APTA’s Current Concepts: The Hip

Nathaniel Yomogida PT, DPT

Pathologies

  • Fractures
  • Avascular Necrosis
  • Systemic Inflammation
  • Infection
  • Femoral Neck Stress Fracture
  • Ankylosing Spondylitis
  • Lumbar disc herniation
  • Lumbar Radiculopathy
  • SIJ Dysfunction
  • Pelvic floor dysfunction
  • Hip Osteoarthritis
  • Hip Microinstability
  • Femoroacetabular Impingement Syndrome
  • Hip Dysplasia
  • Greater Trochanteric Pain Syndrome
  • Piriformis Syndrome
  • Iliopsoas Complex Injuries
  • Adductor muscle strain
  • Hamstring muscle strain

Red flags

  • Fractures
  • Avascular Necrosis
  • Systemic Inflammation
  • Infection
  • Femoral Neck Stress Fracture
  • Ankylosing Spondylitis
  • Lumbar disc herniation
  • Lumbar Radiculopathy
  • SIJ Dysfunction
  • Pelvic floor dysfunction
  • Hip Osteoarthritis
  • Hip Microinstability
  • Femoroacetabular Impingement Syndrome
  • Hip Dysplasia
  • Greater Trochanteric Pain Syndrome
  • Piriformis Syndrome
  • Iliopsoas Complex Injuries
  • Adductor muscle strain
  • Hamstring muscle strain

Lumbopelvic vs Hip

Lumbopelvic

  • Ankylosing Spondylitis
  • Lumbar disc herniation
  • Lumbar Radiculopathy
  • SIJ Dysfunction
  • Pelvic floor dysfunction

Hip

  • Hip Osteoarthritis
  • Hip Microinstability
  • Femoroacetabular Impingement Syndrome
  • Hip Dysplasia
  • Greater Trochanteric Pain Syndrome
  • Piriformis Syndrome
  • Iliopsoas Complex Injuries
  • Adductor muscle strain
  • Hamstring muscle strain

Intraarticular vs Extraarticular

Intra-articular

  • Hip Osteoarthritis
  • Hip Microinstability
  • Femoroacetabular Impingement Syndrome
  • Hip Dysplasia

Extra-articular

  • Greater Trochanteric Pain Syndrome
  • Piriformis Syndrome
  • Iliopsoas Complex Injuries
  • Adductor muscle strain
  • Hamstring muscle strain

Red Flag Screening

Warning

Red flags as pathologies where the patient needs direct medical attention from a physician

At the beginning of your evaluation, screening out red flags is the top priority.

Hip Infection

  • Hip pain
  • Acute onset
  • Localized redness
  • Localized swelling
  • Fever

Immediate attention by a physician is required

Postpone current and future PT visits

Avascular Necrosis (AVN)

  • Onset: >6 weeks
  • ~30-50 years old
  • Traumatic MOI
  • Atraumatic MOI: Hx corticosteroid use
  • Decreased ROM
  • Pain with weightbearing

Presents like OA but with a short onset

Warrants medical referral

Stress Fractures

Overuse injuries resulting in bony degeneration

Presentation

  • Population 1: Athlete undergoing high repetitive loads
  • Population 2: Osteoporosis with weakened bone structure
  • Gradual onset of anterior hip pain
  • Worse with activity, fully relieved with rest
  • Single Leg Balance
  • Single Leg Squat
  • Single Leg Hopping

Stress Fx Diagnosis

Palpation is unreliable diagnostic tool due to the overlying soft tissue.

MRI is considered the gold standard for diagnosis of stress fractures.

Caution

Do not rely on XRAY results alone to rule out stress fractures.

