Evaluation of the Hip: History,
Physical Examination, and Imaging
Marc R. Safran, MD
T here is a recent increase in interest of hip injuries in
athletes. This increased interest is because of the in-
creased awareness of hip problems in athletes as well as im-
provements in diagnostic imaging and less invasive surgical
techniques. There may actually also be an increase in the
incidence of hip problems in athletes with changing mechan-
ics of certain sports, such as the open stance forehand in
tennis; however, this has not been proven. Correct diagnosis
is imperative to appropriate management of athletic injuries,
including the hip.
Some individuals are intimidated by evaluation of the hip,
most often because of the lack of familiarity with this joint
and the fact that the joint is deep to thick soft tissues and is
highly constrained. However, a careful history, physical ex-
amination, and standard radiographs may provide important
clues to the diagnosis, with advanced imaging, such as mag-
netic resonance imaging (MRI) arthrography, helping con-
firm the diagnosis. Arthroscopy has also been advocated as a
diagnostic tool for intra-articular hip pathology, although
this is necessary in only a small minority of patients.
It is imperative to differentiate intraarticular problems that
may require surgical intervention from extra-articular prob-
lems that may require only conservative management includ-
ing medications, injections, and/or therapy. This is particu-
larly important because the majority of patients evaluated in
our sports medicine center for hip pain have an extra-articu-
lar cause that is successfully managed nonoperatively. Fur-
thermore, the hip is commonly a location of referred pain
from the lumbar spine and sacrum as well as the abdomen
and pelvis, confusing the issue further and making an accu-
rate and precise evaluation of paramount importance. As we
begin to understand hip anatomy, mechanics, and pathome-
chanics better, improvements and refinements in examina-
tion and imaging will also advance, along with management
options. This manuscript serves as a review of my compre-
Department of Orthopaedic Surgery, University of California, San Francisco,
San Francisco, CA.
Address reprint requests to Marc R. Safran, MD, Department of Orthopaedic
Surgery, University of California, San Francisco, 500 Parnassus Avenue,
MU-320 West, San Francisco, CA 94143-0278. E-mail: safranm@
orthosurg.ucsf.edu
2 1060-1872/05/$-see front matter © 2005 Elsevier Inc. All rights reserved.
doi:10.1053/j.otsm.2004.09.006
hensive hip evaluation, including history, physical examina-
tion, and ancillary studies.
History
The history of patients with hip pain will vary based on the
pathology causing their pain. It is important to examine the
spine, pelvis, and abdomen to rule out referred pain from
those areas. Details of those examinations are beyond the
scope of this article.
Details of the history should include the location of the
pain, onset of pain, duration, and severity of symptoms. As
an example, patients with labral tears commonly go weeks to
months before accurate diagnosis of their injury. The average
time from onset of symptoms to presentation in 1 study was
nearly 3 years.3 One reason is that up to two thirds of patients
will have no recollection of a precipitating injury or event.
However, other patients with labral tears may relate a history
of antecedent trauma, such as a fall and/or twisting injury.
Interestingly, some individuals with an acute tear of the la-
brum may go years before being correctly diagnosed, thus
resulting in a chronic condition, whereas some individuals
with a degenerative labral tear may present with an acute
onset of symptoms. If there is an injury, the patient should be
queried as to what was the mechanism of injury. Other clues
to diagnosis include type of sporting activity. As an example
joggers and those involved in twisting type sports, such as
soccer players, ice skaters, tennis players, and golfers may
sustain labral tears while repetitive use athletes, such as long
distance runners and triathletes may have hip pain as a result
of a femoral neck stress fracture.5
Patients with symptomatic intraarticular problems, such as
chondral flaps and labral tears, will often complain of pain
and mechanical symptoms. Typically, the pain is deep and
localized in the anterior groin or inguinal region, although
this pain may be referred to the medial thigh, the region
proximal to the greater trochanter laterally, or in the but-
tocks. Patients will often define their pain as being deep in the
joint, localizing between a finger anteriorly in the groin and
one posteriorly at the posterior aspect of the trochanter or
buttock. Other characteristics of intraarticular sources of me-
chanics hip pain include discreet episodes of sharp pain with
Evaluation of the hip
weight bearing that may be exacerbated by pivoting or twist-
ing. Over time, symptoms may progress to the point in which
patients have pain that is dull, positional, or activity related.
The pain may become continuous. Other symptoms related
to mechanical hip problems include discomfort with sitting
with the hip flexed and pain or catching on arising from a
seated position. Patients may also complain of catching, pop-
ping, or locking within the joint with ambulation or other hip
motion, although this is less specific for intraarticular sources
of symptoms. Clicking and catching within the groin should
lead the clinician to rule out labral tears, chondral flaps,
snapping iliotibial band syndrome, snapping iliopsoas ten-
don, osteonecrosis, acute hemorrhage into the ligamentum
teres, and loose bodies. Other mechanical symptoms include
pain climbing or descending stairs and/or having to ambulate
one step at a time. Loss of motion, as occurs in degenerative
arthritis, femoroacetabular impingement and slipped capital
femoral epiphysis (SCFE) may result in difficulty or inability
to put on socks, hose, and/or shoes.
As a general rule, intraarticular and acetabular pain is felt
in the anterior groin/inguinal region, extra-articular pain in
the buttock/posterior trochanteric region, and femoral pain
in the anterior thigh. Furthermore, one must remember that
hip problems may present as pain in the knee.
It is also important to discern a history of ligamentous
laxity or treatment for subtle acetabular dysplasia as an in-
fant. It is also important to obtain a history of hip pain as an
adolescent that may be a clue to previous hip problems such
as SCFE and Legg-Calve-Perthes. Family history of hip prob-
lems, particularly dysplasia, should also be identified.
The history of present problems, past medical history, and
family history should provide the clinician with enough in-
formation to develop a preliminary differential diagnosis.
This differential diagnosis will allow the clinician to pay spe-
cial attention to specific areas of the complete hip examina-
tion.
Physical Examination
Physical examination of the hip follows the same basic prin-
