Author(s): David Alfaro, MD, Brandon Agundez, MD, Nashra Javed, MD, Ibe Gospel, BA, Bryson Reed, BS, Sara Flores, MD
Originally published: September 16, 2015 Last updated: January 22, 2026
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Disease/Disorder

Definition

Anterior and medial hip disorders affecting athletes’ hip include dysfunction and/or pain affecting the anteromedial structures of the hip. These problems may be approached with Doha and Warwick agreement, a classification system that best determines the primary pain generator. Classifications include intra-articular causes (femoroacetabular impingement syndrome [FAIS], labral tears, hip microinstability, developmental dysplasia), extra-articular causes (musculotendinous injuries, iliopsoas-related pain), or referred sources (spine, pelvis, or neurovascular structures).91,92 

Etiology

Etiologies of anteromedial hip disorders can generally be attributed to one or more underlying causes such as: anatomic abnormalities, overuse, and direct neuromechanical damage. Anatomic abnormalities may be either intra- or extra-articular in origin, causing impingement resulting in pain or limited range of motion (ROM). Femoral acetabular impingement (FAI) and sub-spine impingement are intra-articular examples, whereas anterior inferior iliac spine (AIIS) impingement is extra-articular.77,78 Overuse injuries of intra-articular structures include stress reactions and fractures of the femoral neck and pelvis, both which cause anteromedial pain and are more prevalent among athletes.30,31 Extra-articular overuse injuries can be acute and/or chronic, typically affect the musculotendinous portions of the hip flexors and adductors and are more prevalent in the athletic patient population. Finally, neuromechanical damage can be in the form of either direct mechanical injury (labrum, capsule or tendons), compression neuropathies, (i.e., ilioinguinal, genitofemoral, or obturator neuropathies), or referred pain from disorders of the spine or pelvic floor.1,2

Epidemiology including risk factors and primary prevention

Data on the overall incidence and prevalence of anteromedial hip disorders reveal that hip osteoarthritis is the most common, followed by femoroacetabular impingement syndrome (FAIS), hip dysplasia, and other morphologies. The global age-standardized prevalence of radiographic hip OA is estimated at 8.55% (Kellgren-Lawrence grade ≥2).93

In the US, the prevalence of radiographic hip OA among adults ≥ 50 years is 19.6%, while symptomatic hip OA is 4.2%.94 Annual incidence rates for radiographic hip OA in US adults ≥45 years are about 23 per 1,000 person-years, and for symptomatic hip OA, 13 per 1,000 person-years.95  The annual incidence of clinically diagnosed FAIS in patients aged 14–50 years is 54.4 per 100,000 person-years, with higher rates in females.96 Prevalence of acetabular dysplasia is 4.3% in men and 3.6% in women; deep acetabular socket 15–19%; pistol grip deformity 5–20% depending on sex.97 These rates reflect the general population; prevalence is higher in athletes and certain subgroups.

Studies have shown that groin related injuries in sports with rapid directional changes, kicking, and twisting (e.g. ice hockey, soccer, and rugby) account for 5-18 % of injuries.3,4,60,63 Position played also factors into the type of injury that may occur. For example, ice hockey goaltenders may be more prone to intra-articular hip injuries than other positions.64 Labral injuries in particular have been reported in the aforementioned sports as well as golfers, rowers, dancers, karate practitioners, basketball, and baseball players.3-7 According to Epstein et al, 2012 retrospective study of NHL players, the cumulative incidence rate of [both hip and groin injuries was] 19.87 injuries per 100 players per year.8,9 In Feeley et al, 2008 study of the NFL from 1997 to 2006, muscle strains (most commonly the hip flexor), hip contusions, and intra-articular injuries (labral tears, fractures, and dislocations/subluxations) made up 59, 33, and 5% of all NFL injuries, respectively. Although representing only 5% of all injuries, intra-articular hip injuries accounted for the most time lost.3 Athletes are predisposed to these types of injuries because of the high mechanical stresses and loads placed on the hip joint, combined with rapid motions such as cutting and extremes of hip flexion and internal rotation.1-3,10

