropathy Quick Reference Card for a handy refresher.
Health history - Conditions such as diabetes, thyroid disorders, vitamin D deficiency, psoriasis, and osteoporosis can increase the risk or serve as potential catalysts for various hip-related issues.
Age - Clinicians must be especially aware of a slipped capital femoral epiphysis in children and early adolescents. Femoroacetabular impingement frequently affects young adults. Avascular necrosis often occurs in middle-aged individuals, whereas conditions such as osteoarthritis and insufficiency fractures are more prevalent among seniors.

Want more? Check out this prior blog on The 4 Most Commonly Missed Hip Diagnoses.

How To Perform A Hip Exam

The essential components of a physical exam for hip pain include:

Inspection - swelling, deformity, atrophy
Range of motion - active, passive, and resisted movements
General palpation - tenderness, swelling, warmth, muscle wasting
Joint palpation - stability testing, motion palpation
Orthopedic assessment - specific to the differential diagnoses
Functional assessment - hip abductor weakness, lower crossed syndrome, foot hyperpronation, etc.

Want more? Watch this webinar on identifying underlying functional triggers of Hip Abductor Weakness & Lower Crossed Syndrome.

Neuro eval- dermatomes, myotomes, reflexes
Lumbosacral evaluation - an estimated 71% of hip problems arise from an asymptomatic spine. (2)

How to Differentiate Hip vs. Lumbosacral Pain

Although many hip complaints stem from an asymptomatic lumbar spine, clinicians sometimes incorrectly link hip pain to lumbar problems, missing the true hip issue. The two tests below can assist in identifying hip involvement. (ChiroUp subscribers can access the following links in their Clinical Skills library.

C Sign Hip

A positive C-sign hip pain test strongly suggests a hip-related diagnosis.

FABER Test Hip

The FABER hip test is another generalized screening test that is routinely positive (88%) for most causes of hip pathology. (3)

Gluteal Tendinopathy Test

Gluteal tendinopathy is among the leading causes of hip pain, yet it is frequently overlooked. The following two hip exam tests can aid in diagnosing this condition:

Hip Lag Sign

The Hip Lag Sign demonstrates high sensitivity (89.5%) and specificity (96.6%) for detecting gluteal tendon injury. (4)

Resisted External De-Rotation Test

Likewise, the resisted external de-rotation test claims good sensitivity (88%) and specificity (97%) for gluteal tendon pathology. (5)

Femoroacetabular Impingement Test (FAI Test)

Femoroacetabular impingement, an increasingly recognized diagnosis, is particularly prevalent among young, active individuals. It generally occurs due to an egg-shaped mismatch between the shape of the femoral head and the acetabulum, leading to painful impingement. (Cam-type FAI means the femoral head is misshapen, Pincer-type FAI means the acetabulum is deformed, and Mixed-type means both are misshapen.) The two following FAI tests are useful tools in your FAI testing toolbox.

FADIR Test

The FADIR test will typically provoke cam-type FAI. A negative FADIR test is thought to be most useful for ruling out FAI. (6-9)

Posterior Impingement Test

Hip extension and external rotation often provoke pincer-type FAI during the Posterior Impingement FAI test. (10-11)

Want More Clinical Pearls For Hip Pain?

Listen to the top-rated chiropractic podcast 😊 on A Chiropractic Approach to Hip Pain or Deep Gluteal Syndrome.
Check out the top-rated chiropractic blog 🤩 on What Causes Hip Pain, detailing 6 of the most common culprits. Or the related blog on The Most Common Cause Of Hip Pain, highlighting the most prominent cause: Gluteal Tendinopathy.

Pro Tip: ChiorUp subscribers can download exam templates for a hip exam (or any other region) by visiting the Practice Resources forms library and then selecting Clinical/ Regional exam forms.

When To Image The Hip

Guidelines, including the American College of Radiology (ACR) Appropriateness Criteria for Acute and Chrinic Hip Pain, suggest which imaging tests are most suitable for diagnosing acute and chronic hip pain. (12,13)

Imaging Acute Hip Pain

X-rays of the hip and pelvis are prioritized to rule out fractures, especially after a fall or minor injury. (12)
A hip radiographic study commonly consists of an anteroposterior (AP) view (in hip internal rotation) and either a cross table or externally rotated frog-leg lateral view. (14)
If X-rays are unclear but a fracture remains a concern, a non-contrast MRI or CT scan of the pelvis and hip should be considered. (12)

Imaging Chronic Hip Pain

X-rays are often the starting point, but they mainly help identify osteoarthritis, a frequent culprit. (13)
Depending on the patient's specific situation and the provider’s clinical suspicion, other imaging techniques like MRI may be warranted to delve deeper into less common causes of chronic hip pain. (13)

MRI Considerations

Magnetic resonance imaging (MRI) is more sensitive to detect joint effusion/synovitis, cartilage, labral, and bone marrow lesions. (15)
MRI is the gold standard imaging for evaluating the articular cartilage and the chondrolabral complex in the prearthritic painful hip. (16)

Does Hip Arthritis Cause Pain?

Positive imaging findings in musculoskeletal conditions, including hips, often do not always align with patient symptoms. This discrepancy highlights the need for providers and patients to focus beyond visual assessments and address the functional deficits contributing to both pain and degeneration.

“Structural [hip] joint changes are frequent in asymptomatic population and neither radiographs nor MRI have shown a good correlation with pain and functional impairment.” (15)
“The prevalence [of osteoarthritis] among pain-free hips was substantial. Therefore, radiographs provided little assistance with help to identify patients with hip OA among patients who recently presented with hip complaints.” (17)

Pro Tip: ChiroUp subscribers can use the Dysfunction, Degeneration & Pain infographic to quickly educate patients about the dis-relationship between imaging findings and pain. (Search the title in your forms library.)