ciples of any other area of the body. A systematic approach
includes inspection, palpation, range of motion, strength,
and special tests. Again, it is important to rule out other
causes of pain referred to the hip, including lumbar spine,
sacrum/sacroiliac joint, abdomen, abdominal muscle, hernia,
and pelvic sources, such as the pubic symphysis and intrapel-
vic problems. A complete examination of the hip must be
performed, even if the differential diagnosis appears very
narrow, to help reduce the likelihood an incorrect diagnosis
is made.
Inspection
Observation of the patient—the way they walk into the room,
how they are sitting, how they get up from the interview chair
and how they transfer to the examination table—are essential
initial clues in the examination of the hip. Notation is made
with regard to favoring, splinting, or compensating for the
injured limb. Antalgic gait, with decreased stance phase,
shortened swing phase or avoidance of hip extension are
3
noted. Also Trendelenburg gait may be seen because of ab-
ductor weakness or as the patient tries to place their center of
gravity over the hip, reducing the forces on the joint. Sitting
to one side, avoiding the painful hip, and slouching to avoid
flexion and arising and sitting using one’s hands to help bear
load is also noted.
There are many other examples of hip positioning while
observing the athlete that can provide a clue to the diagnosis.
On the field or in the emergency room, seeing a person with
a posterior hip dislocation the position is consistent; the pa-
tient’s hip is shortened, flexed, adducted, and internally ro-
tated. A person with an anterior hip dislocation will have the
appearance of the hip being shortened, extended, abducted,
and externally rotated. With a hip fracture, the hip may be in
a similar position as with the posterior dislocation. With
acute inflammation of the hip, such as with a septic joint, the
patient will hold their hip in a flexed position, taking tension
off the inflamed capsule.
With the subject standing in front of the examiner, a sense of
femoral anteversion may be made. If, with the feet together, the
knee progression angle is such that the patellae squint or point
toward each other, this may be a result of excessive femoral
anteversion. Observation for swelling and bruising, such as at
the greater trochanter with fractures or traumatic bursitis of the
greater trochanter or at the iliac crest for hip pointers or avulsion
fractures or wing fractures of the pelvis, may also provide a clue
to the diagnosis. Observation of the hip itself for asymmetry,
deformity, masses, redness, atrophy, spinal malalignment, and
pelvic obliquity is also made. Leg lengths are measured standing
(assessing from the back for pelvic tilt) and laying supine (mea-
sured from the anterosuperior iliac spine [ASIS] to the medial
malleolus bilaterally).
Palpation
Areas of tenderness are assessed. Intra-articular pathologies
do not have palpable areas of tenderness, although compen-
sation for longstanding intraarticular problems may result in
tenderness of muscles or bursae. Many muscles about the hip
can cause pain and are often tender, especially at their origin,
including the sartorius, rectus femoris, gluteus medius, and
adductors. Common areas of tenderness include the greater
trochanter with trochanteric bursitis and snapping hip from
the iliotibial band. Also, tenderness of the sciatic nerve, com-
mon with sciatica, can be evaluated with the hip flexed to 90°
and the nerve palpated half way between the greater trochan-
ter and ischial tuberosity. The iliac crest is tender and swollen
in cases of hip pointer. Palpation for hernia, particularly fem-
oral hernia, should be made to rule out this confounding
pathology. Deep palpation distal to the midpoint of the in-
guinal ligament in the femoral triangle medial or lateral to the
femoral artery can elicit iliopsoas bursitis.10,14 Palpation of
the femoral artery should be included in the general hip
examination as well as the neurovascular evaluation because
an aneurysm of this artery may uncommonly cause swelling
and pain about the hip. Other areas of pain, as located by the
patient, should be palpated.
It is important not to forget to palpate other potential areas
of referred pain to the hip, including the lumbar spine, the
4 M.R. Safran
Table 1 Active Motions of the Hip
Flexion 110°-120°
Extension 10°-15°
Abduction in extension 30°-50°
Adduction in extension 30°
External rotation in flexion 40°-60°
Internal rotation in flexion 30°-40°
sacrum, the sacroiliac (SI) joint, ischium, and pubic symphy-
sis. The author performs a compression test of the pelvic
wings (see “Special Tests” section) to load the pubic symphy-
sis to help rule out osteitis pubis as well as palpating that
joint.
Range of Motion
Range of motion (Table 1) of the hip may be limited with
intra-articular inflammation. Before evaluating the range of
Figure 1 Thomas test: patient is placed supine and hip flexed. (A)
Examiner’s hand is placed under low back to feel position at which the
lumbar spine is flattened. The subject then holds the hip in that posi-
tion while the other hip is assessed for a flexion contracture. If there is
no flexion contracture, the contralateral hip and extremity will be flat
on the examination table. (B) A patient with a flexion contracture of the
left hip. (Color version of figure is available online.)
motion, the patient is placed supine on the examination table
and the leg rolled medially and laterally/internally and exter-
nally at the hip. With an acute fracture or acute intra-articular
inflammation, such as an infected joint, log rolling will cause
the patient significant pain.
Range of motion is assessed checking the normal, unaf-
fected limb first. With the patient supine, the hip being ex-
amined is flexed while the other hip is extended flat on the
examination table to stabilize the pelvis to avoid pelvic tilt
contribution to hip flexion. Flexion contracture is measured
with the contralateral hip flexed and the lumbar spine stabi-
lized/flush with the examination table using the Thomas test
(Fig. 1).16 This is performed properly by having the subject
flex 1 hip to the chest to flatten out the lumbar spine and
stabilize the pelvis. This is assured by palpating the lumbar
region as the patient’s hip is flexed (Fig. 1A). The patient
holds the flexed hip in that position. If there is no flexion
contracture, the hip being tested remains on the examining
Figure 2 Ober test: this test for hip abductor tightness or iliotibial band
contracture is performed with the subject in the lateral decubitus posi-
tion. The down hip and knee is flexed for stability. (A) The pelvis is
stabilized by the examiner, the hip is flexed, hip abducted, and then hip
extended. (B) The hip is then allowed to adduct. If the hip adducts such
that the knee is at or below midline, the hip abductors are not exces-
sively tight. (Color version of figure is available online.)
Evaluation of the hip 5

