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Table 3

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

DifferentialClinical Features/Orthopedic TestingDiagnostic Imagingb
Hip OAAnterior or posterior hip pain
Persistent deep groin pain that is worse with activity
Increased pain on internal rotation, and concurrent morning stiffness lasting <60 minutes.
Hip internal rotation of <15° with a coexisting limitation of flexion less than or equal to 115°
Trendelenburg sign, resisted hip abduction, and FABERE tests

FAIMore prevalent in athletes (eg, hockey, soccer, dance, and golf)
Persistent stiffness and intermittent groin pain during early stages
Later stages may reveal sharp pain and mechanical symptoms (ie, catching, locking, instability)
Flexion, adduction, and internal rotation and flexion internal rotation tests have high sensitivity only
Thomas test has high sensitivity and specificity for intra-articular pathology

Acetabular labral tearDifferent types of tears exist (post-traumatic; associated with FAI; capsular laxity/hip hypermobility; dysplasia; and degenerative)
Central groin and peritrochanteric pain more common. Unlikely to present with anterior thigh or ischial pain (compare with OA).
Flexion, adduction, and internal rotation and flexion internal rotation tests have high sensitivity only
Thomas test has high sensitivity and specificity for intra-articular pathology
If clicking, catching, or locking of the femoroacetabular joint occur during testing likelihood of labral tear is increased

Internal snapping hipReproducible snap with hip flexion and concomitant painUS

Stress fractureBoth fatigue and insufficiency stress fractures of the femoral neck, pubic rami, or acetabulum may cause anterior hip pain.
For all stress fractures, a high index of suspicion is paramount for early detection
Femoral neck:
  • • Tension-side femoral neck stress fractures have higher risk of complication
  • • Fatigue-type stress fractures are seen in young, active individuals.
  • • Insufficiency-type stress fractures are seen in older patients with osteoporosis
  • • PPPT and stress fracture (fulcrum) test

Pubic rami:
  • • Presents with anteromedial hip pain
  • • Positive fulcrum, pelvic shear, adductor squeeze, and FABERE tests or pain while standing on the affected limb
  • • Tenderness with direct palpation

  • • Rare compared to femoral neck or pubic rami
MRI; R (specific only); SS

ONFHAssociated conditions (ie, trauma, corticosteroid use, alcoholism), although commonly idiopathic
Deep groin pain accentuated with axial loading of the femur
Evaluate the contralateral hip in nontraumatic cases

Hip joint laxitySeen more commonly in female ballet dancers and gymnasts
Beighton scale may be appropriate to evaluate global hypermobility
Anterior, posterior, lateral hip apprehension tests
Often associated with anterior impingement

Inguinal disruption (athletic pubalgia)Anterior hip pain in an athlete not originating from the femoroacetabular joint
Male athletes more common
Point tenderness over the pubic tubercle and conjoint tendon
Pain exacerbated with a resisted curl-up, resisted hip flexion and/or adduction, and the Valsalva maneuver
Adductor squeeze test performed in 90° of hip flexion demonstrates high sensitivity but low specificity for pubic aponeurosis and adductor pathology
Exclude inguinal hernia

Femoral, obturator, ilioinguinal, and genitofemoral neuropathyConsider if prior hip replacement or inguinal hernia surgery
Neurodynamic testing with the femoral nerve tension test

CTA = computed tomographic arthrography
FABERE = flexion-abduction-external rotation, extension
FAI = femoroacetabular impingement
MRA = magnetic resonance arthrography
MRI = magnetic resonance imaging
OA = osteoarthritis
ONFH = osteonecrosis of the femoral head
PPPT = patellar-pubic percussion test
R = radiography
SS = skeletal scintigraphy
US = ultrasonography.

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