Nonarthritic Hip Joint Pain

• Apply cultural awareness and trauma-informed care principles.
• Sociodemographic information: Age, gender, sex, race/ethnicity.
• Main complaint: 
• Location (anterior hip/groin most common; may include deep hip pain or lateral referral), onset (often gradual; may follow changes in sport, training, or occupational load), duration, radiation, frequency, intensity, and character.
• Aggravating/relieving factors (hip flexion or rotation, squatting, running, pivoting, prolonged sitting, getting in/out of a car).
• Associated symptoms (e.g., mechanical symptoms such as clicking, catching, or giving way; back pain; leg symptoms; perceived weakness).
• Body systems review: Neurologic, cardiovascular, genitourinary, gastrointestinal, musculoskeletal, bone density, eyes/ears/nose/throat, respiratory, skin, mental health, reproductive.
• Health, lifestyle, and history: 
• Past medical conditions (e.g., prior hip pathology, osteoarthritis, low back pain, inflammatory disease), medications (including corticosteroids or anticoagulants where relevant), supplements, injuries, hospitalizations, or surgeries.
• Physical activity and sport participation (type, volume, recent changes in load, training errors).
• Sleep habits, smoking, alcohol or substance use, family support, caregiver responsibilities.
• Work or school environment (prolonged sitting, squatting, lifting, repetitive movements).
• Social determinants of health:  Employment, childcare responsibilities, education, nutrition, housing, experiences of discrimination or social isolation, access to care, and ability to modify work, sport, or physical demands.
• Previous treatments and responses: Document prior treatments, effectiveness, and any adverse effects.
• Beliefs and expectations: Assess patient understanding of their condition, treatment goals, and outcome expectations.
• Flag considerations: Identify red, orange, and yellow flags for potential referrals.

​​Outcomes Assessments: Prioritize approaches that align with the patient’s specific goals and clinical presentation.

• Pain: Use pain scales (e.g., NRS) and diagrams.
• Function and Participation: Evaluate impact on daily activities (LEFS, PSFS, WHODAS).
• Recovery: Use Self-rated recovery scales.
• Quality of Life: Assess using tools such as SF-12.
• Work/school Status: Monitor participation and return to activities.
• Sleep quality: Assess using tools such as PSQI.
• Individual Goals: Set SMART goal setting (Specific, Measurable, Achievable, Relevant, Timely).
• Patient Feedback: Gather and integrate patient experience and satisfaction.

Clinicians should promptly address symptoms of potential mental health disorders to prevent harm through appropriate and timely referrals.

ACTION: Refer for immediate care (emergency department, medical/mental health provider):

• Suicidal ideation: Thoughts, plans, or statements about suicide or feelings of hopelessness.   
• Severe, acute symptoms: Acute psychological distress, such as psychosis, severe panic.
• Ideation of harm: Intent or plans to self-harm, commit violence, or harm others.

ACTION: Refer to appropriate medical/mental health provider:

• Persistent, non-urgent symptoms: Symptoms affecting daily functioning (e.g., low mood, anxiety, sleep disturbances, social withdrawal, substance use).

ACTION: Co-management by non-medical/mental health providers:

• Triage: Ensure primary management by medical/psychiatric providers.
• Musculoskeletal (MSK) treatment: Manage MSK conditions related to or comorbid with psychological disorders.
• Screening tools: Selectively use tools to monitor symptoms and severity, guide care, and support escalation without implying a diagnosis. Tools include:
  • PHQ-9 (depressive symptoms)
  • GAD-7 (anxiety symptoms)
  • FABQ (fear related to physical activity/work) 
  • PCS (catastrophic thoughts) 
  • ORT (opioid risk)

Non-health barriers can delay recovery; early identification and intervention can enhance outcomes.

Factors:

• Individual: Worry, fear of movement, low recovery expectations, limited self-efficacy, reliance on passive treatments, activity avoidance.
• Social: Lack of family/social support, limited connections.
• Socioeconomic: Employment status, financial stress, litigation/compensation.
• Environmental/cultural: Social inequality, unsafe/unsupportive environments.
• Life events: Major transitions (e.g., divorce, job loss), chronic stressors (e.g., caregiving).
• Work/school: High stress, poor work-life balance, limited accommodations for injury/illness.