Figure 3 Trendelenburg: this test for hip abductor weakness is performed viewing the patient from behind. (A) The subject
starts with both feet planted on the ground and the examiner placing their hands on the reference points, either the posterior
superior iliac spines, as seen here or on the iliac crest. The subject then stands on 1 leg. (B) If the pelvis rises on the leg opposite
the stance leg, then the hip abductor muscles are functioning appropriately. (C) If the pelvis stays at midline or drops below
the other side, then the hip abductors are weak. The subject in (C) shows right hip abductor weakness because the left pelvis
drops relative to the right when standing on the right leg. (Color version of figure is available online.)

table. If a flexion contracture is present, the patient’s straight flexes, then the rectus femoris is tight and the test is positive.4
leg will rise off the table (Fig. 1B). This test is also known as Ely’s test. The degree of knee
With the hip being examined flexed to 90° of flexion, the flexion should also be compared between the 2 sides.
hip is rotated internally and externally. The hip is then ad- With chondral flaps or labral tears, usually there is only a
ducted and abducted in 90° of flexion. Lastly, with the pa- mild decrease in hip range of motion.3 More often there is
tient lying flat, with the hips extended, both hips are ab- pain or discomfort at the extremes of motion. For those with
ducted maximally. This is measured, using a line connecting
the ASIS as the reference because pelvic rotation may affect
this measurement.
Hamstring tightness is also evaluated by measuring the
popliteal angle. With the subject supine, the hip is flexed 90°
with the knee flexed. The knee is then passively extended.
How straight the knee gets is indicative of hamstring tight-
ness, with full extension being a 0° popliteal angle, which is
indicative of very loose hamstrings.
The patient is rotated into a lateral decubitus position to
measure hip abductor tightness or tensor fascia lata contrac-
ture using the Ober Test (Fig. 2).12 The lower hip and knee
flexed for stability. The examiner then passively flexes the hip
being examined to 90° and then abducts the hip fully and
extends the hip past neutral with the knee in 90° of flexion
(Fig. 2A). At this point, the hip and knee are allowed to
adduct while the hip is held in neutral rotation (Fig. 2B). If
the knee adducts past midline, the hip abductors are not
tight; whereas if the knee does not reach to midline, then the Figure 4 Patrick’s test/FABER test: this test is indicative of hip problems,
SI joint problems, and/or iliopsoas spasm. This is performed with the
hip abductors are tight.
subject lying supine, and the contralateral leg is extended flat on the
The patient is then rotated into the prone position. From examination table. They are positioned on the examination table such
this position, hip extension can be measured. Furthermore, that one half of the buttock is off the table while the ipsilateral leg being
internal and external hip rotation as measured in full hip placed in a figure 4 position on the other knee. The pelvis is stabilized,
extension is performed prone. Rectus femoris tightness can and a downward force is applied to the flexed knee. This may repro-
be assessed in the prone position. The patient’s knee is pas- duce pain in the hip or SI joint. (Color version of figure is available
sively flexed. If on flexion of the knee the ipsilateral hip also online.)
6 M.R. Safran

