This document provides a literature review on differential diagnosis of hip pain. It begins with an overview of hip structure and function. Common causes of hip pain are then discussed, including arthritis, traumatic injuries, vascular disorders, developmental issues, and other soft tissue injuries around the hip joint. For each condition, the document describes definitions, causes, clinical features, diagnosis methods where relevant. Case studies on osteoarthritis, rheumatoid arthritis, and developmental dysplasia of the hip are also summarized. The review provides a comprehensive guide to differential diagnosis of hip pain covering multiple pathologies.

1. REVIEW OF LITERATURE
BY
RUTUJA M. PATHARKAR
1st YEAR MPT
DEPARTMENT OF ORTHOPEDIC MANUAL THERAPY
1

2. DIFFERENTIAL DIAGNOSIS OF
HIP PAIN
2

3. CONTENT
 Structure and Function of Hip.
 Introduction
 Hip Arthritis
 Femoroacetabular impingment
 Iliopsos Bursitis
 Ischiofemoral impingement
 Hip Dislocatiom
 Labral Tear
 Hip Pointer syndrome
 Osteonecrosis
 Legg-Calvé-Perthes disease (LCPD)
 Developmental dysplasia of hip 3

4.  Hamstring muscle strain
 Greater trochanteric pain syndrome
 Piriformis syndrome
 Trochanteric bursitis
 Hip Fractures
 References
4

5. HIP STRUCTURE AND FUNCTION
 The hip joint is a ball and
socket joint that is the point of
articulation between the head of
the femur and the acetabulum of
pelvic bone
 Primary function of the hip joint is
1. To provide dynamic support to
the body/trunk
2. Force and load transmission
from the axial skeleton to the
lower extremities
3. Allowing mobility
5

6. INTRODUCTION
 Hip pain is common in adults of all ages and activity
levels.
 Hip pain is often localized to one of three locations:
anterior, lateral, or posterior
 A focused history and physical examination can
help differentiate the cause of pain.
6

7. 7

8. ANTERIOR LATERAL POSTERIOR
Osteoarthritis Greater trochanteric pain
syndrome
Piriformis syndrome
Rheumatoid Arthritis
Femoroacetabular impingement
(FAI)
Gluteal muscle tear or avulsion Hamstring muscle
strain/avulsion
Legg-Calve-Perthes disease
Hip labral tear Femoroacetabular impingement
(FAI)
Ischiofemoral
impingement
Iliopsoas bursitis (internal
snapping hip)
Osteonecrosis Hip dislocation
Septic arthritis
Hip pointer syndrome
Developmental dysplasia
8

9. HIP ARTHRITIS
1. Osteoarthritis
2. Rheumatoid arthritis
3. Septic arthritis
9

10. Osteoarthritis Rheumatoid
arthritis
Septic arthritis
Definition A degenerative disorder of
cartilage by breakdown
results from mechanical
overload, causing
secondary bony and
synovial changes
Rheumatoid
Arthritis is an
autoimmune disease
that causes
inflammation in
joints.
Septic arthritis is
usually caused by
bacteria, virus or
fungus. The condition is
an inflammation of a
joint that's caused by
infection.
Causes 1. Idiopathic/unknown
2. Previous trauma
Auto-immunity
Idiopathic
Bacteria
Fungus
virus
Risk
Factors
I. Older age
II. Obesity
III. Repetitive stress
Family history
Smoking
obesity
Open wound
Weak immune system
Previous surgery
Symptoms Severe pain
Morning stiffness
Pain at rest
Joint locking
Joint instability
Morning stiffness
Low grade fever
Restricted motion
Severe pain
Swelling
Decreased strength
Functional loss
Fever , chills
Fatigue
Restricted motion
Severe pain
Swelling
warmth
10