Regarding FAIS, there are two subtypes, CAM and Pincer, which correlate with femoral head-neck junction and acetabular head abnormalities, respectively, and can occur independently or together.  There is data to suggest that participation in sports with cutting motions (e.g. soccer, basketball, hockey), particularly during the growth years, may lead to increased CAM type morphologies  and consequently impingement.4,11-13 With studies showing up to 68% of CAM type morphology in young male athletes, it is important that young pre-adolescent athletes participating in sports such as soccer or basketball be educated on avoiding extreme flexion, deep squats, and lunges to prevent the development of such femoroacetabular abnormalities at the time of skeletal maturity.4,11-13, 66 For young athletes participating in sports such as baseball, other recommendations to prevent these abnormalities include rotating playing positions on the field. Additionally, males tend to have larger alpha angles, larger CAM morphologies in males, and more severe chondral damage.88 

Risk factors for the most common anteromedial hip disorders are listed below

  • Intra-articular hip osteoarthritis: FAIS, obesity, and advancing age.14,15
  • Stress reaction or stress fractures: tobacco or alcohol use, osteopenia/osteoporosis, female athlete triad (disordered eating, amenorrhea and osteoporosis), female military recruits, and endurance sports such as track and field, or skaters.30,31
  • Labral tears: female sex, history of Legg-Calve-Perthes disease, developmental hip dysplasia, instability, decreased femoral or acetabular version, decreased head-neck offset.1,16
  • FAIS: labral tear, developmental hip dysplasia, age, cutting sports (basketball, soccer, football); young, active males and larger alpha angles (CAM morphology), middle-aged females (Pincer morphology).16-19
  • Athletic pubalgia or core muscle injury: football, hockey, soccer, and tennis players.1,20,21
  • Iliopsoas impingement and coxa saltans (also known as snapping hip syndrome): ballet dancers (repetitive extreme ROM) and patients with rheumatoid arthritis.1,6,22
  • Sub-spine and AIIS impingement: prior AIIS avulsion injury, anatomic abnormalities such as AIIS excess prominence, acetabular over-coverage, abnormal acetabular retroversion.1,16,77 Sub-spine hypertrophy can be either primary or secondary to traction hypertrophy and is seen commonly in sports with regular hyperextension and rotational hip stresses, e.g.: running and twisting/turning.78-80
  • Ischiofemoral impingement: female athletes at the peak of their developmental trajectory (underlying pelvic morphology predisposes to decreased ischiofemoral distance).82-83

Patho-anatomy/physiology

Different mechanisms will be outlined for the most common diagnoses seen

  • Osteoarthritis (osteochondral layer): occurs due to abnormal joint mechanics and loading, which leads to decreased joint space (narrowing), bony sclerosis, and articular cartilage loss. FAIS, labral tears, hip dysplasia, and acetabular retroversion are proposed to be precursors to this non-inflammatory process, especially in younger patients before the age of 55.14,15,23,24
  • FAIS (osteochondral layer): anatomical abnormality at the femoral head neck junction or acetabular rim with resultant abnormal contact causing reduced range of motion of the hip and leading to impingement. The two subtypes are outlined below.
    • CAM type impingement is caused by an abnormal shaped femoral head or neck contacting the acetabular rim during flexion and internal rotation activities. The anterosuperior acetabular cartilage is most affected.17,18,23-25
    • Pincer type impingement is caused by over-coverage of the acetabulum over the femoral head. Repeated contact leads to circumferential cartilage damage, posteroinferior labral degeneration (from contra-coup mechanism), and acetabular deepening.17,18,23-25
  • Labral tears (inert layer): may be traumatic, degenerative, or result from repeated impingement such as in FAIS or developmental hip dysplasia. Articular cartilage damage is part of and contributes to this process if delamination of the articular cartilage occurs.26-29 
  • Rectus femoris or iliopsoas tendinopathy (contractile layer): results from improper training, repetitive loading, or trauma.1,2,22 
  • Iliopsoas impingement (contractile layer): Psoas tendon snaps over the iliacus as the hip moves from flexion, abduction, and external rotation to extension and internal rotation. Dynamic ultrasound studies have demonstrated that the psoas tendon glides over the medial part of the iliacus and the superior pubic ramus during the return of the hip into a neutral position.2,22
  • Athletic pubalgia or core muscle injury (contractile layer): no actual hernia exists, but shearing forces placed across the pubic symphysis from the adductors, rectus abdominis, and stresses of the inguinal wall musculature may predispose athletes to unilateral groin pain that may radiate into the thigh.1,20,21
  • Compressive neuropathy: may affect the obturator nerve via trauma or entrapment. L1 or L2 radiculopathies may elicit groin pain.1,16,29
  • Ischiofemoral impingement: narrowing of space between the lesser trochanter and ischial tuberosity that leads to the compression of the quadratus femoris muscle. This may lead to pain in the groin area that increases with weight bearing.66,67