Patellar Pubic Percussion Test

  • Patient positioned in supine
  • Stethoscope placed over pubic tubercle
  • Tap ipsilateral patella

(+) Lack of sound propagation indicate femoral neck or pubic rami fracture

Red Flag Summary

  • Lack of radiology
  • Acute onset
  • Trauma or a missing MOI
  • Fever
  • Erythema (redness)
  • Edema (swelling)
  • (+) Patellar Pubic Percussion Test

Ruling out other regions

  • Lumbar
  • SIJ
  • Pelvic Floor
  • Referred pain

Lumbar pathologies

Lumbar radiculopathies that result in radiating pain through and around the hip

Lumbar AROM

Consistent symptom improvement or aggravation with lumbar ROM both point towards lumbar pathologies

Note

Using global trunk movements may not effectively isolate the lumbar spine from the hip region

Neural Tension Tests

Test Nerve Roots
Active slump test Sciatic L4-5
Prone Knee Flexion Femoral L2-4

Special Tests

  • Active Slump Test
  • Straight Leg Raise Test
  • Prone Lumbar Instability Test

Limping

Patients who display a limp are 7x more likely to have a hip or hip and spine disorder compared to an isolated spine issue.

Lumbar spine DDX

  • Aggravated by lumbar AROM (not global AROM)
  • Dermatomal pain pattern
  • Radiating pain starting proximal to the hip
  • Prone Lumbar Instability Test
  • Active Slump Test
  • Straight Leg Raise Test

SIJ

  • Fortin’s Point: Pain around the PSIS
  • SIJ Compression Test
  • SIJ Distraction Test
  • Innominate rotation
  • SIJ Thigh Thrust Test
  • Sacral Thrust Test

Pelvic Floor Dysfunction

  • Bowel and Bladder Changes
  • Hx of Pregnancy or Birth
  • Pain with sexual activity
  • Pain in Pelvic region

Referred pain

  • Kidney
  • Ureter
  • Urinary Bladder
Figure 1: Referred Pain Chart1

Evaluation

Range of Motion Testing

  • Absolute ROM
  • Comparative ROM
  • Quality of end-feel
Movement Range
Flexion 120°
Extension 20°
Abduction 40°
Adduction 25°
Internal Rotation 35°
External Rotation 45°

Muscle Length tests

Test Muscles tested
Thomas Test Iliopsoas
Thomas Test (90° knee flexion) Rectus femoris
Thomas Test (hip IR) Sartorius
Thomas Test (Hip ER Bias) TFL
Hip Adductor length test (neutral) Adductors
Hip Adductor length test (90° hip flexion) Adductors
Straight Leg Raise Hamstrings
Ober’s Test TFL/ITB

Intra-articular vs Extra-articular

Intra-articular

  • Hip Osteoarthritis
  • Hip Microinstability
  • Femoroacetabular Impingement Syndrome
  • Hip Dysplasia

Extra-articular

  • Greater Trochanteric Pain Syndrome
  • Piriformis Syndrome
  • Iliopsoas Complex Injuries
  • Adductor muscle strain
  • Hamstring muscle strain
  • Ischiofemoral Impingement

Intra-articular vs Extra-articular

Intra-articular

Extra-articular

  • Adductor Squeeze Test
  • Glute Derotation Test
  • SLS Provocation Test
  • Active Piriformis Test
  • Seated Piriformis Test

Special Tests

Flexion Abduction ER Test (FABER)

  • Patient in supine
  • Passively bring the patient into the Figure4 position (90° flexion, 90° abduction, 90° ER)
  • Note distance from knee to table

Provocation of hip pain rules in Hip joint or SIJ dysfunction

Scour Quadrant Test

Identifies mechanial hip dysfunction to rule in intra-articular pathologies such as FAIS, acetabular labral tear, and hip OA

  • Patient positioned in supine
  • Passively flex the ipsilateral hip to 90° flexion
  • Apply an axial load along the femoral shaft
  • Move the hip into more flexion and adduction
  • Arc the hip into flexion + abduction

Provocation of anterior hip or groin pain rules in intra-articular conditions. Crepitus indicates abnormal intra-articular structures.

