7.2 Hip, Groin & Pelvis Assessment
Key Takeaways
- Intra-articular hip pain is a FADIR, FABER (groin-localized), log-roll, and scour cluster; adductor squeeze, pubic pain, and a missing bulge separate extra-articular groin from a classic inguinal hernia.
- Athletic pubalgia (sports hernia / core-muscle injury) is a posterior-inguinal-wall or rectus–adductor aponeurotic injury—not a bowel-containing inguinal hernia.
- Femoral-neck stress fracture, especially in female endurance athletes, hurts with hop and axial load: make the athlete non-weight-bearing and refer; missed tension-side or displaced neck fractures can displace and threaten the head.
- SCFE presents with obligate external rotation in an adolescent—do not force internal rotation. AVN risk includes corticosteroids, sickle cell disease, and prior trauma.
- Hip pointer is an iliac-crest contusion; iliac-crest apophysitis is an open-growth-plate overuse injury. Do not treat weeks of adolescent groin pain as a strain.
PA8 task 0202 at the hip, groin, and pelvis is a differential exam. Groin pain is not a muscle until you have ruled out the joint, the physis, the neck of the femur, and lumbar referral.
The Groin Differential
Treat these as competing hypotheses, not synonyms:
- Femoroacetabular impingement (FAI): cam (femoral head-neck asphericity), pincer (acetabular overcover), or mixed. Deep groin or C-sign pain with flexion-IR, cutting, and sitting.
- Labral tear: often rides with FAI. Mechanical catching, pain with scour/FADIR.
- Adductor strain: acute or overload at the adductor longus origin; squeeze-test pain, less intra-articular cluster.
- Athletic pubalgia (sports hernia / core-muscle injury): posterior inguinal wall or rectus–adductor aponeurosis. Pain with cutting, sit-up, and cough without a reducible bowel bulge. Sports hernia is not a classic inguinal hernia.
- Osteitis pubis: pubic-symphysis pain, tender bone, squeeze pain, often kicking sports.
- Inguinal hernia: palpable or reducible bulge. That is a different referral (general surgery) than athletic pubalgia.
- Referred lumbar: SLR/slump/femoral stretch, myotomal clues, lumbar mechanical pattern. Hip IR can be full.
A kicking soccer player can have more than one of these. FAI and athletic pubalgia coexist often enough that a positive FADIR does not 'prove' the groin is not also a core-muscle injury—and a painful squeeze does not prove the joint is clean.
Intra-articular and Extra-articular Tests
Log roll moves the femoral head in the acetabulum and barely stresses extra-articular tendons—pain or a restricted roll argues intra-articular (synovitis, labrum, FAI, infection, SCFE, AVN).
| Test | Structure / construct | Positive finding | What +/− actually means |
|---|---|---|---|
| FADIR (flexion, adduction, IR) | Anterior cam/pincer, anterosuperior labrum | Reproduction of groin pain | Sensitive screen for intra-articular/FAI pain, not specific. A positive FADIR is not an MRI cam diagnosis. |
| FABER (Patrick) | Hip versus SI, depending on where it hurts | Groin pain (hip) or posterior SI pain (SI); limited ROM versus the other side | Location is the test. Groin = hip; sacral sulcus = SI. Do not call every FABER 'SI.' |
| Log roll | Intra-articular hip | Pain, guarding, or click with passive IR/ER in extension | High-yield intra-articular screen. Extra-articular adductor pain should not light up a gentle roll. |
| Scour (quadrant) | Intra-articular surfaces/labrum | Pain, click, or apprehension with axial load through a flexed hip as you sweep IR to ER | Intra-articular provocation. Go slow; it is uncomfortable even in irritable but intact hips. |
| Thomas / Kendall | Iliopsoas versus rectus femoris length | Opposite thigh will not rest on the table (psoas); if the knee cannot flex ~80° in that position, rectus (Kendall) | Tightness tests, not labral tests. |
| Ober | TFL / IT band | Side-lying, abducted-extended hip will not drop into adduction | Lateral extra-articular tightness. Not FAI. |
| Trendelenburg | Gluteus medius / abductor | Stance-side abductors fail; contralateral pelvis drops | Weakness or pain-inhibition. Seen in intra-articular disease, gluteal tendinopathy, and SCFE/AVN the athlete is protecting. |
| 90-90 | Hamstring length | Cannot extend the knee from 90/90 without posterior-thigh stretch | Flexibility—unless it reproduces radicular pain, in which case it is a neurodynamic cousin, not a hamstring diagnosis. |
FADIR is a screen. Pair it with log roll, scour, ROM (especially IR in flexion), and a lumbar exam. Do not name a cam from FADIR alone.
