Clinical evaluation of the painful adolescent and young adult hip

Abstract

The history and physical exam are crucial components of the initial assessment of hip pain in adolescents and young adults to identify the cause of the pain, distinguish between common causes of early degeneration such as femoroacetabular impingement (FAI) and acetabular dysplasia (instability), and guide further workup and management. Different aspects of the history and exam are specific to various common causes of hip pain in this patient population. The purpose of this review is to synthesize these components to provide a comprehensive approach to the history and physical exam for adolescents and young adults presenting with hip pain.

Key concepts: (1)Common signs that suggest a mechanical hip problem, but are not specific for the etiology, include symptoms that worsen with activity, discomfort in a seated position, pain on rising from a seated position, or difficulty with ascending or descending stairs.(2)A Trendelenburg gait is caused by insufficient abductors that are unable to maintain a level pelvis and is commonly associated with hip instability due to the biomechanical disadvantage of the dysplastic hip joint.(3)Obligate external rotation of the hip during hip flexion is concerning for slipped capital femoral epiphysis (SCFE) and warrants an AP pelvis and frog leg lateral view for evaluation.(4)The Prone Apprehension Relocation Test (PART) assesses for anterior undercoverage of the acetabulum, and a positive test has been found to be correlated with radiographic markers of instability.

Keywords: Femoroacetabular impingement; Hip dysplasia; Hip pain; Physical exam; Slipped capital femoral epiphysis.

Figure 1

A patient with a normal left hip but abductor insufficiency of the right hip. In single limb stance, a patient should be able to maintain a level pelvis (left). A positive Trendelenburg sign occurs when hip abductor insufficiency of the stance limb causes a patient’s contralateral hemipelvis to drop away from the stance limb and/or when there is a compensatory trunk lean towards affected hip (right).

Figure 2

Straight leg raise (SLR) test. Radiating pain in a dermatomal distribution along the lower extremity suggests spinal pathology.

Figure 3

Internal rotation (left) and external rotation (right) of hip.

Figure 4

On hip flexion, hip is normally able to maintain neutral alignment (left). With obligate external rotation, hip flexion forces the hip to fall into external rotation, which is concerning for slipped capital femoral epiphysis (SCFE) (right).

Figure 5

Hip is flexed, adducted, and internally rotated (FADIR), with a positive test indicating femoroacetabular impingement (FAI).

Figure 6

Anterior apprehension test. The contralateral hip is flexed, while the affected hip is passively extended and brought into external rotation, producing stress on the anterior capsule and labrum. Pain or apprehension signifies a positivetest for instability.

Figure 7

Prone apprehension relocation test (PART). The affected hip is extended to 10-15° and abducted 10° from midline as the knee is supported in flexion. An anteriorly applied force on the femur reproduces the pain (left). Release of pressure on the femur relieves the pain (right).

Figure 8

Abduction extension external rotation test. The affected hip is abducted to 30°, extended, and externally rotated. Anterior groin pain or apprehension suggests anterior instability.

Figure 9

Assessment for coxa saltans interna. The affected hip is brought from a flexed, abducted, and externally rotated (FABER) position (left) to an extended, adducted, and internally rotated (EADIR) position (right). Reproduction of a snapping sensation indicates coxa saltans.

Figure 10

Ober test with the hip brought into external rotation and abduction. The hip is then allowed to fall into adduction slowly. No restriction to adduction indicates a normal iliotibial (IT) band (left). Restriction to adduction represents a positive Ober test and indicates a tight IT band (right).