Flexion-Adduction-Internal Rotation Test (FADIR)

  • Patient supine
  • Passively flex hip to 90°
  • Passively move to end range adduction and internal rotation

Provocation of Anterior hip pain or groin pain is indicative of FAI or Acetabular Labral injury

Log-Roll Test

Assess anterior capsuloligamentous laxity of the hip joint

  • Patient in supine
  • Passively ER both femurs
  • Note the end position of both feet

Increased external rotation of the femur on the involved limb indicates laxity of anterior capsuloligamentous structures

AB-HEER Test

  • Patient contralateral sidelying (test hip upward)
  • Passively abduct the hip to 30-45°
  • Hip is extended and externally rotated while the femoral head is anteriorly translated

Provocation of anterior hip or groin pain indicates anterior microinstability

Prone Hip Instability Test

  • Patient Prone
  • Passive external rotation and abduction
  • Anterior translation of femoral head

Provocation of anterior hip or groin pain indicates anterior microinstability

Hyper Extension-External Rotation (HEER)

  • Patient supine
  • Contralateral knee-to-chest
  • Ipsilateral knee placed in extended and externally rotated position

Provocation of at point of palpation or Radiating pain is positive for Piriformis/ deep hip stabilizer muscle dysfunction and potential sciatic nerve entrapment

Adductor Isometric Squeeze Provocation Test

  • 0°, 30°, 45°, or 90° Hip flexion
  • The examiner places arm between patient’s knees (if hip is flexed) or distal lower leg
  • Maximal isometric contraction for 5-10 seconds

Provocation of groin pain indicates adductor muscle involvement on symptomatic side.

Provocation with hip in neutral (0°) is a contraindication for return-to-play

Gluteal De-Rotation Test

  • Supine
  • Passively flex to 90° and end-range ER
  • Patient actively de-rotates (Returns hip to neutral rotation)

Provocation of Lateral Hip pain is a indicates GTPS secondary to gluteal tendinopathy

Active Sidelying Piriformis Test

  • Patient positioned in contralateral sidelying (test hip upward) with bent knees and slight hip flexion
  • Clinician palpates the piriformis muscle
  • Patient performs isometric hip abduction + ER against examiner resistance

Provocation of at point of palpation or Radiating pain is positive for Piriformis/ deep hip stabilizer muscle dysfunction and potential sciatic nerve entrapment

Seated Piriformis Stretch Provocation Test

  • Patient seated
  • Ipsilateral heel supported and knee placed in full extension
  • Passively adduct and internally rotate the flexed hip while palpating lateral to the ischium and proximally at the sciatic notch

Provocation of at point of palpation or Radiating pain is positive for Piriformis/ deep hip stabilizer muscle dysfunction and potential sciatic nerve entrapment

Hip Osteoarthritis

Hip Osteoarthritis: Progressive degeneration of the femoroacetabular joint

OA Etiology

Excessive loads on the hip

  • Sports
  • Heavy labor
  • High BMI

Risk factors

  • FAI
  • Dysplasia
  • PMHx joint injuries

Tip

The more risk factors a patient has, the less impact the joint will need to rule in OA

OA Presentation

  • Pain in Groin and Lateral hip
  • Gradual Onset
  • Progressively worsening pattern
  • >50years old
  • ↓ Joint ROM (specifically IR)
  • AM Stiffness: <1 hour after immobile periods
  • Strength: ↓ LE strength

OA Special Tests

Old OA Cluster

  • Moderate anterior or lateral hip pain with weight bearing activities
  • Morning stiffness >1 hour
  • Hip ROM deficits:
    • Hip internal rotation ROM <15°
    • Hip internal rotation and flexion <15° compared to contralateral hip
  • Increased pain with passive hip IR