Femoral Neck Stress Fracture, SCFE, and AVN
Femoral-neck stress fracture is the hip injury you cannot afford to miss. Classic: female endurance runner (also male distance athletes and military recruits, often with RED-S). Groin or anterior-thigh pain that progresses, hurts with single-leg hop and axial load, and may ache at night. Tension-side (superior neck) lesions can displace. Displacement risks AVN of the head and varus malunion.
Decision: non-weight-bearing (crutches) and refer now for imaging (MRI if radiographs are negative). Do not 'run through a hip-flexor strain' for three more weeks. Missed = displacement.
Slipped capital femoral epiphysis (SCFE) is an adolescent (often overweight, often 11–16) displacement of the metaphysis relative to the epiphysis through the proximal femoral physis. Gait: obligate external rotation; flexion of the hip produces more ER rather than flexion in the sagittal plane. Do not force IR. Forcing a SCFE through end-range FADIR can worsen the slip. Make the athlete NWB and refer for AP pelvis and a lateral hip view. Unstable SCFE (cannot walk even with crutches) is an operative urgency.
Avascular necrosis (AVN) of the femoral head: corticosteroids, sickle cell disease, prior trauma or dislocation, and other vascular insults. Groin pain, limited IR, painful log roll. MRI is the early test. This is not an adductor strain.
Hip Pointer versus Iliac Crest Apophysitis
Hip pointer: direct blow to the iliac crest (helmet, fall). Contusion of abdominal-oblique/TFL attachments, acute pain, often bruising. Pad and protect; obtain radiographs if you cannot exclude fracture or avulsion.
Iliac crest apophysitis: open apophysis, overuse (running, kicking, throwing), no single blow. Tender apophysis, pain with abdominal or abductor load. Rest from the offending load; do not treat it as a bruise you can pad and play through all season if the physis is angry.
Palpate the ASIS, AIIS, ischial tuberosity, and iliac crest in adolescents—apophyseal avulsions (sartorius, rectus femoris, hamstring) are acute-pop injuries, not 'strains.'
Worked Scenario: Sixteen-Year-Old Groin Pain
A 16-year-old soccer player has had groin pain for three weeks. Someone labeled it an adductor strain; he has been taping and playing. He now walks with the foot externally rotated. Flexion of the hip obligates ER. Log roll is guarded. FADIR was started and he almost jumped off the table—stop. There is no inguinal bulge. Adductor squeeze is only mildly sore and is not his walk-in-ER problem.
Interpretation: SCFE until imaging says otherwise. Do not force IR, do not keep him on the pitch, NWB and refer. The exam trap is exactly this story: treating a 16-year-old with groin pain as 'a strain' for weeks.
If this same story were a 19-year-old endurance runner with hop and axial-load pain and a normal walk without obligate ER, the label flips to femoral-neck stress fracture—same NWB-and-refer logic, different tissue. A third athlete, a kicking soccer player with pubic pain, a painful squeeze, a negative log roll/FADIR, and no bulge, is the osteitis pubis / athletic pubalgia lane—still not a classic hernia, and still not a reason to ignore the hip joint if FADIR lights up.
Exam trap: weeks of 'strain' care in an adolescent with obligate ER, or calling every groin a sports hernia because there is no bulge.
A 20-year-old soccer player has deep anterior groin pain with cutting. FADIR and scour reproduce the groin pain, log roll is painful, adductor squeeze is only mildly tender, and there is no inguinal bulge. Lumbar SLR is negative. Best interpretation?
A 19-year-old female cross-country runner has progressive anterior hip pain, pain with single-leg hop and axial load, and night ache. She has been treating it as a 'hip flexor strain' for three weeks. What is the correct decision?
A 16-year-old overweight soccer player has weeks of groin pain. He walks with the hip in obligate external rotation, and flexion produces more external rotation. What must the athletic trainer avoid and do?