11. OA RA Septic arthritis
Systemic
involvement
none present Present
Lab tests No findings Positive RA factor
Increased ESR and crp
ESR->30 mm/h in a
women and>20
mm/h in a men
CRP->3.0mg/l
RA factor->20 units/lit
Increased ESR
and crp
ESR->30 mm/h
women
>20mm/ men
CRP->10mg/lit
X-Ray
findings
Grade wise
visible changes
seen
Changes seen visibly Seen in late
stages
Diagnosis Best diagnosed
with radiological
findings
Best diagnosed with
radiological with lab
findings
Best diagnosed
with radiological
with lab findings
11

12. Osteoarthritis
Septic arthritis
Rheumatoid arthritis
12

13. 13

14. Title Methodology Result and Conclusion
•Association of
hip pain with
radiographic
evidence of hip
osteoarthritis:
diagnostic test
study
•Authors-Chan
Kim,Michael C
Nevitt et.al
•Journal-The
Journal of
biomechanics
•In this diagnostic test study, 946
pelvic radiographs were assessed
for hip osteoarthritis
•Using visual representation of
the hip joint, participants reported
whether they had hip pain on
most days and the location of the
pain
• (n=946), For the assessment of
symptoms, participants filled out a
questionnaire on the presence
and frequency of joint symptoms.
•location of the pain: anterior,
groin, lateral, buttocks, or low
back
•Study showed that pain was
not present in many hips with
evidence of osteoarthritis on
radiography, and many
painful hips did not show
radiographic evidence of hip
osteoarthritis.
•Most older participants
highly suspected of having
clinical hip osteoarthritis (both
groin or anterior pain and/or
painful internal rotation) did
not have radiographic hip
osteoarthritis
•suggesting that many older
people with hip osteoarthritis
might be missed if
diagnosticians relied on hip
radiographs. 14

15. Title Methodology Conclusion
•Rheumatoid Arthritis
and Bone Mineral
Density in Elderly
Women
•Authors-Nancy E.
Lane, Alice R.
PRESSMAN Et.Al
•Journal-journal of
Bone And Mineral
Research
• The purpose of this
investigation was to determine
the association of RA and
BMD from a community-based
sample of ambulatory
Caucasian women age 65 and
over.
•BMD was measured by dual-
energy X-ray absorptiometry
(DXA) at the hip and lumbar
spine
•Study subjects included 120
postmenopausal women with
RA who were further classified
according to corticosteroid
use, i.e., never users, current
users, and ex-users, and 7966
age-similar controls.
•Women with RA who were
current users of steroids had
the lowest BMD at both
appendicular sites and at the
hip
• Those who never used
steroids had a significantly
moreBMD at all sites.
•Prevention of disability and
avoidance of long-term
steroid use may decrease
the risk of fractures in elderly
women with RA.
•These findings support the
need for good rheumatologic
care to prevent functional
disability in persons with RA
and the need for judicious
use of steroids to reduce the
incidence of osteopenia and
fractures
15

16. TRAUMATIC HIP PATHOLOGIES
1.Hip dislocation-
I. Anterior hip dislocation
II. Posterior hip Dislocation
2.Labral tear
I. Anterior labral tear
II. Posterior Labral tear
3.Hip pointer syndrome
16

17. Labral tear Hip dislocation
Definition A hip labral tear is an injury to the
labrum, the soft tissue that
covers the acetabulum (socket)
of the hip.
A hip dislocation is when
the thighbone (femur)
separates from the hip bone
(pelvis)
Causes Direct trauma
Sports injury
twisting movements
Trauma
Chronic hip instability
Signs Pain
Locking /catching hip
Pain aggravate on activity
Pain
Swelling
Tenderness
Decreased muscle power
Immobility
Site and type of pain Anterior or posterior aspect
Dull aching pain
Pain on activity
Anterior or posterior
Continues pain
Vascular complication No vascular complication Can lead to avascular
necrosis
17

