Topics in diagnostic imaging
Posterior, Lateral, and Anterior Hip Pain Due to Musculoskeletal Origin: A Narrative Literature Review of History, Physical Examination, and Diagnostic Imaging

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Abstract

Objective

The purpose of this study was to present a narrative review of the literature of musculoskeletal causes of adult hip pain, with special attention to history, physical examination, and diagnostic imaging.

Methods

A narrative review of the English medical literature was performed by using the search terms “hip pain” AND “anterior,” “lateral,” and “posterior.” Additionally, specific entities of hip pain or pain referral sources to the hip were searched for. We used the PubMed search engine through January 15, 2016.

Results

Musculoskeletal sources of adult hip pain can be divided into posterior, lateral, and anterior categories. For posterior hip pain, select considerations include lumbar spine and femoroacetabular joint referral, sacroiliac joint pathology, piriformis syndrome, and proximal hamstring tendinopathy. Gluteal tendinopathy and iliotibial band thickening are the most common causes of lateral hip pain. Anterior hip pain is further divided into causes that are intra-articular (ie, labral tear, osteoarthritis, osteonecrosis) and extra-articular (ie, snapping hip and inguinal disruption [athletic pubalgia]). Entrapment neuropathies and myofascial pain should also be considered in each compartment. A limited number of historical features and physical examination tests for evaluation of adult hip pain are supported by the literature and are discussed in this article. Depending on the clinical differential, the gamut of diagnostic imaging modalities recommended for accurate diagnosis include plain film radiography, computed tomography, magnetic resonance imaging, skeletal scintigraphy, and ultrasonography.

Conclusions

The evaluation of adult hip pain is challenging. Clinicians should consider posterior, lateral, and anterior sources of pain while keeping in mind that these may overlap.

Introduction

Self-reported hip pain is common, afflicting approximately 14% of the population over the age of 60 years.1 Providing a focused differential diagnosis for a chief complaint of hip pain is challenging, and sources may originate around, or within, the bony ring between the lumbar spine and the pubic symphysis. Clinicians need to consider both local and distant osteoligamentous, tendinous, nervous, and muscular anatomy when examining patients with complaints related to the posterior, lateral, or anterior hip. Additionally, myofascial pain syndrome is a common and overlooked cause of pain.2 Genitourinary, gastrointestinal, and vascular pathology should be excluded when examining a patient with hip pain but are beyond the scope of this review.

History and physical examination are crucial in the evaluation of any patient complaint. Unfortunately, the history and physical examination results of a patient with hip pain are typically nonspecific,3 reflecting the complex anatomy of the hip and pelvis and the overlapping organ systems that are included in the differential diagnosis. As such, diagnostic imaging is indispensable in narrowing and arriving at an accurate differential diagnosis that will guide efficient and cost-effective treatment. Therefore, the aim of this review was to provide musculoskeletal differential considerations for posterior, lateral, and anterior hip pain in the adult patient.

Section snippets

Methods

A narrative review of the English medical literature was conducted. For the purpose of organizing hip pain into a clinically useful context, it was subdivided into posterior (ie, ischial), lateral (ie, trochanteric), and anterior (ie, inguinal) locations. Furthermore, myofascial pain was considered separately as a source of hip pain. Randomized controlled trials, cohort and case-control studies, case series, and both systematic and narrative reviews were included. Individual case reports were

Results

The authors selected 116 papers to include in this narrative review.

Discussion

The following is a discussion of posterior, lateral, and anterior hip pain in an adult patient. Myofascial pain is discussed first as a separate entity because it may present in any hip compartment, although the underlying pathophysiology is constant. Additionally, there is limited information on objective clinical examination and imaging findings for the diagnosis of myofascial pain. For these reasons, myofascial pain is discussed separately, with the understanding that it should be considered

Limitations

This was a narrative review and therefore was not a rigorous systematic review; by default, lower-quality studies were included. However, the aim of our work was to present a comprehensive yet practical review of studies on hip pain to serve clinicians in daily practice. Some diagnostic entities (eg, obturator internus tendinopathy) may be important to consider clinically but have been investigated very little and therefore have limited findings on history and physical examination or imaging.

Conclusions

The diagnosis of hip conditions may be challenging for clinicians. Although the history and physical examination are useful, the results are often equivocal. Diagnostic imaging is used routinely to achieve a differential diagnosis and thus increase the specificity, advance a diagnosis, and aid in the development of a prognosis. Furthermore, once a diagnosis is established, imaging may be used to monitor treatment response. This review has presented the diagnostic possibilities of the

Supplementary data

Supplementary data to this article can be found online at doi:10.1016/j.jcm.2016.08.004.

Funding Sources and Conflicts of Interest

No funding sources or conflicts of interest were reported for this study.

Contributorship Information

  • Concept development (provided idea for the research): P.J.B., K.D., N.W.K.

  • Design (planned the methods to generate the results): P.J.B., K.D., N.W.K.

  • Supervision (provided oversight, responsible for organization and implementation, writing of the manuscript): P.J.B., K.D., N.W.K.

  • Data collection/processing (responsible for experiments, patient management, organization, or reporting data): P.J.B., K.D., N.W.K.

  • Analysis/interpretation (responsible for statistical analysis, evaluation, and

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