Posterior, Lateral, and Anterior Hip Pain Due to Musculoskeletal Origin: A Narrative Literature Review of History, Physical Examination, and Diagnostic Imaging
Patrick J. Battaglia, DC, Kevin D’Angelo, DC,
Norman W. Kettner, DC, DACBR
Department of Radiology,
Logan University, Chesterfield, MO.
OBJECTIVE: The purpose of this study was to present a narrative review of the literature of musculoskeletal causes of adult hip pain, with special attention to history, physical examination, and diagnostic imaging.
METHODS: A narrative review of the English medical literature was performed by using the search terms “hip pain” AND “anterior,” “lateral,” and “posterior.” Additionally, specific entities of hip pain or pain referral sources to the hip were searched for. We used the PubMed search engine through January 15, 2016.
RESULTS: Musculoskeletal sources of adult hip pain can be divided into posterior, lateral, and anterior categories. For posterior hip pain, select considerations include lumbar spine and femoroacetabular joint referral, sacroiliac joint pathology, piriformis syndrome, and proximal hamstring tendinopathy. Gluteal tendinopathy and iliotibial band thickening are the most common causes of lateral hip pain. Anterior hip pain is further divided into causes that are intra-articular (ie, labral tear, osteoarthritis, osteonecrosis) and extra-articular (ie, snapping hip and inguinal disruption [athletic pubalgia]). Entrapment neuropathies and myofascial pain should also be considered in each compartment. A limited number of historical features and physical examination tests for evaluation of adult hip pain are supported by the literature and are discussed in this article. Depending on the clinical differential, the gamut of diagnostic imaging modalities recommended for accurate diagnosis include plain film radiography, computed tomography, magnetic resonance imaging, skeletal scintigraphy, and ultrasonography.
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CONCLUSIONS: The evaluation of adult hip pain is challenging. Clinicians should consider posterior, lateral, and anterior sources of pain while keeping in mind that these may overlap.
KEYWORDS: Diagnostic Imaging; Femoroacetabular Impingement; Hip; Musculoskeletal Pain; Physical Examination; Review
From the FULL TEXT Article:
Self-reported hip pain is common, afflicting approximately 14% of the population over the age of 60 years.  Providing a focused differential diagnosis for a chief complaint of hip pain is challenging, and sources may originate around, or within, the bony ring between the lumbar spine and the pubic symphysis. Clinicians need to consider both local and distant osteoligamentous, tendinous, nervous, and muscular anatomy when examining patients with complaints related to the posterior, lateral, or anterior hip. Additionally, myofascial pain syndrome is a common and overlooked cause of pain.  Genitourinary, gastrointestinal, and vascular pathology should be excluded when examining a patient with hip pain but are beyond the scope of this review.
History and physical examination are crucial in the evaluation of any patient complaint. Unfortunately, the history and physical examination results of a patient with hip pain are typically nonspecific,  reflecting the complex anatomy of the hip and pelvis and the overlapping organ systems that are included in the differential diagnosis. As such, diagnostic imaging is indispensable in narrowing and arriving at an accurate differential diagnosis that will guide efficient and cost-effective treatment. Therefore, the aim of this review was to provide musculoskeletal differential considerations for posterior, lateral, and anterior hip pain in the adult patient.
The authors selected 116 papers to include in this narrative review.
The following is a discussion of posterior, lateral, and anterior hip pain in an adult patient. Myofascial pain is discussed first as a separate entity because it may present in any hip compartment, although the underlying pathophysiology is constant. Additionally, there is limited information on objective clinical examination and imaging findings for the diagnosis of myofascial pain. For these reasons, myofascial pain is discussed separately, with the understanding that it should be considered in all cases of hip pain. Also, peripheral neuropathies have a similar clinical presentation, with the greatest variability being the distribution of the nerve involved. For this reason, the signs and symptoms of a peripheral neuropathy are discussed in the posterior hip pain section and are not repeated in subsequent sections. Rather, just the nerves that may be implicated, along with likely mechanisms and pertinent neurodynamic tests, are presented in the lateral and anterior hip pain sections. Table 1–3 provide summaries of differential diagnoses, clinical features, orthopedic testing, and diagnostic imaging for adults presenting with posterior, lateral, and anterior hip pain, respectively.