CLINICAL

Miguel Fernandez
Peter Wall
John ODonnell
Damian Griffin

Hip pain in young adults

Background
Traditionally, the management of hip pain has been well defined by age groups
such as the limping child and older patients with symptomatic osteoarthritis (OA).
However, young adults (typically aged 1650 years) with persistent hip pain who
do not have OA or a childhood hip disorder have presented a diagnostic challenge
and their management less well defined.

Objective
We present a clinical review intended as a guide for general practitioners to aid
the identification of such patients through focused history taking and examination.
We outline the primary care management and provide guidance on when to refer.

Discussion
Our understanding of the causes of hip pain in young adults has increased
significantly over the last decade. This has led to the recognition that subtle
hip shape abnormalities, termed femoroacetabular impingement, can cause
symptomatic soft tissue damage and may initiate OA. This is important as it now
raises the possibility of identifying and treating young adults with pre-arthritic
symptoms (the at-risk hip).

Keywords
hip pain; femoracetabular impingement; young adult

There is a wide range of possible causes

of hip pain in a young adult (Table 1). A
specific diagnosis of the cause of pain
is important to guide management. It is
now understood that subtle hip shape
abnormalities, termed femoroacetabular
impingement (FAI), can cause soft tissue
damage and may initiate osteoarthritis
(OA).1,2 This understanding raises the
prospect of identifying and treating young
adults with pre-arthritic symptoms.

Assessment
Patients typically present when their hip pain
impairs activities such as work, exercise or
sport. Symptoms suggestive of hip pathology
include localised symptoms (such as catching
sensations), symptoms related to activity or when
going up and down stairs, or symptoms related to
prolonged sitting or standing.

History helps to localise the hip as the source

of pain rather than make a specific diagnosis as
there is significant overlap in symptoms originating
from different structures in and around the hip.
For example, pain and tenderness over the greater
trochanter, buttock or lateral thigh can suggest
trochanteric bursitis, a tear of the gluteus medius
muscle or a snapping hip.3 Patients with FAI most
commonly report groin (88%), lateral hip (67%) and
anterior thigh (35%) pain but may also complain of
buttock (29%), knee (27%) and lower back (23%)
pain.4 Other conditions that present predominantly
with groin pain (eg. osteitis pubis, incipient inguinal
hernia, adductor tendinopathies) have been the
focus of a previous review article5 and are not
addressed here.

Hip examination
The aim of a focused hip examination is to confirm
the hip as the source of symptoms and to exclude
alternative diagnoses such as referred pain
rather than make a definitive diagnosis. Clinical
examination has been shown to have a high
sensitivity (98%) in localising intra-articular hip
pathology but is poor in exactly defining its nature.6

Look
Inspection of the patients standing posture and
gait will reveal any obvious asymmetry in the
musculature or alignment. An antalgic gait (short
stance phase relative to swing phase) reflects pain
on weight bearing and may indicate a painful joint.
The Trendelenberg gait reflects the integrity of the
hip abductor muscles on the side of the standing leg.
The patient can also indicate the site of symptoms.
The patient may have one of the clinical
signs suggestive of intra-articular hip pathology
(Figure 1). Cupping of the greater trochanter in the
trochanteric C-sign7 (Figure 1A), pointing with two
fingers towards the hip joint in the triangulation sign
(Figure 1B) or pointing deep within the groin crease
in the deep pointer sign (Figure 1C. It is important
to note that these signs are commonly reported

REPRINTED FROM AUSTRALIAN FAMILY PHYSICIAN VOL. 43, NO. 4, APRIL 2014 205

CLINICAL Hip pain in young adults

anecdotally rather than being evidence-based and

their sensitivity for detecting intra-articular hip
pathology is not known.

Feel
Palpation may reproduce symptoms over
anatomical landmarks suggestive of extraarticular pain. Pain reproduced by palpation
over the greater trochanter is suggestive of
trochanteric bursitis or a snapping hip (iliotibial
band irritation over the greater trochanter).
Buttock tenderness to palpation suggests
muscular pathology (such as gluteus medius

tear) and tenderness over the psoas tendon

(located lateral to the femoral nerve just below
the inguinal ligament) is suggestive of psoas
tendonitis.

