Problems involving the hip are some of the most frequently undiagnosed or misdiagnosed conditions. When a patient presents with hip pain, evidence-based chiropractors immediately consider the most probable culprits –like greater throchanteric pain syndrome and osteoarthritis. But what if the diagnosis is not so straightforward? A new paper by Lee (1) identified the four top undiagnosed causes of hip pain.
Here’s a quick summary of each condition’s most essential clinical features to help you catch these elusive problems.
Evidence-based clinicians are wary of hip joint pathology when patients complain of pain in the groin crease, anterolateral thigh, or buttock. Our suspicions grow when patients report difficulty walking steps, transitioning out of a vehicle, or sitting figure-four to tie their shoes. Hip patients will classically describe the location of their pain with the “C” sign, demonstrated by placing their index finger over the anterior aspect of the hip, near their ASIS, and their thumb over the posterior trochanteric region. (2) Clinical evaluation often shows limited hip ROM with pain that intensifies upon FABER test.
But these classic clinical findings paint a broad swath across the hip orthopedic spectrum – in which some diagnoses are harder to spot than others. In patients younger than 50, greater than 85% of hip pain that is undiagnosed or misdiagnosed by primary providers falls into one of the four following diagnoses (1):
1. Femoroacetabular impingement (FAI) (55.3% of missed hip diagnoses)
Femoroacetabular impingement (FAI) is an anatomical mismatch between the head of the femur and the acetabulum, creating abnormal friction in the socket, causing damage to the articular or labral cartilage. There are three subclassifications of FAI, defined by whether the anatomical malformation involves the femoral head (cam), acetabular rim (pincer), or both (mixed).
Illustration reprinted with permission from Kevin Neeld, Endeavor Sports Performance.
Most patients presenting with FAI are young and physically active. (3,4) Although morphologic abnormalities are often present bilaterally, symptoms are usually unilateral. (4) Presenting complaints typically include insidious onset, anterior hip or groin pain. (5,6) The pain is generally described as dull and achy. (7) Symptoms are often exacerbated by prolonged periods of sitting, stair climbing, or stressful activity- including work or sports that require hip flexion and rotation. (6-10)
The quadrant test has high reported sensitivity for FAI. (11) The log roll test is also helpful, particularly for assessing clicking or generalized capsular laxity. The test entails rotating the patient’s straightened lower extremity between full internal and external rotation. (11)
Clinical evaluation of cam-type FAI characteristically demonstrates painfully limited hip flexion and internal rotation. (4,5,12,13) Not surprisingly, FADIR test is the most sensitive indicator for FAI. (2) FABER test is a generalized screening test that is routinely positive (88%) for most causes of hip pathology (14) but is often negative in cam impingement. (15)
2. Hip dysplasia (13.3% of missed hip diagnoses)
Hip dysplasia means that the acetabulum is too shallow to protect the femoral head. This causes excess stress on the joint – ultimately leading to painful degeneration. While more severe cases are detected early in life, the condition is sometimes silent throughout childhood and becomes symptomatic during adolescence or adulthood. Dysplasia is the most common reason for hip OA before age 50 and is the trigger for up to 10% of all hip replacements. (16)
Hip dysplasia frequently goes unrecognized; with most adults seeking three or more opinions before the diagnosis is established. (16) A “limp” is a typical presenting complaint. Additional symptoms of hip dysplasia include pain that increases during sitting, walking, or strenuous activity – sometimes accompanied by “catching” or “popping”. (17) The diagnosis is confirmed by x-rays or advanced imaging.
3. Lumbar spine referral (9.3% of missed hip diagnoses),
It is unlikely that chiropractors miss 9.3% in the lumbar spine referral category. Our minds are trained to think spine first…and second. Most of us are very good at identifying lumbar referral. However, the concept of pain centralization on lumbar directional preference testing is an invaluable tool for nailing referred and radicular presentations.