Disease progression including natural history, disease phases or stages, disease trajectory (clinical features and presentation over time)

Acute muscle strains tend to resolve with basic conservative care (relative rest, ice, compression, and elevation), whereas tendinopathies may continue to progress to chronic phases without proper eccentric strengthening programs. With hip osteoarthritis, progression is seen with further decreases in joint space, increased osteophyte formation, and bony sclerosis (severity may be graded with the Tonnis grading scale), though this may not always correlate clinically with increased pain or decreased function.14,15 Injuries resulting from untreated stress fractures tend to be more symptomatic at initial onset but may resolve quickly and only be reproduced with specific activities. However, in the case of femoral neck stress fractures, and compression fractures they should be worked up and monitored with limited weight bearing activity to start, whereas tension stress fractures should be immediately evaluated by an orthopedic surgeon due to an increased risk of fracture and displacement.30,31

Specific secondary or associated conditions and complications

FAIS and labral tears may increase the risk for the development of early hip osteoarthritis.1,14,17,18 Associated conditions may include hip abductor dysfunction, chronic lower back pain, and poor flexibility of the quadriceps, hamstrings, tensor fasciae latae and iliotibial band tendons.1,16,20 Biomechanical changes in the hip may lead to the development of lumbar pathology, otherwise known as a secondary hip-spine syndrome.76

Essentials of Assessment

History

A comprehensive history should include onset and duration of symptoms, quality and character of pain or dysfunction, location, radiating symptoms, exacerbating/alleviating factors, whether the disorder is affecting the athlete’s sport participation or performance, education (if in school), and functional activities. Obtaining a history of similar injuries, nutrition, and the menstrual cycle, if appropriate, are also relevant details. “Red flag symptoms” (i.e. unexplained weight loss, night sweats, prolonged corticosteroid use) should generally be assessed to reduce the likelihood of “can’t miss diagnoses” including malignancy and focal infection as is generally recommended when assessing suspected musculoskeletal pathology.98 Mechanical symptoms (i.e. locking, catching, clicking) should be assessed as presence of these symptoms in conjunction with structural abnormalities such as labral tears or chondral lesions may warrant surgical referral.99

Physical examination

The physical exam should be carried out in 4 different positions: standing, sitting, supine, and prone. The standing exam assesses for general body habitus, gait, lumbopelvic alignment, ligamentous laxity, and Trendelenburg testing for functional hip abductor weakness. The seated exam checks for any abnormalities in skin, vasculature, lymph, ROM of the hip and neurologic testing, such as lower extremity sensory testing (light touch and pinprick) and deep tendon reflexes can be assessed in this position.32 To aid in honing in on a specific differential, an examiner should perform corresponding maneuvers that correlate with the prioritized differential diagnosis. Findings corresponding to relevant diagnoses are described below.

  • Femoroacetabular Impingement Syndrome (FAIS): Key findings include pain with the Flexion-Adduction-Internal Rotation (FADIR) test and often with the Flexion-Abduction-External Rotation (FABER) test. Restricted internal rotation and pain with passive hip flexion and rotation are common. Groin pain is typically the main location, and combining groin pain with a positive FABER or FADIR increases diagnostic sensitivity.100,101
  • Labral Tears: Similar to FAIS, with positive FADIR and FABER tests, and sometimes mechanical symptoms (clicking, catching) during hip motion. Pain may be reproduced with deep flexion, adduction, and internal rotation.100,101
  • Hip Microinstability: Physical exam maneuvers include the anterior apprehension test (pain or apprehension with extension and external rotation), abduction-hyperextension-external rotation test, prone instability test, and axial distraction test. Findings may be subtle and require careful assessment for excessive femoral head translation or apprehension.102
  • Adductor-Related Groin Pain
    • Findings: Point tenderness at the adductor origin (usually adductor longus) and pain with resisted hip adduction. The squeeze test (isometric adduction against resistance) is often positive. Palpation and resisted adduction are the most reliable clinical tests.103-105
  • Iliopsoas-Related Groin Pain
    • Findings: Tenderness along the iliopsoas muscle or tendon, pain with resisted hip flexion (especially seated), and pain with stretching the iliopsoas. Palpation over the iliopsoas and resisted hip flexion help differentiate this entity.103-105
  • Inguinal-Related Groin Pain (Athletic Pubalgia/Core Muscle Injury)
    • Findings: Tenderness at the external inguinal ring, pubic tubercle, or rectus abdominis insertion. Pain is often reproduced with resisted sit-up, forced cough/sneeze, or Valsalva maneuver. Evaluation for hernia is essential, and pain may be aggravated by abdominal straining or sports movements.106-108
  • Pubic-Related Groin Pain (Pubic Bone Stress Injury)
    • Findings: Point tenderness over the pubic symphysis, pain with direct palpation, and sometimes pain with single-leg stance or resisted adduction. Symptoms are typically activity-related and may be confirmed by imaging if diagnosis is unclear.103-105