Move
Active range of movement (ROM) will test muscle
integrity. Further assessment of specific muscle
groups should be made where weakness or
pain is identified. Passive ROM assesses the
integrity of the joint and surrounding soft tissues,
a reduction in which suggests FAI or labral/
chondral injury in this patient group.

Table 1. Differential diagnosis of hip pain in young adults

Extra-articular

Intra-articular

Muscles
Abductor muscle injuries
Gluteus muscle tears

Bones
FAI
OA*
AVN*
DDH*
Fractures*
Perthes*
Septic arthritis*

Nerves
Sciatica
Obturator nerve irritation
LFCN irritation
Piriformis syndrome
Tendons
Snapping hip (ITB or iliopoas)
Bursa
Trochanteric bursitis

Soft tissues
Labral tear
Chondral defect
Ligamentum teres injury

Special tests
Special tests are indicated where intra-articular
hip pathology is suspected after exclusion of acute
conditions that require emergency department
referral (eg. septic arthritis, fracture, slipped
upper femoral epiphysis (SUFE), dislocation). The
anterior impingement test (flexion, adduction and
internal rotation; Figure 2) and the FABER test
(flexion, abduction and external rotation; Figure 3)
have the highest sensitivities and specificities
of the special tests available (>0.9) for detecting
intra-articular hip pathology.8 A reproduction of
symptoms, pain and a decreased ROM relative
to the unaffected side represent a positive test
result. Although >90% of patients with FAI will
have a positive anterior impingement and FABER
test, a positive test can indicate intra-articular
hip pathology unrelated to FAI (eg. traumatic
labral tears). These tests are therefore not
diagnostic but aid in identifying intra-articular hip
pathology.

Basic imaging
An anteriorposterior (AP) radiograph of the
pelvis is an essential initial investigation to
exclude fractures, developmental dysplasia

Ligaments
Inguinal ligament strain
Joint capsule*
Referred pain*
Lumbar spine
Knee
Non-musculoskeletal pathology
ITB = iliotibial band, LFCN = lateral femoral cutaneous nerve, FAI = femoroacetabular
impingement OA = osteoarthritis, AVN = avascular necrosis, DDH = developmental
dysplasia of the hip.
*Not covered in this review

Figure 1. Clinical signs often performed by patients with FAI syndrome A) trochanteric
C-sign, B) triangulation sign, C) deep pointer sign

206 REPRINTED FROM AUSTRALIAN FAMILY PHYSICIAN VOL. 43, NO. 4, APRIL 2014

Figure 2. The anterior hip impingement

test. The hip is positioned in flexion,
adduction and internal rotation

Hip pain in young adults CLINICAL

Figure 3. The FABER test (flexion,

abduction and external rotation)

of the hip, avascular necrosis, OA, malignancy

and a missed childhood SUFE. However, for
most conditions described in this review, the
radiograph may be normal or show only subtle
abnormalities that are easily overlooked.9
Figure 4 shows an AP pelvis in a patient with
cam-type FAI. We suggest that additional views
such as a Dunn view or frog leg lateral, and CT
and MRI are best conducted by a specialist.

Hip conditions in young

adults
There are a number of conditions that may
present with hip pain. Trochanteric bursitis
typically presents with tenderness over the
greater trochanter. The snapping hip originates
from either the iliopsoas tendon or the iliotibial
band (ITB). Snapping from the iliopsoas tendon
is often audible and recreated when the hip is
passively moved from flexion, abduction and
external rotation to a position of extension with
internal rotation.7 Snapping from the ITB is more
visible than it is audible and patients often refer
to the sensation of subluxation or dislocation
as the tensor fascia lata snaps back and forth
across the greater trochanter.7 Gluteus muscle
tears typically present with buttock pain, which
is reproduced by palpation, but symptoms may
also include pain over the greater trochanter and
later hip pain. These pathologies can be grouped
as the greater trochanteric pain syndrome in
recognition that symptoms often overlap and are
sometimes linked (eg. trochanteric bursitis due to
a snapping hip).3 Patients typically present with
pain and tenderness over the greater trochanter,
buttock or lateral thigh. The prevalence is 1.8 per
1000 in the general population10 and although
the incidence is thought to be low among young