4. Inflammatory spondyloarthritis (SpA) (7.3% of missed hip diagnoses)
On the contrary, chemically mediated pain is a diagnosis that “mechanical” practitioners sometimes overlook – so we need to be vigilant for findings that suggest inflammatory disease (18):
- Morning stiffness > 30 minutes
- Relief of pain with exercise but not rest
- Awakening because of back pain during the second half of the night
- Alternating buttock pain
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1. Lee YJ, Kim SH, Chung SW, Lee YK, Koo KH. Causes of Chronic Hip Pain Undiagnosed or Misdiagnosed by Primary Physicians in Young Adult Patients: a Retrospective Descriptive Study. J Korean Med Sci. 2018;33(52):e339. Published 2018 Dec 11. doi:10.3346/jkms.
2. Byrd JW. Physical examination. In: Operative Hip Arthroscopy. New York, NY: Springer; 2005:36–50.
3. Banerjee P, Mclean CR. Femoroacetabular impingement: a review of diagnosis and management. Curr Rev Musculoskelet Med 2011;4:23-32.
4. Tannast M, Siebenrock KA, Anderson SE. Femoroacetabular impingement: radiographic diagnosis—what the radiologist should know. Am J Roentgenol 2007;188(6):1540–52
5. Ito K, Leunig M, Ganz R. Histopathologic features of the acetabular labrum in femoroacetabular impingement. Clin Orthop Relat Res 2004;429:262–71.
6. Reid GD, Reid CG, Widmer N, Munk PL. Femoroacetabular impingement syndrome: an underrecognized cause of hip pain and premature osteoarthritis?. J Rheumatol. 2010 Jul;37(7):1395-404. Epub 2010 Jun 1.
7. Dooley PJ. Femoroacetabular impingement syndrome: Nonarthritic hip pain in young adults. Can Fam Physician. 2008;54(1):42–7
8. Ganz R, Parvizi J, Beck M, et al. Femoroacetabular impingement: a cause for osteoarthritis of the hip. Clin Orthop Relat Res 2003;417:112–20
9. Nepple JJ, Brophy RH, Matava MJ, et al. Radiographic findings of femoroacetabular impingement in National Football League combine athletes undergoing radiographs for previous hip or groin pain. Arthroscopy 2012;28(10):1396–403
10. Banerjee P, McLean CR. Femoroacetabular impingement: a review of diagnosis and management. Curr Rev Musculoskelet Med 2011;4(1):23–32.
11. Clohisy JC, Knaus ER, Hunt DM, Lesher JM, Harris-Hayes M, Prather H. Clinical presentation of patients with symptomatic anterior hip impingement. Clin Orthopaedics Relat Res 2009;467(3):638-44
12. Ito K, Minka MA 2nd, Leunig M, Werlen S, Ganz R. Femoroacetabular impingement and the cam-effect. A MRI-based quantitative anatomical study of the femoral head-neck offset. J Bone Joint Surg Br 2001;83(2):171-176
13. Ganz R, Gill TJ, Gautier E, et al. Surgical dislocation of the adult hip. A technique with full access to femoral head and acetabulum without the risk of avascular necrosis. J Bone Joint Surg Br 2001;83: 1119–
14. Schmerl M, Pollard H, Hoskins W. “Labral injuries of the hip: a review of diagnosis and management.” J Manipulative Physiol Ther. 2005;28(8):632
15. Tijssen M, van Cingel R, Willemsen L, de Visser E. Diagnostics of femoroacetabular impingement and labral pathology of the hip: a systematic review of the accuracy and validity of physical tests. Arthroscopy 2012; 28(6):860-71
16. International hip dysplasia institute website. https://hipdysplasia.org/adult-hip-dysplasia/ Accessed 2/16/19.
17. Washington University Orthopedics Department website. https://www.ortho.wustl.edu/content/Patient-Care/3205/Services/Hip-Knee/Adult-Reconstruction-and-Hip-Preservation-Overview/Hip-Dysplasia.aspx Accessed 2/18/19
18. Sembrano JN, Polly DW. How often is low back pain not coming from the back? Spine. 2009;34(1):E27–E32
About the Author
Dr. Tim Bertelsman
DC, CCSP, DACO
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