Clinical functional assessment: mobility, self-care cognition/behavior/affective state

Although this varies from disorder to disorder, activities such as transitional movements, walking, stair climbing, and deep squats are commonly reported to aggravate most anteromedial hip disorders. Alternative modes of exercise such as a stationary bike or switching to a cross-training program may be necessary while an injured athlete undergoes a specific lower extremity rehabilitation program.

Laboratory studies

Routine laboratory studies are not indicated for mechanical hip or groin pain. However, presence of red-flag features may raise suspicion for infection, rheumatologic disease, or malignancy. In such cases, a basic cell blood count may show leukocytosis with elevated inflammatory markers (e.g.: erythrocyte sedimentation rate and C-reactive protein levels). Inflammatory or infectious disorders of the pelvis may need to be ruled out in unusual cases. A full rheumatologic panel may be ordered if necessary. Depending on clinical context, tumor-specific markers or myeloma screening may also be indicated.

Imaging

Initial work-up should include radiographic imaging with at least two views, the anteroposterior (AP) and axial cross table view. The latter view is used to better visualize the femoral neck-head junction where the hip is placed in a neutral position or internally rotated at 15 degrees.87 Lumbar spine x-rays may also be done to rule out an overlapping spine disorder.16,33 MRI of the hip may be ordered if there is suspicion for a symptomatic labral tear or to assess for a specific tendon or muscle tear (e.g.: rectus femoris), or fracture.34,35 MR arthrography (MRA) is considered the best imaging modality to assess for labral tears, although this is debated.34-36 Labral tears are often found in asymptomatic individuals.109 MRI (non‐contrast) may suffice in many cases; MRA remains an option for high suspicion of labral tear if plain MRI is inconclusive.  The costs vs. benefits of such a study may need to be determined.62

Musculoskeletal ultrasound has proven useful for both diagnostic and interventional purposes.37 Sonopalpation may help diagnose and reveal the location of an injury if pressure at a specific location reproduces the patient’s pain.60 This may be useful for planning injection procedures. Ultrasound can help correlate findings in real time and attain dynamic images in various positions, including Valsalva in the evaluation of athletic pubalgia. This also gives the physician increased patient interaction.61 Iliopsoas impingement, bursitis, tendinopathies, and intra-articular hip effusions may also be visualized using this dynamic, real-time imaging modality.37,38 It should be noted, however, that ultrasound alone does not adequately image the hip joint itself or the cartilaginous labrum, unlike MRI.

Supplemental assessment tools 

Existing hip research tools have primarily focused on patients with hip fractures, arthritis or post op hip replacements. The most common measure used is the Modified Harris Hip Score. The Multicenter Arthroscopy of the Hip Outcomes Research Network (MAHORN) group developed a 33-question survey tool that was applicable to several common bony or labral hip pathologies.41 However, it is not applicable to muscular or referred pain from spine or knee sources. The Hip Outcome Score (HOS) has been validated for hip labral injuries.42 Other outcome measures include the Western Ontario and McMaster University Osteoarthritis Index (WOMAC), Short Form-36, Hip Disability and Osteoarthritis Outcome Score (HOOS), Non-Arthritic Hip Score (NAHS), Copenhagen Hip and Groin Outcome Score (HAGOS), and International Hip Outcome Tool-33 (iHOTT-33).39-43 

Electrodiagnostics may also be considered when assessing for compressive peripheral nerve pathology, such as obturator nerve entrapment. In such a case, electromyography would be performed to evaluate for evidence of acute denervation of the adductor muscles (gracilis, adductor longus, and adductor magnus), or chronic reinnervation, which would support the diagnosis of acute or chronic entrapment, respectively.110  

Early prediction of outcomes 

There are factors which may help predict a positive outcome in patients with anteromedial hip sports-related injury. For example, patients with an acetabular labral tear without hip OA are more likely to have a positive outcome.28 As with the management of other musculoskeletal conditions, the principles of close follow-up, compliance with prescribed treatment, and a comprehensive physical therapy program will generally alleviate and improve patient’s symptoms. 