Updated OA Cluster

  • Moderate anterior or lateral hip pain with weight bearing activities
  • Morning stiffness >1 hour
  • Hip ROM deficits:
    • Hip internal rotation ROM <24°
    • Hip internal rotation and flexion <15° compared to contralateral hip
  • Increased pain with passive hip IR

OA Treatment approach

Minimize joint irritation and inflammation

Short term

  • Modalities
  • Distraction
  • Activity modification
  • Gentle OKC strengthening

Long term

  • Closed Kinetic Chain
  • Improve hip stabilization
  • Improve hip load absorption

Treatment Dosage

Type Days Sets Reps
Resistance 2-3 3-4 8-12x
Stretching 2-3 2-4 10-30s
Aerobic 3-5 20-90min 55-90% HRmax

Refer to Aquatic Therapy

  • Decreases impact of high BMI
  • Minimizes joint loads
  • Introduction to swimming as exercise

Femoral Acetabular Impingement Syndrome (FAIS)

Femoral Acetabular Impingement Syndrome (FAIS): Clinical presentation of hip pain caused by premature contact between femur and acetabulum bones.

Presentation

  • Pain in C-Sign distribution
  • Impingement positions: Repetitive/prolonged hip flexion + adduction + IR
  • (+) FADIR
  • Younger population
  • Functional impairments

FAIS: Single Leg Squat

  • Decreased depth
  • Loss of contralateral pelvic height
  • Genu valgum/varus
  • Trunk compensations
  • Poor lower extremity control

FAIS: Star Excursion Balance Test

Limited in Posterolateral and Posteromedial directions

Tip

I often use this test since it can be used as a treatment and easily added to the HEP

Treatment

There is limited literature for FAIS treatment

Tip

Sharing clinical expertise is even more valuable when managing this population!

Hip Flexor Mobility

Addressing hip flexor muscle length issues should be prioritized as tightness of these structures can have a postural effect by increasing anterior pelvic tilt.

Functional training

Progressing patients towards single-leg closed chain positions and movements

Hip Microinstability

Hip Microinstability: The combined entity of capsuloligamentous laxity and clinical symptoms (i.e. pain) with or without apprehension.

Etiology

In general there is no single traumatic event that causes hip microinstability. Bony dysplasia may be present but is not considered a necessary criterion.

The mechanism is repetitive microtrauma generally due to insufficient passive stabilization from the anterior joint capsule and iliofemoral ligament

Presentation

  • No hx of trauma

  • Aggravation with Weight bearing ER + extension (anterior instability)

  • Pain:

    • Groin or Deep joint pain
    • C-Sign Hip Pain Distribution

  • Functional difficulties

    • Particularly in hip extension + ER

  • Weak hip abductor and rotator muscles

Diagnosis

  • 3 Test cluster:
    • AB-HEER test
    • Prone instability test
    • Hyperextension-external rotation (HEER) test
  • 3 positive tests was associated with a 95% chance of microinstability.

DDX

Differentiate between local anterior microinstability and Global laxity

Anterior microinstability (local)

  • Log Roll Test
  • AB-HEER Test
  • Prone Hip Instability test
  • HEER Test

Global Laxity

  • Beighton Scale

Beighton Scale

Criteria Left Right
5th finger metacarpophalangeal joint extension >90° 0 or 1 0 or 1
Ability to place thumb to forearm 0 or 1 0 or 1
>10° knee hyperextension 0 or 1 0 or 1
>10° elbow hyperextension 0 or 1 0 or 1
Ability to touch palms to floor with knees straight 0 or 1

Total: /9

≥4pts → Presence of joint laxity

Adductor Muscle Injuries

Adductor muscle strains are a common injury in sports like hockey and soccer

with the MOI including acute, overuse, and acute-on-chronic

Acute Population

In kicking athletes, such as soccer, the injury is generally acute and occurs when rapidly transitioning between hip extension → flexion.

. . .