Figure 4. AP pelvis radiograph showing

cam-type hip shape in FAI (left hip,
red arrow)

adults, this diagnosis should be considered where

the symptoms are activity-related or follow injury.
Neuropathies causing symptoms around the
hip joint include irritation of the sciatic nerve,
obturator nerve and lateral femoral cutaneous
nerve (LFCN) of the thigh. Symptoms include
shooting pains, stinging or numbness, and
neuropathic pain in the nerve distribution. They
typically arise from nerve entrapment, such as
piriformis syndrome and inguinal ligament strain,
causing entrapment of the LFCN of the thigh.
The acetabular labrum is a cartilaginous ring
surrounding the acetabulum and its function is
to increase hip joint stability.11 Labral tears can
arise from FAI, trauma, dysplasia, capsular laxity
and degeneration.12 The ligamentum teres arises
from the transverse ligament of the acetabulum
and inserts into the fovea capitis of the femoral
head. It is thought to provide stability, vascularity,
proprioception, and nociception to the hip joint
and ligamentum teres injury is recognised
as a source of pain from the hip.13 Chondral
defects refer to damage of the mature articular
cartilage, which causes pain and may initiate the
degenerative process of OA.14

FAI
The term FAI describes subtle deformities in
hip shape that cause impingement between the
femoral neck and anterior rim of the acetabulum
during the normal range of functional hip
movement, particularly in flexion adduction and
internal rotation. The impinging surfaces can
irritate and damage the soft tissues of the hip

joint of which most at risk are the acetabular

labrum and the adjacent acetabular cartilage.
Hip shape deformities are classified into three
types:15
1. cam type asphericity of the femoral head;
widening of the femoral neck. The term comes
from the cam-lobes on engine cam-shafts,
which open and close valves by impinging on
the appropriate surface as they rotate
2. pincer type over coverage of the
anterosuperior acetabular wall; a deep socket.
Similar to the tips of pincer forceps
3. mixed type a combination of cam and pincer
deformities.
Cam impingement is more common in young
men, and pincer in middle-aged women. Other
types exist and are related to the orientation of
the acetabulum and femoral neck. We use the
term FAI syndrome to refer to patients with hip
shape abnormalities and symptoms suggestive of
impingement.

What is the prevalence of hip

shape abnormality and FAI
syndrome?
Hip shape abnormalities characteristic of FAI are
quite common in the young adult population.16
In a prospective study of 200 asymptomatic
volunteers aged 2150 years, the prevalence of
cam-type hip shape was found to be 14%.17 The
prevalence of hip shape abnormality is reported
to be higher in asymptomatic athletes than in
the general population and the reasons for this
remain unclear. A prospective study of American
college football players (average age 21 years)
found that 95% of the 134 asymptomatic hips had
at least one radiological sign of cam or pincer
shape18 and in a retrospective review of elite
soccer players, radiographic hip abnormality was
present in 72% of men and 50% of women.19 In
patients with hip pain the prevalence of shape
abnormality is even higher. A retrospective review
of the pelvic radiographs of 157 patients aged
1850 years revealed that 87% were found to
have a hip shape abnormality.9

Why do some people get

symptoms and others do not?
It is not yet understood why some people
develop symptoms (FAI syndrome) and others
do not. It is likely that the mechanism involves a