For patients who require operative management, younger age, female sex, hip dysplasia, instability, and residual intra and extra-articular impingement were identified as risk factors for revision arthroscopic or open hip preservation surgery in a cross-sectional study of 147 patients.59 

Environmental 

Environmental factors include whether the sport is played indoor or outdoor, the type of surface or terrain, and any related clothing, equipment, or gear that is used. Hip motion, especially extremes of flexion and internal rotation, can affect the condition of the hip. Athletes should be counseled on modifying their training regimen, particularly if at high risk for hip disorders. 

Social role and social support system 

When athletes or patients are unable to participate in their preferred sport or exercise during treatment or recovery, they are at heightened risk for anxiety, depression, loss of athletic identity, and social isolation.111These psychosocial factors can significantly affect both rehabilitation adherence and overall recovery outcomes. Therefore, it is essential to educate and counsel athletes, families, coaches, and personal trainers regarding alternative sports or exercise activities they may safely participate in during treatment to maintain physical conditioning. In addition, clinicians should promote strong social support networks—including family, teammates, and healthcare providers—to help athletes preserve a sense of belonging and motivation throughout the rehabilitation process. 

Professional issues 

Education and open communication with the athlete’s family, friends, athletic trainers, and coaches is necessary to prevent recurrent injury and to maintain effective physician-team rapport. Special precautions must be taken with college or professional athletes, as there may be a financial incentive or institutional pressure to have the athlete return to play before he or she is ready to. In such cases, emphasis must be placed on the athlete’s health and safety before team commitments.

Rehabilitation Management and Treatments

Available or current treatment guidelines

There are no available consensus statements or treatment guidelines for most of the disorders discussed above. There is, however, an abundance of literature to support the surgical management of certain conditions including FAIS and labral tears. Unfortunately, there are no double blinded, randomized controlled trials comparing the efficacy of physical therapy and conservative care versus surgical intervention in the treatment of these and other anteromedial hip disorders.44 One study from the United Kingdom conducted by Griffin et. al as a multicenter, assessor-blinded, randomized controlled trial compared hip arthroscopy and personalized hip therapy for patients with FAIS. Both interventions improved hip-related quality of life, however hip arthroscopy led to a clinically significant greater improvement, albeit with a higher rate of serious adverse events compared to physical therapy.84 A recent systematic review demonstrated lower rate of progression to osteoarthritis and need for total hip arthroplasty in patients who underwent hip arthroscopy in treatment of FAIS.112 Although surgical studies do promote the use of activity modification and physical therapy as the initial treatment, there is no agreed upon “best practice” when treating athletes with anteromedial hip pain and dysfunction.3,16,44-48 

Conservative treatment usually involves rest, NSAIDs, heat and/or ice. In FAI, as well as the other anteromedial hip disorders discussed above, rehabilitation efforts should focus on core muscle strengthening and treating the imbalance between the hip and abdominal muscles.  Improving range of motion of the hip external rotation and abduction in extension and flexion has shown to be beneficial.64,75 

Treatment for osteitis pubis also begins with conservative management focusing on physical therapy. A study evaluated the use of shock wave therapy versus sham shock wave therapy directly to the pubis and reported promising results with earlier return to sport with the use of shock wave therapy.65 

In ischiofemoral impingement, the reduced space between the lesser trochanter and ischial tuberosity may cause a leg length discrepancy. Conservative management with the use of insoles or shoe modifications have been proposed.66 For the treatment and management of athletic pubalgia, a position statement put forth by the British Hernia Society in 2014 advised at least a 2 month program consisting of active, supervised physical therapy emphasizing core and lumbopelvic stabilization and strengthening (initially isometric then progressing to eccentric and concentric) exercises, cross training, and appropriate injections (not specific, but ilioinguinal nerve blocks were cited) prior to any surgical consultation.48-49 More recent reviews endorse 3 months of conservative therapy prior to surgery.81 There is a current push in the United States to describe this condition as a core muscle injury.50

