The Causes of Hip Pain and Differential Diagnosis

Have you experienced difficulty in diagnosing the cause of your hip pain? Femoralacetabular Impingement (FAI) is increasingly being recognized as a cause of this pain, although it is oftentimes misdiagnosed early on and treated for a variety of conditions such as, lumbar spine pain, trochanteric bursitis, iliopsoas tendonitis, sports hernia, osteoarthritis and labral tear. This diagnostic dilemma may be attributed to the complexity of the hip joint, its overlapping and diverse referral pain patterns, and close relationship to the spine.1Also, both types of FAI (Cam and Pincer) have been shown to cause cartilage delamination, labral tears, and have been linked to early osteoarthritis of the hip.2

Common impairments of FAI include: sharp, anterior groin pain in a position of hip flexion, limiting the patients’ ability to tolerate activities like prolonged sitting, squatting, and stair climbing, resulting in both work limitations and decreased social participation.3

History: FAI usually occurs in young and middle-aged adults, typically men, with insidious onset groin pain that may be preceded by minor trauma, although many patients will report no history of any specific precipitating factor.3

Below is a chart that will help guide clinical decisions regarding hip differential diagnosis:

  • Impingement Provocation Test (passive abduction, extension and external rotation) – SN of 97% for posterior inferior labrum4,5
  • Impingement Test (passive adduction, flexion and internal rotation) – SN of 96% for anterior superior labrum3,4,5
  • Less squat depth and altered lumbo-pelvic kinematics4
Labral Tear
  • Thomas Test – SN of 89% and SP of 92%5
  • Corresponding trauma story
  • Severe pain with impingement tests3,5
  • Hip Internal Rotation ROM <15 degrees
  • Hip flexion ROM <115 degrees
  • Age > 50 years
  • Morning hip stiffness < 60 minutes6
Sports Hernia
  • Bilateral adductor test with SP of 93% with a LR+ of 7.77
  • Squeeze test and single adductor test with SP of 91% and LR+ of 4.8 and 3.3 respectively7
Trochanteric Pain Syndrome
  • Single leg stance for 30 seconds – SN of 100% and SP of 97.3%8
  • Resisted External De-rotation Test – SN 88% and SP 97.3%9
  • Pain with palpation of greater trochanter.
Iliopsoas Tendonitis
  • Pain with palpation of iliopsoas and resisted hip flexion
Lumbar Spine
  • Concordant sign with active physiologic movements of lumbar spine4
  • Radicular symptoms9

*** All hip physical examination tests are considered positive if pain or discomfort is present.

Note: Few of the current studies are of substantial quality to dictate clinical decision-making. Currently, only the patellar-pubic percussion test is supported by the data as a stand-alone HPE test. Further studies involving high quality designs are needed to fully assess the value of HPE tests for patients with intra- and extra-articular hip dysfunction.7


  1. Conservative management of femoroacetabular impingement (FAI) in the long distance runner Janice K. Loudon*,1, Michael P. Reiman Physical Therapy Division, DUMC 100402, Duke University, Durham, NC 27709, USA.
  2. McCarthy JC, Nobel PC, Schuck MR, et al. The Otto E. Aufranc Award: the role of labral lesions to development of early degenerative hip disease. ClinOrthop Relat Res 2001 (393): 21. Philippon MJ, Maxwell RB, Johnston TL, et al. Clinical presen-25-37.
  3. Keogh MJ, Batt ME. A review of femoroacetabular impingement in athletes. Sports Med 2008;38:863–78.
  4. Reiman et al. Diagnostic accuracy of clinical tests of the hip: a systematic review with meta-analysis. Br J Sports Med. 2012.
  5. Cook, CE & Hegedus, EJ. Orthopedic Physical Examination Tests: An Evidence Based Approach. Pearson Education; Upper Saddle River, NJ: 2013.
  6. 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.
  7. Verrall GM, Slavotinek JP, Barnes PG, et al. Description of pain provocation tests used for the diagnosis of sports-related chronic groin pain: relationship of tests to defined clinical (pain and tenderness) and MRI (pubic bone marrow oedema) criteria. Scand J Med Sci Sports 2005;15:36–42.
  8. Lequesne, M. et al. Gluteal Tendinopathy in refractory greater trochanter pain syndrome: diagnostic value of two clinical tests. Arthritis Rheum. 2008;59:241-246.
  9. Cleland JA, Flynn TW, Whitman JM. “User’s Guide to the Musculoskeletal Examination Fundamentals for the Evidence-Based Clinician: Evidence in Motion”; 2008.