Ready to Up Your Game One More Notch?

Now that you’ve got the lowdown on the essential tests for diagnosing hip pain, it’s time to take that knowledge and run with it. ChiroUp subscribers can dive into the Clinical Skills tab for step-by-step tutorials on all the related best-practice treatments, exercises, and ADL advice that your patients need.

Not a subscriber yet? Here’s your chance to see just how straightforward accessing and sharing resources can be. We’re talking lay-friendly condition descriptions and exercise demos that you can pull up in a snap—actually, four clicks to be precise. Check out this video on how to whip up fully customized condition reports for your patients in seconds. It’s a game-changer!

Take a test drive today and join us on our journey to make our shared profession the undeniable best choice for patients and payors.

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1. Christmas C, Crespo CJ, Franckowiak SC, Bathon JM, Bartlett SJ, Andersen RE. How common is hip pain among older adults. J Fam Pract. 2002 Apr 1;51(4):346-8. Link
2. Rosedale R, Rastogi R, Kidd J, Lynch G, Supp G, Robbins SM. A study exploring the prevalence of Extremity Pain of Spinal Source (EXPOSS). Journal of Manual & Manipulative Therapy. 2020 Aug 7;28(4):222-30. Link
3. Schmerl M, Pollard H, Hoskins W. Labral injuries of the hip: A review of diagnosis and management. Journal of Manipulative and Physiological Therapeutics. 2005 Oct 1;28(8):632-e1. Link
4. Kaltenborn A, Bourg CM, Gutzeit A, Kalberer F. The Hip Lag Sign-prospective blinded trial of a new clinical sign to predict hip abductor damage. PLoS one. 2014 Mar 12;9(3):e91560. Link
5. Lequesne M, Mathieu P, Vuillemin-Bodaghi V, Bard H, Djian P. Gluteal tendinopathy in refractory greater trochanter pain syndrome: diagnostic value of two clinical tests. Arthritis Care & Research. 2008 Feb 15;59(2):241-6. Link
6. Shanmugaraj A, Shell JR, Horner NS, Duong A, Simunovic N, Uchida S, Ayeni OR. How Useful Is the Flexion-Adduction-Internal Rotation Test for Diagnosing Femoroacetabular Impingement: A Systematic Review. Clinical journal of sport medicine: official journal of the Canadian Academy of Sport Medicine. 2018 Mar. Link
7. Pålsson A, Kostogiannis I, Ageberg E. Combining results from hip impingement and range of motion tests can increase diagnostic accuracy in patients with FAI syndrome. Age (years). 2020 Apr 25;36:9. Link
8. Shanmugaraj A, Shell JR, Horner NS, Duong A, Simunovic N, Uchida S, Ayeni OR. How Useful Is the Flexion–Adduction–Internal Rotation Test for Diagnosing Femoroacetabular Impingement: A Systematic Review. Clinical Journal of Sport Medicine. 2020 Jan 1;30(1):76-82. Link
9. Wong SE, Cogan CJ, Zhang AL. Physical Examination of the Hip: Assessment of Femoroacetabular Impingement, Labral Pathology, and Microinstability. Current Reviews in Musculoskeletal Medicine. 2022 Feb 16:1-5. Link
10. Ganz R, Gill TJ, Gautier E, Ganz K, Krügel N, Berlemann U. Surgical dislocation of the adult hip: a technique with full access to the femoral head and acetabulum without the risk of avascular necrosis. The Journal of bone and joint surgery. British volume. 2001 Nov;83(8):1119-24. Link
11. Khanduja V, Villar RN. The arthroscopic management of femoroacetabular impingement. Knee Surg Sports Traumatol Arthrosc. 2007 Aug;15(8):1035-40.
12. Ross AB, Lee KS, Chang EY, Amini B, Bussell JK, Gorbachova T, Ha AS, Khurana B, Klitzke A, Mooar PA, Shah NA. ACR appropriateness criteria® acute hip pain-suspected fracture. Journal of the American College of Radiology. 2019 May 1;16(5):S18-25. Link
13. Jawetz ST, Fox MG, Blankenbaker DG, Caracciolo JT, Frick MA, Nacey N, Said N, Sharma A, Spence S, Stensby JD, Subhas N. ACR appropriateness criteria® chronic hip pain: 2022 update. Journal of the American College of Radiology. 2023 May 1;20(5):S33-48. Lin
14. Gold GE, Cicuttini F, Crema MD, Eckstein F, Guermazi A, Kijowski R, Link TM, Maheu E, Martel-Pelletier J, Miller CG, Pelletier JP. OARSI clinical trials recommendations: hip imaging in clinical trials in osteoarthritis. Osteoarthritis and Cartilage. 2015 May 1;23(5):716-31. Link
15. Mourad C, Vande Berg B. Osteoarthritis of the hip: is radiography still needed?. Skeletal Radiology. 2023 Nov;52(11):2259-70. Link
16. Weber AE, Jacobson JA, Bedi A. A review of imaging modalities for the hip. Current reviews in musculoskeletal medicine. 2013 Sep;6:226-34. Link
17. Rondas GA, Macri EM, Oei EH, Bierma-Zeinstra SM, Rijkels-Otters HB, Runhaar J. Association between hip pain and radiographic hip osteoarthritis in primary care: the CHECK cohort. British Journal of General Practice. 2022 Oct 1;72(723):e722-8. Link

Mastering the Hip Exam: Top Tests for Hip Pain