Version May 2024
| Cause | Typical age/risk factors | Clinical features | Laboratory features | Radiographic features |
| Infectious | ||||
| Septic arthritis of the hip | 0 to 6 years M>F | Fever and ill-appearance Pain with any active or passive motion and refusal to bear weight Preferred position: Flexion, abduction, and external rotation of the hip | Elevated WBC count (>12,000 cells/microL), ESR (>40 mm/hour), and CRP (>2 mg/dL [20 mg/L]) Positive synovial fluid or blood culture | Unilateral joint effusion |
| Septic arthritis of the sacroiliac joint | Late childhood | Pain over sacrum Fever Pain with maneuvers that twist the pelvis (eg, positive FABERE test) | Elevated WBC count, ESR, CRP Positive synovial fluid or blood culture | Widening of the joint space Blurring of the subchondral plate |
| Lyme disease | Any age Residence in or travel to Lyme endemic region | Fever uncommon Willing to bear weight | IgG antibodies to Borrelia burgdorferi | |
| Osteomyelitis of femoral head or pelvis | Fever and ill appearance Localized pain Decreased mobility (but may permit passive motion of the hip) | Elevated WBC count, ESR, and CRP | Early (3 to 7 days): deep soft-tissue swelling; obliteration of fat pads Late (10 to 21 days): lytic sclerosis; periosteal new bone formation | |
| Psoas abscess (referred pain) | Pain is increased with hip extension but diminished with hip flexion | Elevated WBC count, ESR, and CRP | Loss of psoas muscle definition Abnormal soft tissue shadows (CT is preferred study) | |
| Appendicitis or abdominal/pelvic abscess (referred pain) | Any age | Associated gastrointestinal complaints (pain, vomiting, anorexia) | Elevated WBC count, ESR, CRP | Calcified appendicolith (US is usually the preferred initial imaging study) |
| Discitis (referred pain) | 0 to 5 years | Loss of lumbar lordosis Refusal to bend forward Minimal systemic toxicity | WBC count usually normal Elevated ESR | Narrowing of intervertebral joint space after two to three weeks of symptoms, followed by destruction of vertebral end-plated and disc herniation Diagnosis is best made by MRI |
| Inflammatory | ||||
| Transient synovitis | 3 to 8 years M>F Fall/winter season | Afebrile Well-appearing | WBC count <12,000 cells/microL ESR <20 mm/hour CRP <2 mg/dL (20 mg/L) | Unilateral or bilateral joint effusion |
| Systemic arthritis | ||||
| Rarely causes isolated hip pain | Elevated ESR and/or CRP Positive ANA, RF, or CCP in some cases | Joint space narrowing Erosive changes of the femoral head and acetabula | |
| Variable ages | Associated clinical features of underlying infection | Depend upon underlying infection | |
| Variable ages | History of antecedent respiratory, gastrointestinal, or genitourinary infection | Elevated ESR or CRP Evidence of antecedent or concomitant infection | Evidence of enthesitis or arthritis |
| Idiopathic chondrolysis of the hip | 10 to 20 years | Insidious onset Decreased range of motion in all planes Absence of systemic symptoms | None | Narrowing of the joint space, osteopenia, protrusion acetabuli, and premature physial fusion |
| Chronic recurrent multifocal osteomyelitis | Any age F>M | Fever (rarely) Bone pain May be associated with pustular eruption on palms and soles | Elevated ESR or CRP (sometimes) | |
| Mechanical/orthopedic | ||||
| Slipped capital femoral epiphysis | Early adolescence Mean age: M>F (slightly) Obesity Endocrine disorders | Bilateral in 20 to 40% of cases Pain may be localized to the knee or thigh | Normal WBC count, ESR, CRP | Nondisplaced: Normal or widening and irregularity of the capital femoral physis, osteopenia, and increased density of the metaphysis Displaced: Posterior displacement of femoral epiphysis |
| Avascular necrosis | ||||
| 3 to 12 years M>>F | Insidious onset Pain increases with activity | Normal WBC count, ESR, CRP | Early: Joint space widening and subchondral fracture Late: Sclerosis, fragmentation, subchondral collapse of the ossification center |
| Variable ages | Signs and symptoms of underlying condition (eg, renal failure, glucocorticoid use, systemic lupus erythematosus) | Depend upon underlying condition | Early: Joint space widening and subchondral fracture Late: Sclerosis, fragmentation, subchondral collapse of the ossification center |
| Femoral stress fracture | Adolescents and young adults Endurance sports | Pain may localize to the anterior thigh Pain reproduced with hopping on affected leg | Normal WBC count, ESR, CRP | Periosteal elevation, cortical thickening, sclerosis, fracture line |
| Muscular strain | Any age | Pain with movement Weakness | Normal WBC count, ESR, CRP | |
| Iliac apophysitis | Adolescents Sports that involve twisting (eg, golf), sprinting, and kicking | Pain and swelling at iliac crest Slowly progressive pain with activity | Normal WBC count, ESR, CRP | |
| Snapping iliopsoas tendon | Young athletes (ballet, karate) | Snapping sensation in anterior groin Sensation may be reproduced by bringing the hip from a flexed abducted position to an extended adducted position | Normal WBC count, ESR, CRP | Catching of the posterior iliotibial band or anterior portion of the gluteus maximus muscle over the greater trochanter can be seen on dynamic ultrasonography |
| Trochanteric bursitis | Lateral hip pain over the outer thigh Pain aggravated by direct pressure | Normal WBC count, ESR, CRP | Calcification occasionally present in the region of the bursa or adjacent soft tissues | |
| Acetabular labral tear | Adolescent athletes, particularly sports that involve pivoting or twisting History of Legg-Calvé-Perthes disease or SCFE | Snapping, catching Pain with internal rotation and extension | Normal WBC count, ESR, CRP | |
| Femoroacetabular impingement | Dancers | Groin pain with turning, twisting, and squatting Pain is reproduced with flexion and internal rotation of the hip | Normal WBC count, ESR, CRP | Nonspherical femoral head; lack of femoral head-neck offset; acetabular overcoverage |
| Neoplastic | ||||
| Osteoid osteoma | 10 to 20 years | Nocturnal pain Prompt relief with NSAIDs | Osteoid nidus with or without calcification (osteoid nidus may be obscured by dense sclerosis) | |
| Malignant neoplasms, primary or metastatic (eg, leukemia, lymphoma, Ewing sarcoma, etc) | Variable ages | Nighttime pain Constant pain (unchanged by activity) Pain <3 months duration Systemic symptoms (eg, fever, weight loss) | Abnormal CBC (anemia, leukopenia, thrombocytopenia) Elevated LDH, uric acid | Bony destruction Subtle signs of space-occupying lesion (separation or thinning of the pedicles) |
| Pigmented villonodular synovitis | Adults | Recurrent joint effusions Minimal pain | Well circumscribed areas of bone erosion | |
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