With respect to return to play, assessing the athlete’s level of pain and its effect on functional activities is important.31 General treatment includes a thorough work up of risk factors and treatment followed by relative rest, activity modification, and weight bearing precaution, with activity titrated using pain as a guide during an average period of 4 to 8 weeks depending on the severity of the stress fracture.31 While the stress fracture is allowed to heal, athletes should be encouraged to cross-train with other sports such as swimming, cycling, or aqua-running. They should also be counseled on nutrition, and to be screened for low bone mineral density.31 Athletes who have pain from FAIS and labral injuries may improve with a focused rehabilitation program that avoids motions that aggravate and reproduce symptoms.

At different disease stages 

In the acute to subacute setting, anteromedial hip disorders may be approached with activity modification (e.g.: avoidance of deep hip flexion and internal rotation to prevent impingement symptoms), rest for a limited time away from the sport, modalities such as ice or heat, a short course of oral anti-inflammatory medications, and an emphasis on an appropriate physical therapy and home exercise program.3,17,18

Most patients with anteromedial hip dysfunction (especially FAIS) will have weakness with hip adduction, abduction, flexion, [and/or] external rotation, as well as have disturbances with core trunk and lumbopelvic stability and control.3,16,20,44 Hence, the physical therapy prescription should address such strength deficits found on physical exam, accompanied with the goal of improving their lumbopelvic range of motion, proprioceptive training, and reducing pain during sport-specific functional tasks.16 It is very important to include both hip and spine stability exercises before the patient is progressed to sport specific training.16,20,51

If patients do not improve with non-operative management, then their diagnosis should be reconsidered and further work-up done as necessary. On the other hand, if they are unable to advance their rehabilitation program because of pain, other conservative treatments are available. For intra-articular lesions (osteochondral or inert layer disorders) such as hip osteoarthritis, FAIS, or labral tears, an image guided intra-articular hip injection consisting of a combination of local anesthetic with or without corticosteroid may be used both diagnostically and therapeutically to alleviate pain and help the athlete continue in physical therapy or return to play sooner. They also appear to hold a prognostic value in predicting the need for surgical interventions.1,3 Extra-articular or contractile layer disorders (e.g.: psoas impingement syndrome) may similarly benefit from an image-guided bursa or tendon sheath injection. Initial injections may be performed with local anesthetic and corticosteroid but may be transitioned to more novel treatments such as platelet rich plasma (PRP), with or without percutaneous needle tenotomy, if the underlying dysfunction is due to tendinopathy, however PRP efficacy continues to be studied.2,52-55

Chronic disorders can be managed similarly but often require a longer recovery process. In chronic intra-articular conditions secondary to hip osteoarthritis, ultrasound guided viscosupplementation injections, although not yet approved for hip OA by the Food and Drug Administration, may be used and are preferred over repeat corticosteroid injections.58-60

Coordination of care

It is crucial that a multidisciplinary team approach involving the patient’s physician(s), family, athletic trainers, coaches, and physical therapists is utilized to maximize healing before returning to play. It is important that communication remains consistent, and that the athlete’s diagnosis(es) are always kept in mind.

Patient & family education

As discussed earlier, proper education regarding an athlete’s diagnosis, available treatment options, prognosis, injury prevention, and expected return to play should be communicated to both the athlete and his or her family. In addition, at follow up visits or in the training room, gentle reminders should also be used to reinforce avoidance of specific lower extremity motions and the maintenance of a home exercise program to prevent re-injury. 

Measurement of treatment outcomes including those that are impairment-based, activity participation-based and environmentally based 

Expanded patient-reported outcome measures such as the International Hip Outcome Tool (iHOT-33), Hip Disability and Osteoarthritis Outcome Score (HOOS), Copenhagen Hip and Groin Outcome Score (HAGOS), and the Kerlan-Jobe Orthopaedic Clinic (KJOC) Athletic Hip Score are recommended because they assess broader domains including sports/recreation, social and emotional well-being, and overall quality of life. These tools provide a more holistic view of recovery and are validated for use in athletic populations.113,114 

Translation into practice: practice “pearls”/performance improvement in practice (PIPs)/changes in clinical practice behaviors and skills 

Providers should keep in mind to examine both the spine and knee, as pain patterns at the anteromedial hip may be referred. Additionally, low back pain may accompany many of the disorders. Initial work-up may include imaging of such regions depending upon patient presentation. 