ACTION: Co-management by non-medical/mental health providers: 

• Education & self-care: Provide resources for (e.g., stress management, coping strategies, graded activity).  
• Monitor & coordinate: Regularly assess psychosocial challenges; refer to medical/mental health provider if persistent.
• Screening tools: Selectively use tools to monitor symptoms and severity, guide care, and support escalation (aligned with Orange Flag guidance), without implying a diagnosis. Tools include:
  • PHQ-9 (depressive symptoms)
  • GAD-7 (anxiety symptoms)
  • FABQ (fear related to physical activity/work) 
  • PCS (catastrophic thoughts) 
  • ORT (opioid risk)

The physical examination should be used to confirm consistency with nonarthritic hip joint pain, exclude serious pathology, and guide conservative management. Findings should be interpreted in combination with the health history and symptom behaviour.

• Observation and posture:
  Standing and sitting posture, pelvic alignment, lower-limb alignment, and movement patterns. Observe for antalgic gait, reduced stride length, or altered weight-bearing.
• Gait assessment:
  Walking, stairs, and task-specific movements relevant to the individual’s activities (e.g., running, squatting). Note pain provocation, asymmetry, or compensatory strategies.
• Range of motion (ROM):
  Active and passive hip ROM, with particular attention to flexion, internal rotation, and combined flexion-adduction-internal rotation positions. Assess symptom reproduction and end-range behaviour.
• Resisted range of motion / strength testing:
  Assess hip flexion, extension, abduction, adduction, and rotation. Note pain reproduction, strength deficits, and tolerance to load rather than isolated strength grading alone.
• Functional loading tests:
  Tasks such as squatting, step-downs, lunges, single-leg stance, or sport-specific movements to assess symptom response under load.
• Special tests:
  Provocative tests (e.g., FADIR, FABER) may reproduce symptoms. Results should be interpreted in context and not used in isolation to determine pathology.
• Lumbar spine and pelvic screening:
  Assess lumbar ROM and symptom reproduction to evaluate potential referral or co-existing contributors.
• Neurological screening:
  Brief screening of lower-limb strength, sensation, and reflexes to exclude neurological involvement.

Clinical Interpretation

• No single physical examination test is diagnostic for nonarthritic hip joint pain.
• Symptom reproduction with combined movements and functional loading, rather than isolated findings, is most informative.
• Examination findings should inform management planning.

Nonarthritic hip joint pain typically presents with mechanical, activity-related symptoms originating from the hip joint, in the absence of advanced osteoarthritis or serious underlying pathology. Presentations are common in adolescents and adults, particularly those who are physically active.

General Presentation

• Pain location: Most commonly anterior hip or groin pain; may also be described as deep hip pain or pain radiating to the thigh.
• Symptom behaviour: Symptoms are typically load- and position-dependent, aggravated by hip flexion, rotation, squatting, running, pivoting, prolonged sitting, or getting in and out of a car.
• Onset and course: Often gradual and insidious; may follow changes in training volume, sport participation, or occupational demands.
• Associated features: Mechanical symptoms such as clicking, catching, or sensations of instability may be reported but are not diagnostic in isolation.

Common Nonarthritic Hip Joint Presentations

Femoroacetabular Impingement (FAI)–related Pain

• Activity-related anterior hip or groin pain.
• Symptoms provoked by combined hip flexion, adduction, and internal rotation positions.
• Functional limitations with squatting, sitting, running, and sport-specific tasks.

Labral-Related Hip Pain

• Deep hip or groin pain, sometimes accompanied by clicking or catching sensations.
• Symptoms may worsen with prolonged sitting, pivoting, or directional changes.
• Labral findings on imaging are common in asymptomatic individuals and should be interpreted cautiously.

Other Intra-Articular Mechanical Hip Pain

• Pain reproduced with hip joint loading and end-range movements.
• Overlap with lumbar spine or pelvic contributions is common.

Clinical Interpretation

• Most individuals with nonarthritic hip joint pain can be managed initially with conservative care, regardless of imaging findings.
• Clinical presentations are often overlapping and non-specific, and pain location or mechanical symptoms alone do not identify a single pain generator.
• Imaging findings (e.g., cam/pincer morphology, labral tears) are not synonymous with symptoms and should not be used in isolation to guide management decisions.