and is strong, the pelvis on the unsupported side elevates as

the patient raises their leg (Fig. 3B). This is assessed by look-
ing at both posterior superior iliac crests or the iliac wings. If
the pelvis on the unsupported side remains in position or
drops below the other side, the gluteus medius muscle is
either weak or nonfunctional (Fig. 3C).
The patient is seated on the edge of the examination table
to assess the strength of the iliopsoas and knee extensors. The
iliopsoas muscle–tendon complex is tested by having the
patient lift their thigh off the examination table with the knee
flexed to 90°. Once elevated off the examination table, the
examiner pushes down on the anterior lower thigh/suprapa-
tellar area. Pain reproduction is consistent with the iliopsoas
as the etiology, and, particularly, a pop or snap with this
maneuver is consistent with snapping hip syndrome from the
iliopsoas.
Supine strength testing includes measurement of thigh cir-
cumference. This, again, gives a sense of chronicity and com-

Figure 5 Anterior labral stress test: this test is to stress the acetabular
labrum causing reproduction of pain, clicking, or clunking in the hip as
a result of an anterior labral tear. (A) The hip is flexed, abducted, and
externally rotated in the supine patient, as the start position. (B) The hip
is then extended, internally rotated, and adducted. This may cause
symptoms from an anterior labral tear. (Color version of figure is avail-
able online.)

SCFE and femoroacetabular impingement, it is common for

the individual’s hip to abduct and externally rotate as the hip
is being flexed. Those with arthritis will have diffuse loss of
range of motion. However, the first ranges to be lost are
internal rotation and abduction.
Strength
Strength testing may elicit weakness as a cause of pain or
compensatory loss from hip pathology. Pain with strength
testing may guide the diagnosis as to whether the etiology of
hip pain is musculotendinous in origin because resisted con-
traction may reproduce localized symptoms of the muscle
Figure 6 Posterior labral stress test: this test is to stress the acetabular
being tested. labrum causing reproduction of pain, clicking or clunking in the hip as
Strength testing begins in the standing position. Hip ab- a result of a posterior labral tear. (A) The hip is flexed, adducted, and
ductor weakness is assessed with the Trendelenburg test in internally rotated in the supine patient, as the start position. (B) The hip
single leg stance (Fig. 3).17 The clinician stands behind the is then extended, externally rotated, and abducted. This may cause
patient and has the patient stand on 1 leg. If the gluteus symptoms from a posterior labral tear. (Color version of figure is avail-
medius muscle on the supportive side is functioning properly able online.)
Evaluation of the hip 7