Incorporate functional tests, such as the SLS and SDT, into your physical examination for dynamic evaluation of range of motion, strength, and proprioception. 

The core encompasses the lumbar spine through the thighs. The iliopsoas is the only muscle that has its origin in the spine and crosses the hip joint. It works both as a spine stabilizer and hip flexor. Assessing lumbopelvic muscle groups, abdominal muscles, and the surrounding musculature of the hip must all be assessed individually and as part of the kinetic chain.77 All these elements must be addressed to return athletes to sport. 

Focused hip flexor concentric strengthening can exacerbate symptoms. Focus on strengthening the abductors and core stability. Eccentric and isometric exercises can be initiated as the pain subsides. 

Femoral neck stress fractures can mimic hip impingement. Always keep it in mind when a patient with risk factors for a stress fracture has multiple impingement signs encountered on physical exam.

If pelvic floor dysfunction/pain is part of the differential diagnosis, a more detailed obstetric, and social history should be elicited including any history of physical or sexual abuse, as well as any past psychiatric illness.

Gaps in the Evidence-Based Knowledge

The current medical literature does not contain any double blinded, randomized controlled studies assessing the benefits of a structured rehabilitation program versus surgical intervention for patients or athletes with anteromedial hip disorders.44 There is also no data as to whether or not structured rehabilitation programs modify the natural history of degenerative joint changes found in symptomatic FAIS.17 

Regenerative medicine procedures, such as PRP or stem cell injections, have the potential for both pain relief and healing of damaged tissue.56-58,68-72 Studies have shown that PRP can reduce pain in patients with hip OA, with improvements up to one year.90 Several studies have examined the use of PRP in hip arthroscopy with mixed findings. In a randomized controlled trial published by Foo et al., using PRP after hip arthroscopy did not improve outcomes in the long term, however another prospective study concluded that there were lower post op pain scores with using PRP and fewer joint effusions at 6 months.85-86,89 Other research could focus on comparing these injections to other physical and pain-relieving modalities, surgery, and also assess for long-term benefit. 

Cutting Edge/Emerging and Unique Concepts and Practice 

The use of musculoskeletal ultrasound to assess for dynamic impingement, tendinosis, and for guidance of interventional procedures has shown promise as part of the spectrum of conservative management of patients and athletes who decline surgery or are not ideal surgical candidates.37 

Dynamic imaging modalities like leg-traction magnetic resonance imaging (MRI) can be effective for differentiating intra-articular anteromedial hip disorders, particularly those involving the labrum and cartilage. Leg-traction MRI can be useful for differentiating FAI, osteoarthritis, hip microinstability, and iliopsoas impingement by enhancing visualization of intra-articular structures but is less effective for extra-articular disorders such as athletic pubalgia and ischiofemoral impingement.  It does this by enhancing joint distraction and separation of articular surfaces. This technique allows for improved visualization of the femoroacetabular cartilage layers, labral tears, and the ligamentum teres, which is especially relevant for distinguishing between femoroacetabular impingement syndrome (FAI), osteoarthritis, and iliopsoas impingement.115,116

In addition, PRP injections may be beneficial for improving pain from rectus femoris or iliopsoas tendinopathies and potentially for intra-articular conditions such as hip osteoarthritis, when combined with a supervised rehabilitation program.37,56-58

In addition to evidence for the clinical benefit of PRP in OA,56-58,68 there is also evidence that it may help in the treatment of acetabular labral tears73 and when combined with bone marrow-derived mesenchymal stem cells, may be beneficial in osteonecrosis of the hip.71 Stem cell injections on their own may also be clinically effective in OA69,70 and osteonecrosis of the hip.72,74

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Original Version of the Topic

Peter J. Moley, MD, Richard G. Chang MD, MPH. Sports medicine disorders of the hip: Anterior-Medial. 9/16/2015.

Previous Revision(s) of the Topic

Timothy Tiu, MD, FAAPMR, CAQSM, Natalia Miranda-Cantellops, MD. Sports medicine disorders of the hip: Anterior-Medial. 12/8/2019.

Timothy Tiu, MD, Natalia Miranda-Cantellops, MD, Robin Mata, DO, MPH. Sports Medicine Disorders of the Hip: Anterior-Medial. 11/30/2022.

Author Disclosure

David Alfaro, MD
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