Journal of Sport Rehabilitation, 2009, 18, 3-23
© 2009 Human Kinetics, Inc.
Benjamin G. Domb, Adam G. Brooks, and J. W. Byrd
In recent years, a quantum leap has been made in the diagnosis and treatment of nonarthritic hip injuries. This evolution can be attributed in part to better imaging, improved understanding of the anatomy and biomechanics of the hip, and progress in surgical technology and techniques. Among other advances, labral tears and early cartilage damage have been identified as common sources of pain. Furthermore, important etiologies for hip injury have been explained, including femoroacetabular impingement (FAI).These advances have led to a rapid increase in the correct diagnosis of nonarthritic hip pain.
Concurrent with the advances in diagnosis, a revolution in surgical treatment of hip injuries is emerging. Many joint-preserving surgeries including labral debridement or repair and decompression of impinging bone lesions can now be performed arthroscopically. These arthroscopic hip surgeries have provided new options with high clinical success rates for patients with nonarthritic hip pain.
The nonarthritic hip poses a diagnostic dilemma because pain is difficult to localize for both the patient and the clinician. As many as 60% of patients requiring hip arthroscopy are initially misdiagnosed, and in one study these patients remained misdiagnosed for an average of 7 months. With the new body of knowledge involving nonarthritic hip injuries, clinicians have a tremendous opportunity to help such patients arrive at a diagnosis and be successfully treated. A thorough history and physical are extremely important in determining hip pathology, which is exceptionally relevant given current innovations in therapy for hip pathology. Although the hip is frequently overlooked as the original source of pain or pathology, one study demonstrated that clinical assessment can be 98% reliable in detecting the presence of a hip-joint problem.4 Examination of the hip region can be complex, however, because of coexistent pathology, secondary dysfunction, or coincidental findings. For example, hip-joint disease migt coexist with lumbarspine disease. Disorders of the paravertebral muscles can cause soft-tissue instability and irregular tension on the hip,5 and contractures of the iliopsoas and hamstrings can cause back pain.6 In addition, hip pathology might coexist with athletic pubalgia, especially in male athletes. Symptoms of athletic pubalgia require a systematic and reproducible physical examination of the hip with appropriate imaging and diagnostic tests to distinguish pubalgia from intra-articular hip pathology.
Hip-joint disorders often remain undetected for protracted periods of time. In the course of compensating for their symptoms, patients often develop secondary dysfunction. This chronic pathology can lead to symptoms of trochanteric bursitis or chronic gluteal discomfort. The examination findings for the secondary disorders might be more evident and mask the underlying problem with the hip. In addition, there might also be coincidental findings unrelated to disorders of the hip. Snapping of the iliopsoas tendon and iliotibial band is usually an incidental finding without clinical significance, but this snapping can become a source of symptoms or might exist coincidentally with hip-joint pathology.
Myriad structures can create similar or overlapping symptoms. In addition to the joint, the clinician must be cognizant of bone problems, surrounding musculotendinous and bursal structures, circulatory pathology, neurological disorders including numerous small sensory nerves, and even visceral disorders that can refer symptoms to the hip area. To separate these problems this article will detail appropriate evaluation of the hip by history and physical exam, which will consist of inspection, measurements, symptom localization, and muscle-strength and special tests.