18.  a
Labral tear Hip dislocation
18

19. HIP POINTER SYNDROME
 A hip pointer is a contusion of the iliac crest and/or the greater trochanteric
region of the femur following a direct impact or striking.
 Causes-
 A hip pointer is usually caused by a direct blow or a fall striking the iliac crest or
greater trochanter.
 Most commonly, patients present with varying degrees of ecchymoses or
contusion around the area of impact.
Clinical features-
 The patient will be tender directly over these areas, and
 Often range of motion (ROM) about the hip is limited secondary to pain.
19

20. VASCULAR DISORDERS
1.Osteonecrosis
2. Legg-Calvé-Perthes disease (LCPD),
20

21. OSTEONECROSIS Legg-Calvé-Perthes disease
(LCPD),
Definition Necrosis of femoral head seen in
adults
Idiopathic osteonecrosis of the
femoral epiphysis seen in children.
Age and
onset
At any age but more between the
ages of 40 and 65.
present in children 2-13 years of age.
The average age is 6year
Causes  Blood supply to the femoral head is
disrupted
Fracture of neck of femur
 Trauma
 Idiopathic
Chronic alchoholic
Steroid use
The cause not known.
disrupt blood flow to the femoral
epiphysis, e.g. trauma (macro or
repetitive microtrauma),
 Coagulopathy.
Thromobophilia
Clinical
features
Bilateral pain with increasing frequency
Pain in hip while walking and standing
Painful hip ROM.
Contracture and shortening of lower
limb in late stage.
Decreased ROM
Pain referred to the anteromedial
thigh and/or knee.
Atrophy of thighs and buttocks from
pain leading to disuse.
Limb length discrepancy 21

22. Osteonecrosis Legg-Calvé-Perthes disease (LCPD),
22

23. DEVELOPMENTAL DYSPLASIA OF THE HIP
 DDH (developmental dysplasia of the hip ) is a disorder that occurs due to
abnormal development of acetabulum with or without hip dislocation.
 Multifactorial in nature, a combination of genetic, environmental, and
mechanical factors plays a role
 Causes-
1. Hormonal
2. Breech position.
3. Family history: Many genes have postulated in the Asian population: COL2A1,
DKK1, HOXB9, HOXD9, WISP3.
4. Swaddling in the adducted and extended position explains the increased
incidence.
Diagnosis-
Barlow and Ortolani manoeuver.
(video)
23

24. 24

25. Title Methodology Conclusion
•Clinical application
of artificial
intelligence- assisted
diagnosis using
anteroposterior pelvic
radiographs in
children with
developmental
dysplasia of the hip.
•Authors-S- C.
Zhang, J. Sun et.al
•Journal-The bone
and joint Journal
•Aim was to develop an anteroposterior
pelvic radiograph deep learning system
for diagnosing ddh in children and
analyze the feasibility of its application.
•Total, 10,219 anteroposterior pelvic
radiographs were retrospectively
collected, Clinicians labelled each
radiograph using a uniform standard
method.
•Radiographs were grouped according
to age and into ‘dislocation’ (dislocation
and subluxation) and ‘non- dislocation’
(normal cases and those with dysplasia
of the acetabulum) groups based on
clinical diagnosis.
•The deep learning system was trained
and optimized using 9,081 radiographs;
1,138 test radiographs were then used
to compare the diagnoses made by
deep learning system and clinicians.
•The deep learning
system was highly
consistent, more
convenient, and more
effective for diagnosing
ddh compared with
clinician- led diagnoses.
•Deep learning systems
should be considered for
analysis of
anteroposterior pelvic
radiographs when
diagnosing DDH.
• The deep learning
system will improve the
current artificially
complicated screening
referral process.
25

26. INJURIES AROUND HIP JOINT
 Trochanteric bursitis
 Piriformis syndrome
 Femoroacetabular impingment
 Iliopsos bursitis
 Hamstring muscle strain
 Greater trochanteric pain syndrome
 Ischiofemoral Bursitis
26

