History

A focused history should localize the dominant pain generator, define its effect on function, and identify factors that may change treatment. The differential should remain broad because hip-region pain may arise from intra-articular, periarticular, spinal, abdominal, pelvic, neurologic, or systemic pathology. A more detailed discussion of specific hip pain generating pathologies are discussed in the section on hip pathologies.

Pain location and behavior: Ask the patient to point with one finger to the worst pain. Deep anterior groin pain, often described with a C-sign, is compatible with intra-articular pathology but is not specific. Lateral pain broadens the differential to the abductors, greater trochanteric pain syndrome, lumbar referral, or a snapping iliotibial band. Posterior pain may be hip-related, but the sacroiliac joint, lumbar spine, proximal hamstring, deep gluteal space, and pelvic causes should also be assessed.

History item	Useful details to know
Onset and trajectory	Acute pivoting injury, insidious activity-related pain, timing in relation to a prior operation, or a steadily worsening pattern.
Mechanical symptoms	Catching, clicking, locking, giving-way, or a painful snap. Ask whether the symptom is deep, reproducible, and associated with the familiar pain.
Load sensitivity	Sitting, squatting, pivoting, stairs, running, cutting, cycling, sexual activity, work, and sport. The provoking position is often more useful than the adjective used for pain.
Previous care	Physiotherapy content and duration, activity modification, NSAIDs/analgesia, prior injections and the agent used, if it was done under image guidance/not, magnitude/duration of response, previous hip imaging, and prior hip surgery including operative report if available.
Patient context	Sport/work demands, goals, pregnancy/postpartum context when relevant, hypermobility, connective-tissue history, tobacco/substance use, medical comorbidity, and expectations of surgery.

Anatomy-based differential: A useful first pass is intra-articular versus extra-articular versus referred. Intra-articular possibilities include femoroacetabular impingement syndrome (FAIS), labral or chondral pathology, dysplasia-related overload, inflammatory arthritis, osteoarthritis, loose bodies, and osteonecrosis. Extra-articular sources include iliopsoas, rectus femoris, adductor, abductor, proximal hamstring, pubic, and deep-gluteal pathology. Referred pain may arise from the lumbar spine, sacroiliac joint, abdomen, genitourinary tract, or gynecologic organs. The diagnosis should remain open until history, examination, imaging, and, when used, injection response are concordant.

Important questions:

Have symptoms limited daily life, work, sleep, sport, or sitting? And what result would make treatment worthwhile to this patient?
Was there childhood hip disease, prior trauma, previous arthroscopy, hip dysplasia, stress injury, inflammatory disease, or a family history of early hip arthroplasty?
Are there radicular symptoms, numbness, weakness, bowel/bladder symptoms, constitutional symptoms, fever, night pain, or unexplained weight loss?
If there was a prior injection, what was injected, where, with what guidance, and how much relief occurred during the anesthetic window versus later?

Important considerations:

Document the patient’s pain beyond simply “hip pain” alone. A detailed description of the pain will help correlate it with other diagnostic investigations and track changes in pain following treatment.

Fever or systemic illness, inability to bear weight after trauma, progressive neurologic deficit, severe unexplained or progressive rest/night pain, risk factors for malignancy or infection, and a history concerning for stress fracture require urgent assessment rather than a routine work-up.

References