Hip — Fast Exam

Tap a diagnosis. Tests first, interpretation underneath.

30-second screen

Run this before any special testWhere is the pain → range → load → is it even the hip
  1. Red flags? Trauma, inability to weight-bear, fever, night pain — listed at the bottom.
  2. Ask them to point. Groin or the "C-sign" grip → intra-articular. Lateral → trochanteric. Buttock or posterior → sacroiliac or lumbar. Anterior thigh → hip flexor. This single question is the highest-yield step in the whole exam.
  3. Range of motion, especially internal rotation. Lost internal rotation is the earliest and most reliable sign of hip joint pathology in every age group.
  4. FADIR. The best screening test for intra-articular pathology. Very sensitive, poorly specific.
  5. FABER. Screens hip, sacroiliac joint and lumbar spine in one movement — read where it hurts, not whether.
  6. Single-leg stance and Trendelenburg for the abductors and lateral hip.
  7. Always screen the lumbar spine and sacroiliac joint. The hip only refers to the groin and thigh; pain below the knee is rarely the hip.

Intra-articular

FAI and acetabular labral tearGroin pain with deep flexion — young, active, no trauma
Hallmark
Groin pain, worse with deep squatting, sitting for long periods, and pivoting. Often a young athlete. Restricted internal rotation is the constant finding.
Tests
  • FADIR — supine, hip flexed to 90°, then adduct and internally rotate. Positive: reproduction of familiar groin pain. labral tear: Sn up to 100% · FAI: Sn 77% / Sp 17%very sensitive, barely specific — a screening test only
  • FABER / Patrick — hip flexed, abducted, externally rotated, foot on the opposite knee, then press the knee down. Positive: groin pain → hip; posterior pain → sacroiliac joint. Sn 0.08–1 across studies — wildly variable
  • IROP (internal rotation over pressure) — supine, hip flexed 90°, internally rotate against resistance. Positive: groin pain. highest sensitivity for FAI in a recent systematic review: 91%
  • Log roll — passively roll the relaxed leg. Positive: groin pain with no resistance applied → strongly suggests intra-articular pathology.
Hip osteoarthritisOver 50, groin pain, lost internal rotation, morning stiffness
Hallmark
Groin pain with activity, stiffness after rest, a limp, and progressive loss of internal rotation and then flexion. Pain may refer to the anterior thigh and knee.
Tests
  • Internal rotation in flexion and extension — the earliest sign. Positive: restricted and painful, with a capsular pattern.
  • FADIR — Positive: groin pain with restricted movement.
Hip microinstabilityYoung, hypermobile, deep groin pain in end range
Hallmark
Deep groin pain in positions of combined extension and external rotation, often in a dancer or gymnast, with generalised joint laxity and no trauma.
Tests
  • AB-HEER — abduction, extension, external rotation with an anteriorly directed force. Positive: apprehension, or reproduction of the deep pain.highest sensitivity for microinstability in the same systematic review

Lateral hip

Greater trochanteric pain syndromeLateral hip pain — the patient lies on the good side to sleep
Hallmark
Lateral hip pain, worse lying on that side, on stairs, and with prolonged standing. Tender directly over the greater trochanter. This is the commonest cause of lateral hip pain — gluteal tendinopathy and bursitis, not "trochanteric bursitis" alone.
Tests
  • Direct palpation of the greater trochanter — Positive: focal reproduction of the pain. The single most useful finding here.
  • Single-leg stance for 30 seconds — Positive: lateral hip pain reproduced → gluteal tendon loading.
  • Trendelenburg sign — stand on one leg. Positive: the pelvis drops on the opposite side → abductor weakness.
  • Resisted hip abduction — Positive: pain over the trochanter.
  • Ober test — assess iliotibial band and lateral soft tissue tightness. Positive: the leg cannot adduct past neutral.

Muscle & tendon

Snapping hipAn audible clunk — ask the patient to reproduce it
Hallmark
A palpable and often audible snap. The patient can usually reproduce it on demand, which is the best part of the examination.
Tests
  • Iliopsoas snap — flexed, abducted, externally rotated hip, then extend into adduction and internal rotation. Positive: a palpable snap anteriorly, often with guarding. Ask them to hold the leg against gravity to confirm the tendon is the cause.
  • Iliotibial band snap — the same movement produces a lateral snap over the greater trochanter, usually painless.
Adductor strain and athletic groin painGroin pain with kicking or change of direction
Tests
  • Resisted hip adduction — supine, knees straight, squeeze against the examiner. Positive: pain at the adductor origin or along the muscle belly.
  • Squeeze test at 0° and at 45° — Positive: pain at 0° favours adductor; pain at 45° is less specific.
  • Palpation of the adductor origin at the pubic bone. Positive: focal tenderness.
Iliopsoas and hip flexor tendinopathyAnterior groin and thigh pain with resisted hip flexion
Tests
  • Resisted hip flexion — seated or supine with the hip flexed, press the thigh down. Positive: anterior hip and thigh pain.
  • Thomas test — supine, hug one knee to the chest, let the other leg extend. Positive: the thigh lifts off the table → hip flexor tightness; pain at the anterior hip implies tendinopathy.
  • FADIR with a flexed hip lower than 90° — can help separate tendon from joint.

Other & referred

Is it the hip, the spine, or the sacroiliac joint?Read where FABER hurts — that is the whole answer
Tests
  • FABER, read by location — Positive: pain in the anterior groin → hip joint. Pain in the buttock or posterior pelvis → sacroiliac joint. Pain in the lumbar region → spine.
  • Straight leg raise and slump — a neural tension screen. Positive: radiating leg pain reproduced → the spine is at least part of it.
  • Gaenslen and sacroiliac provocation — Positive: posterior pelvic pain.
Choosing the imagingRadiograph first · MRI for the young with a normal film
  • Radiograph first — every hip. Weight-bearing AP pelvis plus a lateral. Looks for osteoarthritis, cam or pincer morphology, and avascular necrosis.
  • MRI — the young patient with a normal radiograph and real pain. Also the test for a suspected femoral neck stress fracture or avascular necrosis.
  • Ultrasound — good for trochanteric bursitis, gluteal tendons, effusion and guided injection.
  • Intra-articular local anaesthetic injection — the definitive test of whether the pain is coming from the joint, when examination and imaging disagree.

Red flags — before you test

Re-route before you testSix findings that take precedence over any special test

Stop and re-route

  • Cannot weight-bear after a fall, especially in an older patient → femoral neck fracture. Radiograph; if negative and suspicion persists, urgent MRI.
  • Fever, hot joint, severe pain with any movement → septic arthritis. Aspirate. Urgent.
  • Insidious groin pain in a runner or military recruit with pain on hopping → femoral neck stress fracture. MRI. Do not treat as a strain.
  • Corticosteroid use, alcohol excess, or sickle cell with new deep hip pain → avascular necrosis.
  • Night pain, unexplained weight loss, or a history of cancer → malignancy. Urgent referral.
  • Groin lump or a pulsatile swelling → hernia or vascular. Not a musculoskeletal problem.