27. Trochanteric bursitis
27

28. Piriformis syndrome Trochanteric bursitis
Definition Piriformis syndrome occurs due to
sciatic nerve entrapment at the level
of the ischial tuberosity
Trochanteric bursitis is
inflammation of the bursa (fluid-
filled sac near a joint) at the
greater trochanter.
Causes Trauma
Piriformis hypertrophy
Sitting for prolonged periods
Injury
Overuse
Long term sitting
Clinical
Features
Chronic pain in the buttock and hip
area
Pain when getting out of bed
Inability to sit for a prolonged time
Pain in the buttocks that is
worsened by hip movement
Pain at rest
Pain hip and thigh or in the
buttock.
Pain lying on the affected side
Pain with walking up stairs.
Pain on activity
Special test FAIR test Ober’s Test
28

29. GLUTEAL MUSCLE AVULSION OR TEAR
 A gluteal muscle strain is a stretch or partial tear of the muscle
or tendon
 A gluteal tear causes a bruise to the muscle area.
Causes
 Trauma, either by a fall or a direct blow to the buttock area,
causes most gluteal injuries.
 Overuse injuries of the hip may cause inflammation and
damage to the gluteal muscles.
29

30.  Inspection-bruising of the skin or the buttock may appear
swollen and red
 Palpation: Tenderness present with warmth and redness
 Injury may decrease hip range of motion
 Pain during movement
30

31.  Femoroacetabular Impingment-
 Iliopsos Bursitis
31

32. Femoroacetabular
impingment
Iliopsos bursitis
Definition It is a motion-related clinical
disorder of the hip involving
premature contact between the
acetabulum and the proximal
femur.
Iliopsoas bursitis is an inflammatory
response in the bursa located under
the iliopsoas muscle
Location of
pain
Pain reported in the thigh and
groin
Located in the anteromedial aspect of the
thigh and groin
Symptoms Stiffness
Pain
Restricted hip range of
motion
Clicking and/or catching
Locking or giving way
Pain
Restricted range
Snapping sensation
Palpation Not seen Oedematous mass in the groin
region
Causes Repetitive and hip rotation
flexion during development
Malunion following femoral
Overactivity in Athletes
Overuse
Trauma
32

33. Femoroacetabular impingment Iliopsos bursitis
Diagnosis FADDIR Test Thomas test
33

34. ISCHIOFEMORAL IMPINGEMENT
 Ischiofemoral impingement is a syndrome defined by hip
pain associated with narrowing of the space between
Ischial tuberosity and lesser trochanter, results in
compression or impingement of the quadratus femoris
muscle.
 Clinical Symptoms
 Pain of the lower buttock inner thigh and groin
 A snapping or clunking may present
 Symptoms may be provoked by movement and walking
34

35.  Causes-
 The trauma
 Overuse
 Surgery of hip and pelvis
 Special test-Ischiofemoral Impingment test (video)
35

36. Hamstring muscle strain Greater trochanteric pain
syndrome
Definition Hamstring strain, sometimes called a
pulled hamstring, happens when one or
more of these muscles gets stretched too
far and starts to tear.
Overuse causes friction between GT and
microtrauma of gluteal insertion
Degenerative condition that affects
gluteal tendon and bursa
Causes Older age
Previous hamstring injury
Limited hamstring flexibility
Increased fatigue
Strength imbalance
Overuse,long standing
Mechanical overload
Incomplete or failed healing
Compression of the tendon at the enthesis
Site of pain Pain at posterior aspect of thigh
Pain aggravate on activity
pain over the lateral aspect of the
thighs
exacerbated with prolonged sitting,
climbing stairs, high impact physical
activity, or lying over the affected area
Clinical
features
Tenderness
Pain,swelling
Warmth
Reduced mobility
Pain-
Side lying,sitting,weighbearing
Tenderness
Reduced mobilty
Gait Antalgic gait Tredelenberg Gait
36