Overuse Population

Ice hockey consists of repetitive eccentric loading of the adductors and injuries are generally due to overuse

These injuries generally occur due to hip muscle weakness and lack of off-season conditioning. When ruling in an adductor strain, look for recent increases in activity

Most common adductors injured

  1. Adductor Longus
  2. Adductor Magnus
  3. Gracilis
Figure 2: Deep muscles of the medial thigh2

Risk Factors

  • Previous groin injury (2x risk)
  • Lack of off-season sport-specific training
  • Hip muscle weakness
    • Adductor to abductor muscle strength ratio <80%
  • Lower abdominal muscle weakness
  • Decreased hip joint ROM

Prevention

Adductor:Abductor Strength ratio: >80%3

Note

Pro hockey had 17x increase risk of adductor mm injury if <80%

The Copenhagen 5-second adductor squeeze test3

Table 1
Pain Sport Readiness
0–2 Ready
3–5 Caution
6–10 Not Ready

Framework for Muscle Injury Rehab

  • ROM: Limited → Full ROM
  • Strengthening: Isometric → Concentric → Eccentric
  • Improve stabilization at nearby regions
  • Maintain strength in unaffected hip musculature

Hamstring Injuries

Presentation

  • Common injury in athletes
  • Myotendinous junction of Biceps Femoris Long Head
  • Pain and tightness in posterior thigh

Rule out Tendon avulsion

  • Proximal posterior thigh pain
  • Traumatic onset
  • Inability or unwillingness to bear weight
  • Visible ecchymosis
  • Palpable defects in the hamstring musculature

H-Test

  • Supine
  • Perform 3x SLR’s at max ROM as fast as possible
  • Rate apprehension 0-100 (most apprehension)

Delaying RTS until apprehension was at a minimum significantly reduced reinjury rates

Greater Trochanteric Pain Syndrome (GTPS)

Definition

Greater Trochanteric Pain Syndrome: lateral hip pain that may originate from numerous sources surrounding the greater trochanter3.

PathoMechanism

GTPS is theorized to be an overuse injury due to chronic movement dysfunction of Hip Adduction and IR due to poor eccentric control3.

An attempt to create stability by sitting into passive structures such as IT band and glute tendons

Population

Non athlete

  • 40-60 years old
  • Female

Athletic

  • High impact
  • Jumping on hard floor

Gluteal tendinopathy

Piriformis Syndrome

Piriformis Syndrome: Posterior hip pain that is present with radiating pain related to piriformis activation

Figure 3: Hip and Thigh Muscles1
Figure 4: Muscles of the gluteal and posterior femoral region2

Four clinical signs and symptoms

  • Buttock pain
  • Pain with sitting
  • Tenderness near greater sciatic notch
  • Pain with maneuvers that cause tension of the piriformis

Special Tests

  • Active piriformis test
  • Seated piriformis test

My Treatment

Deep Hip Stabilizer Dysfunction

  • Femoral head will be pushed forward and be passively resting on hip flexor tendons anteriorly

The long muscles will attempt to perform the job of stabilization. Long muscles such as sartorius, TFL, rectus femoris, hip flexors, and hamtrings. I think of this similar to dysfunctional deep neck flexors that result in overactive scalenes, upper trapezius, and levator scapulae.

Prone Hip IR Test

  • Prone Hip IR/ER arthrokinematic test
    • Symmetry
    • End feel
    • ROM

FAddER Contract-Relax

  • Supine
  • Hip flexion, adduction, & ER
  • Long axis compression force
  • Have the patient attempt to return the hip to neutral

References

1.
Betts JG, Blaker W. Openstax Anatomy and Physiology. 2nd ed. OpenStax; 2022. https://openstax.org/details/books/anatomy-and-physiology-2e/?Book%20details
2.
Gray H. Anatomy of the Human Body. 20th ed. (Lewis WH, ed.). Lea & Febiger; 1918. https://www.bartleby.com/107/
3.
APTA. Current Concepts of Orthopaedic Physical Therapy. 5th ed.; 2024.