is asked to stand on 1 leg. This results in the weight of the

trunk causing the sacrum and ilium to shift distally and for-
ward, while the ilium moves in the opposite direction. This
may cause pain in the pubis as a result of shearing. This is also
done radiographically (see later).
While assessing hip range of motion with the subject lay-
ing supine, the hip is flexed with the knee extended. This is
the straight-leg raise test (Lasegue’s sign) to assess for lumbar
nerve root irritation. Patrick’s test, also known as the FABER
test (flexion, abduction, and external rotation) is indicative of
hip problems, SI joint problems, and/or iliopsoas spasm (Fig. 4).
This is performed with the subject lying supine and the con-
tralateral leg is extended flat on the examination table. They
are positioned on the examination table such that one half of
the buttock is off the table while the ipsilateral leg being
placed in a figure 4 position on the other knee. The pelvis is
stabilized, and a downward force is applied to the flexed
knee. A negative test is indicated by the test leg’s knee falling
to the table at or at least parallel to the other leg.
An anterior labral stress test is performed while the patient

Figure 7 Lateral compression test: to evaluate hip pathology of pelvic

origin, such as osteitis pubis, the subject can be rotated to the lateral
decubitus position and a downward force applied. Symptoms at the
pubis would be consistent with osteitis pubis. (Color version of
figure is available online.)

pensation for hip pain or lumbar nerve irritation. A straight-

leg raise is performed with the patient lifting the leg being
examined off the table approximately 2 feet. The examiner
has the subject maintain the leg in an elevated position while
the examiner applies a downward pressure to the anterior
lower leg/ankle. This can help assess strength as well as pain.
Pain reproduction may suggest hip flexor muscle-tendon in-
flammation/injury or intra-articular pathology by loading the
joint. The examiner may also note grinding, crepitation, and
the subject may note their pain is reproduced and catching.
Hip abduction and adduction strength may be measured
while the patient is lying flat on their back as well. Iliopsoas
bursitis symptoms may be exacerbated by testing flexion
strength at fifteen degrees of hip flexion.1,10 The patient is
then rotated into a lateral decubitus position to measure hip
abduction strength. The patient is rotated prone and hip Figure 8 Piriformis test: this test is to assess for piriformis syndrome.
extension strength is measured. The patient is examined in the lateral decubitus position with the ex-
tremity being tested uppermost. The patient flexes the test hip to 60° of
Special Tests flexion with the knee also flexed. The examiner stabilizes the hip with
Special tests can be helpful for confirming specific sources of 1 hand and applies a downward force to the knee. If the piriformis is
pain from the hip and ruling out other sources of pain. While tight, pain is elicited in the muscle. If the piriformis is compressing the
assessing the standing patient for a Trendelenburg sign, the sciatic nerve, the pain may be in the buttocks and radiate distally to the
author also has the patient perform the Flamingo maneuver if back of the thigh to the knee. (Color version of figure is available
osteitis pubis is suspected. During this maneuver, the patient online.)
8 M.R. Safran

Figure 9 Routine hip radiographic series. An AP pelvis (A and B) can be helpful because it allows comparison with the
asymptomatic side to evaluate subtle variations in bony architecture as well as allowing visualization of closely related
areas that may present with hip pain. (A) A posterior dislocation of the right hip in a competitive soccer player. (B)
Chronic osteitis pubis in a professional football player. (C) A routine AP radiograph of a hip in a collegiate baseball
player, revealing an acetabular stress fracture as his cause of hip pain. (D) A frog lateral radiograph of the hip. Notice
how this is a true lateral of the femoral head and neck, revealing the asymmetry of the anterolateral neck, as seen in
femoral-acetabular impingement.

