Other differential diagnosis/mimics of hip pathology

Pain perceived around the hip does not necessarily originate from the intra-articular hip joint. Pathology may arise from structures extending from the skin and superficial soft tissues to the periarticular musculature, joint, and bone, while disorders of the lumbar spine, pelvis, or visceral organs may produce referred symptoms 1. This distinction is particularly important in hip preservation because structural abnormalities such as cam morphology or labral tears may coexist with an alternative pain generator and should not automatically be assumed to explain the clinical presentation.

A practical differential can therefore be approached from superficial to deep anatomical layers.

Superficial causes of hip-region pain are relatively uncommon in the hip arthroscopy population but should remain recognizable. Local skin infection, subcutaneous inflammation, postoperative scar-related pain, or herpes zoster may produce pain over the hip before or alongside visible cutaneous abnormalities. Superficial sensory nerve disorders may similarly produce pain or dysesthesia without primary intra-articular pathology. In particular, irritation or entrapment of the lateral femoral cutaneous nerve can cause meralgia paresthetica, characterized by burning, tingling, numbness, or hypersensitivity over the anterolateral thigh without motor deficit or intrinsic hip-joint disease 2,3. Symptoms are typically sensory and may be aggravated by prolonged standing, walking, or tight clothing.

Other cutaneous nerve disorders, including injury or neuroma involving the ilioinguinal, iliohypogastric, or genitofemoral nerves, may produce focal groin or proximal thigh pain, particularly after abdominal, pelvic, or hip surgery 4. A careful examination of the skin and superficial tissues, including inspection for rash, erythema, swelling, or hypersensitivity, can therefore help distinguish these conditions from deeper intra-articular pathology.

Extra-articular soft-tissue pathology represents one of the most important groups of hip mimics and can be considered according to location:

Greater trochanteric pain syndrome encompasses several disorders of the peritrochanteric space, particularly gluteus medius and minimus tendinopathy or tearing, associated bursitis, and external snapping of the iliotibial band 5. Posterior hip symptoms may arise from deep gluteal syndrome, in which the sciatic nerve is irritated or entrapped within the deep gluteal space by structures such as the piriformis, obturator internus–gemelli complex, proximal hamstring region, or adjacent tissues 6.

These disorders may occur independently or coexist with intra-articular abnormalities.

Bone pathology should be considered when symptoms cannot be adequately explained by soft-tissue or intra-articular abnormalities. Important causes include femoral neck stress injury or stress fracture, occult fracture, osteonecrosis, and neoplastic bone lesions 1.

Femoral neck stress injury is particularly important in active individuals because early disease may present predominantly with activity-related hip or groin pain before progression to a complete fracture. Bone causes may therefore represent both diagnostic mimics and conditions in which delayed recognition has important consequences.