Aim is to move from the most common "bread and butter" presentations to the clinical "landmines" that you should never miss (even though they are very uncommon).

Arbitrarily I'll use a triage-based framework as this speeds things up.

Part 1: The Bread and Butter¶

Focus: High-frequency pathologies categorized by age and activity.

1. The Degenerative Hip (Osteoarthritis)¶

Epidemiology: The most common cause of hip pain in patients.
Key Indicators: Morning stiffness mins, loss of internal rotation (the "capsular pattern"), and the "C-sign" (patient gripping the hip between thumb and index finger).
Evidence Note: Discuss why X-ray findings often correlate poorly with pain levels.

2. Femoroacetabular Impingement Syndrome (FAIS)¶

The Triad: Symptoms, clinical signs (FADIR test), (and imaging findings).
Morphology: Differentiating Cam (femoral head) vs. Pincer (acetabular rim) vs. Mixed.
Clinical Pearl: FAIS is a motion-related clinical entity, not just a "bony bump." That is, treat the man, not the scan

Knowledge Check

What distinguishes Primary Cam Morphology (PCM) from Femoroacetabular Impingement Syndrome (FAIS)?

PCM is always painful while FAIS is asymptomatic PCM only occurs in non-athletes FAIS is diagnosed by imaging alone PCM is a structural finding; FAIS requires the clinical triad of symptoms, signs, and imaging

Answer: PCM is a structural finding; FAIS requires the clinical triad of symptoms, signs, and imaging
Primary Cam Morphology (PCM) is the presence of a bony bump at the femoral head-neck junction, often a benign structural adaptation to high-load sport during adolescence. FAIS is only diagnosed when the clinical triad (symptoms, clinical signs like FADIR test, and imaging findings) is present. Most athletes with PCM have "happy hips" and compete without symptoms.

1. Terminology: "Morphology is not Pathology"¶

The New Standard: Distinguish between Primary Cam Morphology (PCM) and FAIS.

PCM: The presence of a bony bump at the femoral head-neck junction. Dijkstra et al. (2021) argue that for many athletes, this is a benign structural adaptation to high-load sport during adolescence (the "bog-standard" bump), not a disease.

FAIS: Only diagnosed when the clinical triad (symptoms, signs, and imaging) is present.

Key Message: Most athletes with PCM "thrive" and compete with "happy hips." We should stop labeling asymptomatic athletes with the word "impingement," as it implies a negative mechanical fate.

2. The Imaging Paradox & Poor Reliability¶

Alpha Angles: Dijkstra et al. (2023) highlight that current imaging measures (like the alpha angle) have low reliability and lack a universally agreed-upon cut-off.

Predictive Value: We cannot accurately predict which adolescent athlete with PCM will develop FAIS or future osteoarthritis (OA). However, "Size Matters"---larger bumps (very high alpha angles) are more strongly associated with a higher long-term risk of OA, but this is still not a guarantee of pain.

Clinical Pearl: Discourage routine screening of young athletes for PCM. Labeling a child with a "hip condition" based on an X-ray can cause psychological harm and unnecessary worry for parents and coaches.

3. Management: Beyond "Physiotherapy"¶

Terminology Shift: The Oxford Consensus recommends the term "Clinician-led progressive exercise rehabilitation" rather than just "physiotherapy."

Why? This emphasizes that the treatment is not passive (massage/stretching) but active, loaded, and led by a clinician who understands the athlete\'s specific sporting demands.

Success Rates: Most patients with FAIS do well with non-surgical management. Education should focus on "normalizing" the morphology while optimizing the "capacity" of the hip to handle the load.

Old Approach (Warwick 2016)	New Approach (Dijkstra/Oxford 2023)
Focus on the "Triad" as a diagnosis of exclusion.	Focus on PCM as a benign adaptation in most athletes.
Morphological findings are "abnormalities."	Morphological findings are often "happy hip" adaptations to sport.
Use "Impingement" as a general term.	Use "Primary Cam Morphology" for the bone; "FAIS" only for the syndrome.
Physiotherapy for symptom relief.	Clinician-led progressive exercise for load tolerance.

"If 60% of elite youth footballers have a cam 'bump' but only 5% have pain, is the bump the problem, or is it the athlete's inability to manage the load through that specific morphology?" This prompts students to think about Load Management and Neuromuscular Control rather than just surgical "bone-shaving."

3. Greater Trochanteric Pain Syndrome (GTPS)¶

The Shift: Moving away from the term "Trochanteric Bursitis" toward Gluteal Tendinopathy.
Assessment: The "Single Leg Stance" test (30 seconds) and FAFER (Flexion, Adduction, Functional External Rotation).
Management: Why corticosteroid injections (CSI) are a short-term "win" but a long-term "fail" compared to load management.

Knowledge Check

What is the recommended management approach for Greater Trochanteric Pain Syndrome (GTPS)?

Immediate corticosteroid injection for long-term relief Load management and progressive exercise over corticosteroid injections Rest and avoid all weight-bearing activities Surgical trochanteric bursectomy as first-line treatment

Answer: Load management and progressive exercise over corticosteroid injections
While corticosteroid injections may provide short-term pain relief for GTPS (also known as gluteal tendinopathy), they are a long-term "fail" compared to load management and progressive exercise. The focus has shifted away from the term "Trochanteric Bursitis" toward recognizing this as a tendinopathy requiring load-based rehabilitation.

4. The "Doha Agreement" on Groin Pain¶

Classification:
Adductor-related (most common).
Iliopsoas-related.
Inguinal-related.
Pubic-related.

(Hip-related covered earlier)

Part 2: The "Must-Not-Miss" (40 Minutes)¶

Focus: Red flags and serious pathologies that require urgent referral.

Condition Why you "Must Not Miss" Key Red Flags

Femoral Neck Stress Fracture Risk of displacement and AVN. Night pain, "full" feeling in the groin, pain with weight-bearing, "heel strike" test.

Avascular Necrosis (AVN) Rapid joint destruction. History of long-term steroid use, excessive alcohol, or trauma.

Slipped Capital Femoral Epiphysis (SCFE) Pediatric emergency; risk of permanent deformity. Teenager/Pre-teen with "knee pain" and an antalgic gait.

Cauda Equina / Referral Neurological emergency. Groin/Saddle anesthesia, bladder/bowel changes (referred from Lumbar).

Malignancy / Infection Life-threatening. Unexplained weight loss, fever, night sweats, non-mechanical pain.

Knowledge Check

Which "must-not-miss" condition commonly presents as knee pain in children and adolescents?

Femoral neck stress fracture Avascular necrosis (AVN) Slipped Capital Femoral Epiphysis (SCFE) Greater trochanteric pain syndrome

Answer: Slipped Capital Femoral Epiphysis (SCFE)
SCFE is a pediatric emergency with risk of permanent deformity. Key red flags include a teenager or pre-teen presenting with "knee pain" and an antalgic gait. Any child with knee pain should have their hip range of motion (especially internal rotation) cleared and likely needs an X-ray with medical follow-up. This is a classic example of referred pain from the hip.

Part 3: Clinical Reasoning & Differential Diagnosis¶

Focus: Integration and the "Triage" Mindset.

The Triage Triangle:¶

Is it the hip joint? (Deep groin pain, limited ROM).
Is it soft tissue? (Contractile testing, palpation).
Is it referred? (Lumbar spine screen, SIJ screen).

The "Masked" Hip:¶

Screening the knee and lumbar spine to ensure the pain source isn\'t proximal or distal.

When to Image:¶

Guidelines on when to order X-ray vs. MRI (and why MRA---Magnetic Resonance Arthrography---is becoming less frequent).