is supine. The examiner places the hip into full flexion, ex-
ternal rotation, and abduction (FABER) as the starting posi-
tion (Fig. 5A). Then the examiner extends the hip while also
internally rotating and adducting it (Fig. 5B). Reproduction
of pain and/or clunk is consistent with an anterior labral tear.
The posterior labral stress test is also performed supine.
However, the starting position is full flexion, adduction, and
internal rotation (Fig. 6A). The hip is then brought into ex-
tension while externally rotating and abducting the hip (Fig.
6B). Reproduction of pain and/or clunk is consistent with a
posterior anterior labral tear. Hase and Ueo7 reported that all
patients had pain with axial compression with the hip flexed
at 90° and slightly adducted. They reported that forced inter-
nal rotation with the hip flexed to 90° and tenderness poste-
rior to the greater trochanter were slightly less reliable but
useful physical examination findings for posterior labral
tears.
Sprains of the pubic symphysis or SI ligaments may be
assessed by the gapping and approximation tests. The Gap-
ping test, also known as the transverse anterior stress test,
assesses the pubic symphysis and the anterior SI ligaments.11
The patient is tested supine while the examiner applies
downward and outward pressure to the ASIS. If this causes
pain to the unilateral gluteal or posterior leg, this is consistent
with an anterior SI joint sprain, whereas pain at the pubic
symphysis would indicate a sprain here. With the approxi-
mation test, also known as the transverse posterior stress or
compression test, the examiner pushes from the patient’s iliac
crests toward the midline.11 Alternatively, the patient may be
placed in the lateral decubitus position and the examiner
pressing down on the iliac crest (Fig. 7). This movement
causes forward pressure on the sacrum and compression of
the pubis. Thus, posterior pain may be indicative of a poste-
Evaluation of the hip 9

this position without motion at the pelvis. A negative test has

the pelvis and body still.
A last test commonly performed on patients presenting to
my clinic with hip pain includes the single-leg deep knee
bend. In this test, subjects stand next to the examination table
and perform a deep knee bend on just 1 leg, whereas the
other leg is non–weight bearing. A patient with intraarticular
pathology will be unable to perform this motion without
significant catching or pain in the joint, although those with
extra-articular hip pain may also have a positive test.

Figure 10 Measurement of the CE angle; a center edge angle of less
than 20° to 25° is consistent with acetabular dysplasia. (Reproduced
with permission from Hughes PE, Hsu JC, Matava MJ: Hip anatomy
and biomechanics in the athlete. Sports Med Arthrosc Rev 10:103-
114, 2002.)
Imaging
Plain Radiographs
Routine radiographs should be obtained in all patients with
hip pain. Plain hip radiographic series includes an anteropos-
terior (AP) of the pelvis, an AP of the affected hip, and a lateral
(usually frog leg lateral) of the hip (Fig. 9). The AP of the
pelvis is imperative because it allows comparison with the
asymptomatic side to evaluate subtle variations in bony ar-
chitecture as well as allowing visualization of closely related
areas that may present with hip pain, such as the pubic sym-
physis, sacrum, sacroiliac joints, ilium, and ischium. The frog
leg lateral, although not a true lateral, is a good lateral of the
femoral head and neck and is easier to obtain than a cross
table lateral and provides more information about the prox-
imal femur. For those with suspected acetabular pathology,
Judet views are helpful, whereas other pelvic pathology may
be better assessed with inlet, outlet, and standard AP pelvis
views.

rior SI joint sprain and anterior pain may be consistent with

pubic symphysis inflammation, including osteitis pubis.
The piriformis test is used to confirm or rule out piriformis
syndrome (Fig. 8). To test for this clinical syndrome, the
patient is examined in the lateral decubitus position with the
extremity being tested uppermost. The patient flexes the test
hip to 60° of flexion with the knee also flexed. The examiner
stabilizes the hip with 1 hand and applies a downward force
to the knee. If the piriformis is tight, pain is elicited in the
muscle. If the piriformis is compressing the sciatic nerve, the
pain may be in the buttocks and radiate distally to the back of
the thigh to the knee.11
There are many tests recently described to evaluate core
stability because this is being more commonly discussed in
the treatment and prevention of injuries in athletes. One test
the author prefers is performed in the supine position. The
subject bends 1 hip and ipsilateral knee while maintaining
the other leg straight. Then they use the bent hip/knee ex-
tremity to lift their pelvis off the examination table while
keeping the other leg straight and off the examination table. Figure 11 Hip arthrogram to rule out detached osteochondral frag-
Those with core weakness will have difficulty maintaining ment from the femoral head.
10 M.R. Safran

for a prominent femoral neck indicative of hip impingement.