REPRINTED FROM AUSTRALIAN FAMILY PHYSICIAN VOL. 43, NO. 4, APRIL 2014 207

CLINICAL Hip pain in young adults

non-arthritic hip pain with physical therapy, as

failure to respond to this may well then be used
as an indication to expedite surgery.22
For non-operative care, exercise-based
physical therapy probably has the most evidence
for effect but it is also reasonable to consider a
short course of non steroidal anti-inflammatory
drugs (NSAIDs), activity modification, education
and advice, although limited evidence exists for
this.21,23 Although non-arthritic hip pain is not a
life- or limb-threatening condition, some causes,
particularly FAI, are associated with an increased
risk of OA. Therefore, it is advisable to obtain a
specialist referral/diagnosis in a timely manner
and within 36 months if symptoms do not
improve with conservative management.
Early specialist referral may be indicated
in athletes where the prevalence of hip shape
abnormality has been shown to be substantially
higher than in the general population.18,19 At
present there is no evidence that patients with
asymptomatic incidental findings of FAI benefit
from any intervention, but patient education
regarding presenting early if symptoms develop
is advised.

Specialist assessment
Figure 5. 3-Dimensional reconstructed
CT images of cam-type deformity
(red arrows)

combination of factors: a hip shape abnormality

together with a level and type of activity that
provokes impingement. There may also be a
genetic predisposition to shape abnormality and/
or soft tissue damage in these patients.20 The
natural history of FAI and long-term progression
to OA remain topics of much debate and ongoing
research.

Management in primary
care
Many conditions described in this review
require diagnosis by a specialist. Many of these
conditions respond to a course of non-operative
care, particularly physical therapy, and there is
no evidence that such treatment is harmful.21
Therefore, for young adults with persistent hip
pain it would be reasonable to commence a
course of physical therapy pending a diagnosis.
In many cases the specialist will continue to treat

208 REPRINTED FROM AUSTRALIAN FAMILY PHYSICIAN VOL. 43, NO. 4, APRIL 2014

Patients who attend a specialist will have a

reassessment of their symptoms and clinical
examination. They may also be asked to complete
a validated hip score questionnaire to quantify
their symptoms and monitor changes over time
and treatment response. The specialist may
use more detailed imaging techniques, such as
magnetic resonance arthrography (MRA) and
3-dimensional CT, to diagnose soft tissue and
bony pathology and to plan treatment.
When the diagnosis remains unclear or when
multiple pathologies are suspected, a diagnostic
intra-articular injection of local anaesthetic may
be used. This has been shown to be an indicator
of intra-articular pathology with an accuracy of
90%.6 Three-dimensional surface reconstructed
CT provides the best impression of all aspects
of hip shape and is particularly useful in preoperative planning for FAI surgery (Figure 5).24
Treatments often involve targeted
physiotherapy, which has shown good short-term
outcomes in pain and function for patients with
mild FAI, although there is limited experimental
data.21,25 The therapeutic aims are to increase the

pain-free passive range of movement, improve the

precision of hip motion, avoid hip hyperextension
and femoroacetabular rotation under load, and
to optimise the balance of muscle strength and
length at the pelvis.25
Surgical management may be considered for
extra- and intra-articular hip pathologies when
patients do not improve with non-operative care
and where the symptoms are judged severe
enough to justify the risks of surgery. Trochanteric
bursitis, the snapping hip, and focal isolated
gluteus medius and minimis tendon tears can be
treated effectively with arthroscopic surgery.26,27
Shape-corrective surgery for the treatment
of FAI, as well as soft tissue repairs (eg. labral
repair/reconstruction, microfracture and repair of
ligamentum teres injuries) can be also be carried
out arthroscopically.12,14,28 A growing body of
literature now exists showing favourable shortto-mid-term outcomes of arthroscopic surgery for
FAI in young adult and adolescent populations,
although long-term data are still awaited and
guidelines suggest that such surgery should only
be carried out by specialists with expertise in
arthroscopic hip surgery.29

Key points
Persistent hip pain in young adults should not
be ignored.
Clinical examination and basic imaging are
important to exclude conditions such as
childhood hip disorders, OA, septic arthritis
and fractures.
Commence conservative management
(NSAIDs, activity modification and
physiotherapy) and follow up within 3 months.
Refer patients with persistent hip pain of 36
months duration for specialist review and
further investigation.

