Diagnostic Approach to Hip Pain in Adolescents

Critical Red Flags to Exclude First

In adolescents presenting with hip pain, it is essential to immediately rule out slipped capital femoral epiphysis (SCFE), infection, tumors, and stress fractures before considering other diagnoses, as recommended by the British Journal of Sports Medicine 1, 2, 3
Tumors and stress fractures present with insidious onset, night pain, constitutional symptoms, and inability to bear weight, according to the British Journal of Sports Medicine 1, 2, 4
Perthes disease must be excluded as a serious pathological condition in this age group, as stated by the British Journal of Sports Medicine 1, 2

SCFE can present as medial thigh or knee pain rather than hip pain, making it easy to miss, as noted by the British Journal of Sports Medicine 1, 2, 3

Femoroacetabular impingement (FAI) syndrome becomes the predominant diagnosis, characterized by groin pain with hip flexion, adduction, and internal rotation, associated with cam, pincer, or mixed morphology on imaging, according to the British Journal of Sports Medicine 1, 5, 6
Acetabular dysplasia causes misalignment between the femoral head and acetabulum, resulting in instability and rim overload during normal activities, as stated by the British Journal of Sports Medicine 1, 2

Always screen the lumbar spine as a competing musculoskeletal source in all adolescent hip pain evaluations, as recommended by the British Journal of Sports Medicine 1, 2, 4, 6
Lumbar spine pathology presents as sharp lancinating pain radiating down the leg, induced by sitting, standing, or walking, often present at rest and improved by position change, according to Praxis Medical Insights 4, 6

Determine if red flag features are present: night pain, constitutional symptoms, inability to bear weight, fever, or external rotation deformity, as recommended by the British Journal of Sports Medicine 1, 2, 3

Perform FADIR test (flexion-adduction-internal rotation): a negative test helps rule out hip-related pain, though clinical utility is limited, as noted by the British Journal of Sports Medicine 5, 6
Mandatory lumbar spine screening in all cases to exclude referred pain, as recommended by the British Journal of Sports Medicine 1, 2, 6

Incidental imaging findings are extremely common in asymptomatic adolescent athletes—clinical correlation is mandatory, as stated by the British Journal of Sports Medicine 1, 5
Hip pathology frequently presents as knee pain, and spine pathology can present as hip pain, according to Praxis Medical Insights 4, 6
A comprehensive approach combining clinical examination and imaging is essential, as neither has adequate diagnostic utility alone, as noted by the British Journal of Sports Medicine 5