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Table 1

Differential Diagnosis, Clinical Features, Orthopedic Testing, and Diagnostic Imaging for an Adult Presenting With Posterior Hip Paina

DifferentialClinical Features/Orthopedic TestingDiagnostic Imagingb
Femoroacetabular pathologyUnder-recognized cause of posterior hip pain
Consider especially if posterior pain presents with concomitant anterior hip pain or if posterior pain is exacerbated with hip motion
MRA (labral tear); MRI; R

Spinal or SIJ pathologyCentralization of symptoms with repeated spinal movement favor spinal involvement and should be done to exclude spine referral
Composite testing of positive thigh thrust, distraction, compression, sacral thrust, and Gaenslen test favors SIJ origin, especially when symptoms are not reproduced with spinal movement

Proximal hamstring tendinopathyPrevious hamstring injury, pain with activity, and pain while seated
Symptoms may mimic sciatica
Active, passive, and resisted range of motion tests and tenderness with palpation

Sacral stress fractureFatigue fracture:
  • • Common in athletes, especially female athletes with RED-S
Insufficiency fracture:
  • • Osteoporotic females most at risk
Positive fulcrum, pelvic shear, adductor squeeze, and FABERE tests or pain while standing on the affected limb Tenderness with direct palpation Mimics other hip pathologies including sciatica
MRI; R (specific only); SS

Piriformis syndromeTenderness with palpation of the muscle
Positive Freiberg sign, Pace sign, Beatty sign, and FADDIRc test
Primarily used to exclude other sources of hip pain

Obturator internus/gemelli complex tendinopathySimilar HPE features for piriformis syndromePrimarily used to exclude other sources of hip pain

Ischiofemoral impingementOften presents with concomitant anterior hip painMRI

Sciatic neuropathyTypically there is a history of total hip arthroplasty
Neurodynamic testing using the straight leg raise

Pudendal neuropathyAccompanying perineal pain
Symptoms elicited with palpation of inferomedial sciatic notch/ischial spine
Passive internal and external rotation of the hip and resisted hip abduction and adduction at 90 degrees of hip extension may elicit symptoms
CTA = computed tomographic arthrography
FABERE = flexion-abduction-external rotation, extension
FADDIR = flexion-adduction-internal rotation
HPE = history and physical examination
MRA = magnetic resonance arthrography
MRI = magnetic resonance imaging
R = radiography
RED-S = relative energy deficiency in sport
SIJ = sacroiliac joint
SS = skeletal scintigraphy
US = ultrasonography.

a Myofascial pain syndrome should be considered in each compartment.
bDiagnostic imaging recommendations discussed in the manuscript are listed in alphabetical order and not in order of utility.