37.  Special test- 30 sec single leg stand test
 Tredelenberg signVID RL2tred sign.mp4
37

38. FRACTURES
• 79% hip fractures occurs in patients over 65 year
Intracapsular fractures Extracapsular fractures:.
Femoral neck fractures 1. Intertrochanteric fracture
2. Subtronchanteric fracture
38

39. A)Intracapsular fractures
1.Femoral neck fractures:
• Fracture occurs at neck part of femur Occurs within the hip capsule;
• accounts for 45% of all acute hip fractures in the elderly
 Susceptible to malunion/avascular necrosis of the head of femur because of
the limited blood supply to the area.
 Risk of damage of blood supply is greater
• Causes
1. Fall ,Pathological in elderly
2. High impact trauma in adults
• Clinical Features
 Pain
 Swelling
 Tenderness
39

40. 40
 I. Undisplaced And Incomplete
 II. Undisplaced and Complete
 III. Partially displaced and complete
 IV. Fully Displaced and Complete.

41. B)EXTRAARTICULAR FRACTURESS:.
 a)Intertrochantric Fracture-
 Fracture occurs in between greater and lesser trochanters
along intertrochateric line
 Intertrochanteric femur fractures are a very common injury
seen in the elderly, In the younger population, these
fractures typically result from a high-energy mechanism.
 Intertrochanteric fractures are defined as extracapsular
fractures of the proximal femur that occur between the
greater and lesser trochanter.
41

42.  Evan's Classification of Intertrochanteric Fractures
 TYPE 1:Undisplaced 2 part fracture.
TYPE 2 :Displaced 2 part fracture.
TYPE 3 :Displaced 3 part fracture with posterolateral comminuted fragment
TYPE 4 :Displaced 3 part fracture with large posteromedial comminuted
fragment.
TYPE 5- Displaced 4 part fracture with comminution of both trochanter.
42

43. b) Subtronchanteric fracture
 Region is typically defined as the area from lesser
trochanter to 5cm distal to it.
 Subtrochanteric fracture is between the lesser
trochanter adjucent proximal third of the femoral shaft.
 These account for approximately 5% to 34% of all hip
fractures.
 Subtrochanteric femur fractures are difficult to treat due
to strong forces at the fracture site, blood supply.
43

44. 44

45. ACETABULAR FRACTURE
 Fracture that involves acetabulum called as acetabular
fracture.
 It is associated with break in socket of hip joint
 Least common fracture of hip joint.
Types-
1.Anterior wall fracture
2.Posterior wall fracture
3.Trasverse wall Fracture
4.Comminuted Fracture
 Causes-
1. High energy trauma
2. RTA
3. Osteoporosis.
45

46. 46

47. COMPLICATION OF HIP FRACTURE
 Malunion
 Avascular necrosis
 Infection
 Limb length discrepancy
 Arthritis
47

48. THANK YOU
48

49. REFERENCES
 ADAM’S outline of orthopedics, David L Hamblen,
Hamish R,W 14th edition
 Essential Orthopaedics (Including Clinical Methods)-
Maheshwari & Mhaskar, 3rd edition
 S. Brent Brotzman; clinical orthopedic rehabilitation;
2nd edition
 David J magee, Orthopedic physical assessment 6th
edition
 Stanley hoppenfield, treatment and rehabilitation of
fracture
 The hip handbook ,Timothy L.
 Natarajan book of orthopedic and traumatology
Mayil mahanan natrajan 8th edition
 Essentials of orthopedic physiotherapy,John
Ebnezer 3rd edition
49

50.  Babcock S, Kellam JF. Hip Fracture Nonunions:
Diagnosis, Treatment, and Special Considerations
in Elderly Patients. Adv Orthopedics
 Bedi A, Toan Le T. Subtrochanteric femur
fractures. Orthop Clin North Am. 2004
50