Authors
Miguel Fernandez MBBS, MRCS (Eng), PhD,
Academic Clinical Fellow in Trauma and
Orthopaedic Surgery, University Hospitals
Coventry and Warwickshire NHS Trust and
Warwick Orthopaedics, University of Warwick,
UK. [email protected]
Peter Wall MBChB, MRCS (Edin), PhD, Specialty
Registrar in Trauma and Orthopaedic Surgery,
University Hospitals Coventry and Warwickshire
NHS Trust and Warwick Orthopaedics, University
of Warwick, UK

Hip pain in young adults CLINICAL

John ODonnell MBBS, FRACS, FAOrthA,

Associate Professor of Orthopaedic Surgery, St
Vincents Hospital, East Melbourne, VIC
Damian Griffin MA, MPhil, BM BCh, FRCS
(Tr&Orth), Professor of Trauma and Orthopaedic
Surgery, Warwick Medical School, University of
Warwick, UK
Competing interests: John ODonnell has received
payment for Board membership from Smith
and Nephew. He has also received payment for
consultancy from Arthrocare and Medacta, has
grants pending from Arthrocare and has received
royalties from Medacta.
Provenance and peer review: Not commissioned;
externally peer reviewed.

Acknowledgements
The authors would like to thank the Medical
Photography and Illustration Department at
University Hospitals Coventry and Warwickshire
NHS Trust for the production of images included
in this review.
Patient consent was obtained for the publication
of photographs in this review.

References

1. Beck M, Kalhor M, Leunig M, Ganz R. Hip morphology

influences the pattern of damage to the acetabular
cartilage: femoroacetabular impingement as a cause
of early osteoarthritis of the hip. J Bone Joint Surg Br
2005;87:101218.
2. Tanzer M, Noiseux N. Osseous abnormalities and early
osteoarthritis: the role of hip impingement. Clin Orthop
Relat Res 2004;429:17077.
3. Strauss EJ, Nho SJ, Kelly BT. Greater trochanteric pain
syndrome. Sports Med Arthrosc 2010;18:11319.
4. Clohisy JC, Knaus ER, Hunt DM, Lesher JM, HarrisHayes M, Prather H. Clinical presentation of patients
with symptomatic anterior hip impingement. Clin
Orthop Relat Res 2009;467:63844.
5. Braun PP, Jensen SS. Hip pain - a focus on the sporting
population. Aust Fam Physician 2007;36:40603.
6. Byrd JWT, Jones KS. Diagnostic accuracy of clinical
assessment, magnetic resonance imaging, magnetic
resonance arthrography, and intra-articular injection in hip arthroscopy patients. Am J Sports Med
2004;32:166874.
7. Byrd JWT. Evaluation of the hip: history and physical
examination. N Am J Sports Phys Ther 2007;2:23140.
8. Tijssen M, van Cingel R, Willemsen L, de Visser E.
Diagnostics of femoroacetabular impingement and
labral pathology of the hip: a systematic review of the
accuracy and validity of physical tests. Arthroscopy
2012;28:86071.
9. Ochoa LM, Dawson L, Patzkowski JC, Hsu JR.
Radiographic prevalence of femoroacetabular impingement in a young population with hip complaints is
high. Clin Orthop Relat Res 2010;468:271014.
10. Williams BS, Cohen SP. Greater Trochanteric Pain
Syndrome: A Review of Anatomy, Diagnosis and
Treatment. Anesth Analg 2009;108:166270.
11. Ejnisman L, Philippon MJ, Lertwanich P. Acetabular
labral tears: diagnosis, repair, and a method for labral
reconstruction. Clin Sports Med 2011;30:31729.