Both of these problems may result in labral tears.
The center-edge (CE) angle is determined by finding the
center of the femoral head and marking the lateral corner of
the acetabulum (Fig. 10). A horizontal line connects the 2
femoral head centers, and perpendicular lines are drawn
from each center. A line is drawn from the acetabular edge to
the center of the femoral head, and the angle formed is
known as the CE angle. The CE angle should be at least 20°
and preferably 25° to ensure normal seating of the femoral
head and ideally equal distribution of forces on the bony
acetabulum.
Plain radiography is otherwise usually normal in patients
with isolated labral tears but is useful in diagnosing associ-
ated pathology and in excluding other sources of hip symp-
toms. One special test the author obtains in patients with
osteitis pubis includes an AP of the pelvis standing on both
legs and then a film standing on 1 leg and then the other. This
study is to look for displacement or shear of the pubis.

Arthrography/Bursography
Arthrography has been recommended in the evaluation of
patients with suspected labral tears, especially before the ad-
vent of MRI.3 Arthrography can also be helpful in delineating
the stage of the uncommon diagnosis of osteochondritis dis-
secans of the hip (Fig. 11). Arthrography, where contrast is
supplemented with intra-articular local anesthetic and corti-
costeroids, had been advocated by Fitzgerald to help define
the location of the lesion and gauge the patient’s response to

Figure 12 The use of routine MRI in the evaluation of the painful hip
in the athlete. (A) Reveals bony edema in a competitive martial artist
in the lateral femoral head and neck as a result of femoral-acetabular
impingement. Notice the bony bump on the proximal lateral femo-
ral neck. (B) A ballet dancer with a several-year history of hip pain.
Her MRI reveals an osteochondroma of the medial femoral neck.

Plain radiographs will help exclude degenerative joint

changes, osteonecrosis, loose bodies, stress fractures, or
other osseous pathology. For subtle degenerative disease, a
weight-bearing AP pelvis radiograph may be more sensitive
than a standard supine/non–weight-bearing radiograph, al-
though the author is not aware of a study confirming this. Figure 13 MRI arthrogram revealing a torn lateral acetabular labrum.
One should assess for subtle acetabular dysplasia, using cen- Intra-articular gadolinium arthrogram enhances the sensitivity of
ter-to-edge and other appropriate measurements, and assess the MRI in diagnosing these lesions.
Evaluation of the hip 11

sitivity and a 91% specificity.2 As with fluoroscopic arthrog-

raphy, the author uses intra-articular local anesthetic with
gadolinium to assess pain relief in addition to anatomic evi-
dence of intraarticular pathology. Because labral tears may be
asymptomatic and because MRIs may be falsely negative,
pain relief with the lidocaine is considered important in con-
sideration as to whether hip arthroscopy may be of benefit. If
there is no relief with the intra-articular injection, one must
consider sources of pain other than intra-articular causes.
Extravasation of anesthetic precludes this from being 100%
specific for intra-articular etiology of pain. Corticosteroids
are only added when a patient has degenerative arthritis.

Computed Tomography Scan

Figure 14 CT scan of the soccer player in Figure 9A, status post-right Computed tomography (CT) scan has traditionally been used
hip reduction. Notice the loose body in the acetabular fossa of the to evaluate bone and considered to be superior to MRI for
right hip.
assessment of bony congruity. CT scans can be useful to
measure anteversion and retroversion, and they can show the
size and shape of the acetabulum and femoral head and neck.
local anesthetic.3 Arthrography may therefore be viewed as
CT scans are useful to confirm concentric reduction after hip
diagnostic as well as therapeutic in some cases. Arthrography
dislocations and to rule out loose bodies (Fig. 14).
has been shown to be more sensitive in detecting tears of the
anterior labrum as compared with the posterior labrum.8,15
As will be seen later, the author continues these concepts
Radioscintigraphy
with magnetic resonance arthrography. Bone scans are very sensitive tests, particularly when the
The imaging modality of choice for iliopsoas bursitis and source/location of hip pain is unclear. Traditionally, bone
internal snapping hip is iliopsoas bursography.6 The snap- scans have been useful to diagnose stress fractures (especially
ping of the hip can be seen under fluoroscopic visualization femoral neck), osteonecrosis, and tumors (Fig. 15). How-
of the contrast injected bursa. Herniography has also been ever, these roles have largely been replaced by MRI.
recommended to rule out hernias, particularly the difficult to
diagnose “sports” (or Gilmore) hernia. Ultrasound
Iliopsoas bursitis and internal snapping hip may be evaluated
MRI with real-time dynamic ultrasound.9,13 One is able to see the
MRI has traditionally been used for soft-tissue injury, such as
labral tears, bursitis, and tendinous injuries. However, MRI
has been found to be useful in the early detection of stress
fractures of the femoral neck and osteonecrosis. The routine
use of MRI in assessing labral injuries has been questioned by
some because of the relatively low sensitivity and specificity
of MRI when compared with arthroscopy.3 False-positive re-
sults may also occur with MRI. Several studies have shown
morphologic variants, degeneration, and increased signal
within the labrum in asymptomatic controls. MRI has proved
important in identifying sources of hip pain other than labral
tears including osteonecrosis, pigmented villonodular syno-
vitis, synovial chondromatosis, osteochondromas, and other
intraarticular pathology (Fig. 12). Newer techniques and
more powerful magnets have increased the ability to detect
isolated chondral defects of the femoral head and acetabu-
lum.