Approach to Treatment

Conservative management is recommended as first-line care for nonarthritic hip joint pain. Management should be individualized, function-focused, and informed by symptom behaviour, activity demands, and patient goals, rather than imaging findings alone.

The treatments outlined below reflect core domains of care identified in clinical practice guidelines. Not all components are required for every individual or at every stage of recovery. Clinicians are expected to apply professional judgment when selecting and sequencing interventions.

This pathway is not prescriptive and does not list all possible interventions. Where additional treatments are used, they should be applied as adjuncts to core conservative care, not as stand-alone treatments.

Education and Self-Management

Education is a foundational component of care and should emphasize the mechanical, load- and position-related nature of nonarthritic hip joint pain, the common discordance between imaging findings and symptoms, and the generally favourable prognosis with appropriate management.

Key elements include:

• Reassurance and explanation of the condition and recovery expectations
• Guidance on activity modification and load management, including temporary avoidance of provocative positions (e.g., deep hip flexion, sustained rotation, prolonged sitting)
• Promotion of continued movement and participation using pacing and graded exposure strategies
• Support for self-management behaviours (physical activity, sleep, nutrition, stress management)

Exercise Therapy

Exercise therapy is recommended as first-line treatment.

Programs should be:

• Individualized and progressive
• Focused on improving hip and pelvic strength, endurance, movement control, and functional capacity
• Integrated with functional retraining relevant to work, sport, and daily activities
• Progressed based on symptom response and functional tolerance, rather than time alone

No single exercise approach has been shown to be superior. Programs should align with patient goals and participation demands.

Manual Therapy

Manual therapy may be used as an adjunct to support pain modulation, movement confidence, and engagement in active rehabilitation.

Manual therapy should:

• Be integrated with exercise and education
• Not be used as a stand-alone intervention

Activity and Return-to-Participation Planning

• Use criteria-based progression for return to work, sport, and other activities
• Prioritize symptom behaviour, strength, movement control, and confidence
• Address barriers to participation, including fear of movement, access to care, and competing life demands

Medications and Injections (Medical Provider; Selected Cases)

• Short-term use of analgesics or NSAIDs may be considered by a medical provider when pain significantly limits participation in rehabilitation.
• Intra-articular injections may be considered selectively for short-term symptom relief or diagnostic clarification, to support engagement in conservative care, but are not recommended as first-line or definitive treatment.

Escalation and Referral

Consider referral for further assessment when there is:

• Persistent, function-limiting symptoms despite an adequate trial of conservative care
• Progressive functional decline or inability to progress rehabilitation
• Diagnostic uncertainty or concern for alternative pathology

(APTA Academy of Orthopaedic Physical Therapy 2023)

Risk Factors

Nonarthritic hip joint pain is multifactorial. Common risk factors include:

• Activity exposure: High-volume or high-intensity sport participation; repetitive pivoting, cutting, sprinting, deep squatting, or rapid increases in training load.
• Movement and loading factors: Repeated end-range hip flexion or rotation loading and reduced movement control under load.
• Structural features: Cam or pincer morphology and labral pathology, which are common in both symptomatic and asymptomatic individuals and should be interpreted in context.
• Previous hip symptoms or injury: Prior episodes of hip pain or periods of deconditioning followed by rapid re-loading.
• Co-existing conditions: Low back or pelvic pain that may alter movement patterns and load distribution.

Prognostic Factors

Factors associated with slower recovery or persistent symptoms include:

• Longer symptom duration before initiating appropriate conservative care
• Higher baseline pain and functional limitation
• Limited ability to modify provocative activities (e.g., sport or work demands)
• Psychosocial factors that reduce engagement with active rehabilitation (e.g., fear of movement, low recovery expectations)
• Poor adherence to exercise-based care or limited access to rehabilitation services
• Co-existing low back or pelvic pain

Imaging findings alone (e.g., cam/pincer morphology, labral tears) are not reliable predictors of outcome.

Prognosis

The prognosis for nonarthritic hip joint pain is generally favourable with appropriate conservative management.

• Many individuals experience meaningful improvements with education, load management, and structured exercise-based rehabilitation.
• Recovery is often gradual, particularly in those with persistent symptoms or high functional demands.
• Failure to improve after an adequate trial of conservative care should prompt re-evaluation and shared decision-making, rather than escalation based on imaging findings alone.