12. Kelly BT, Weiland DE, Schenker ML, Philippon

MJ. Arthroscopic labral repair in the hip: surgical
technique and review of the literature. Arthroscopy
2005;21:1496504.
13. Bardakos NV, Villar R-N. The ligamentum teres of the
adult hip. J Bone Joint Surg Br 2009;91:815.
14. Wright TM, Maher SA. Current and novel approaches
to treating chondral lesions. J Bone Joint Surg Am
2009;91(Suppl 1):12025.
15. Ganz R, Parvizi J, Beck M, Leunig M, Ntzli H,
Siebenrock KA. Femoroacetabular impingement: a
cause for osteoarthritis of the hip. Clin Orthop Relat
Res 2003;417:11220.
16. Laborie LB, Lehmann TG, Engesaeter IO, Eastwood
DM, Engesaeter LB, Rosendahl K. Prevalence of
radiographic findings thought to be associated with
femoroacetabular impingement in a populationbased cohort of 2081 healthy young adults. Radiol
2011;260:494502.
17. Hack K, Di Primio G, Rakhra K, Beaul PE. Prevalence
of cam-type femoroacetabular impingement morphology in asymptomatic volunteers. J Bone Joint Surg Am
2010;92:243644.
18. Kapron AL, Anderson AE, Aoki SK, et al. Radiographic
prevalence of femoroacetabular impingement in collegiate football players: AAOS Exhibit Selection. ibid.
2011;93:e111.
19. Gerhardt MB, Romero AA, Silvers HJ, Harris DJ,
Watanabe D, Mandelbaum BR. The prevalence of
radiographic hip abnormalities in elite soccer players.
Am J Sports Med 2012;40:58488.
20. Pollard TCB, Villar R-N, Norton MR, et al. Genetic
influences in the aetiology of femoroacetabular
impingement: a sibling study. J Bone Joint Surg Br
2010;92:20916.
21. Wall PD, Fernandez M, Griffin D, Foster N.
Nonoperative Treatment for Femoroacetabular
Impingement: A Systematic Review of the Literature.
PM R 2013;5:41826.
22. Lavigne M, Parvizi J, Beck M, Siebenrock KA, Ganz R,
Leunig M. Anterior femoroacetabular impingement:
part I. Techniques of joint preserving surgery. Clin
Orthop Relat Res 2004;418:6166.

23. Emara K, Samir W, Motasem EH, Ghafar KAE.

Conservative treatment for mild femoroacetabular
impingement. J Orthop Surg (Hong Kong) 2011;19:41
45.
24. Heyworth BE, Dolan MM, Nguyen JT, Chen NC,
Kelly BT. Preoperative Three-dimensional CT Predicts
Intraoperative Findings in Hip Arthroscopy. Clin Orthop
Relat Res 2012;470:1950-57.
25. Hunt D, Prather H, Hayes MH, Clohisy JC. Clinical
Outcomes Analysis of Conservative and Surgical
Treatment of Patients With Clinical Indications of
Prearthritic, Intra-articular Hip Disorders. PM R
2012;4:47987.
26. Voos JE, Rudzki JR, Shindle MK, Martin H, Kelly BT.
Arthroscopic anatomy and surgical techniques for peritrochanteric space disorders in the hip. Arthroscopy
2007;23:1246.e15.
27. Cohen SP, Strassels SA, Foster L, et al. Comparison
of fluoroscopically guided and blind corticosteroid
injections for greater trochanteric pain syndrome:
multicentre randomised controlled trial. BMJ
2009;338:b1088.
28. Wall PD, Brown JS, Karthikeyan S, Griffin D. An
introduction to hip arthroscopy. Part two: indications, outcomes and complications. Orthop Trauma
2012;26:3843.
29. NICE. Arthroscopic femoro-acetabular surgery for
hip impingement syndrome. National Institute for
Health and Clinical Excellence; 2011 Sep. Report
No.: 408. Available at www.nice.org.uk/nicemedia/

REPRINTED FROM AUSTRALIAN FAMILY PHYSICIAN VOL. 43, NO. 4, APRIL 2014 209