MRI Arthrography
MRI combined with arthrography appears to increase the
utility of this imaging modality in the diagnosis and descrip-
tion of labral pathology and articular cartilage loss (Fig. 13).
Magnetic resonance arthrography is a minimally invasive
means of diagnosing these problems with a higher specificity Figure 15 Bone scan of the patient in Figure 9C, revealing the in-
than MRI. Magnetic resonance arthrography had a 90% sen- creased activity of this acetabular stress fracture.
12
sudden lateral to medial shift of the tendon with real-time
ultrasound. Ultrasound is also a nonirradiating way of eval-
uating soft tissues about the hip.
Summary/Conclusion
With advances in the understanding of the hip and improve-
ments in imaging and less invasive surgery, the hip is a joint
of increasing interest to those who treat athletes. Careful his-
tory, physical examination, and appropriate adjunctive im-
aging techniques can reliably provide the correct diagnosis
for the management of these problems. This article serves as
a review of these diagnostic techniques for the clinician car-
ing for those active patients with hip pain.
References
1. Broadhurst N: Iliopsoas tendonitis and bursitis. Aust Fam Physician
24:1303, 1995
2. Czerny C, Hofmann S, Neuhold A, et al: Lesions of the acetabular
labrum: accuracy of MR imaging and MR arthrography in detection and
staging. Radiology 200:225-230, 1996
3. Fitzgerald RH: Anterior labrum tears—Diagnosis and treatment. Clin
Orthop 311:60-68, 1995
4. Gruebel-Lee DM: Disorders of the hip. Philadelphia, PA, JB Lippincott
Co, 1983
M.R. Safran
5. Guanche CA, Sikka R: Runner’s hip. The possible association between
running and the development of degenerative acetabular labral tears.
Arthroscopy (in press)
6. Harper MC, Schaberg JE, Allen WC: Primary iliopsoas bursography in
the diagnosis of disorders of the hip. Clin Orthop 221:238-241, 1987
7. Hase T, Ueo T: Acetabular labral tear: Arthroscopic diagnosis and treat-
ment. Arthroscopy 15:138-141, 1999
8. Ikeda T, Awaya G, Suzuki S, et al: Torn acetabular labrum in young
patients: Arthroscopic diagnosis and management. J Bone Joint Surg
[Br] 70:13-16, 1988
9. Jacobson T, Allen WC: Surgical correction of the snapping iliopsoas
tendon. Am J Sports Med 18:470-474, 1990
10. Johnston CAM, Wiley JP, Lindsay DM, et al: Iliopsoas bursitis and
tendonitis. A review. Sports Med 25:271-283, 1998
11. Lee D: The pelvic girdle (ed 2). Edinburgh, Churchill Livingstone,
1999
12. Ober FB: The role of the iliotibial band and fascia lata as a factor in the
causation of low back disabilities and sciatica. J Bone Joint Surg 18:105-
110, 1936
13. Schaberg JE, Harper MC, Allen WC: The snapping hip syndrome. Am J
Sports Med 12:361-365, 1984
14. Silver SF, Connell DG, Duncan CP: Case report 550. Snapping right
iliopsoas tendon. Skeletal Radiol 18:327-328, 1989
15. Suzuki S, Awaya G, Okada Y, et al: Arthroscopic diagnosis of ruptured
acetabular labrum. Acta Orthop Scand 57:513-515, 1986
16. Thurston A: Assessment of fixed flexion deformity of the hip. Clin
Orthop 169:186-189, 1982
17. Trendelenberg F: Trendelenberg’s Test (1895). Clin Orthop 355:
3-7, 1998