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Does This Patient Have Hip Osteoarthritis?The Rational Clinical Examination Systematic Review

Educational Objective
To understand how physicians can identify patients who are most likely to have hip osteoarthritis (OA)?
1 Credit CME
Key Points

Question  How can physicians identify patients who are most likely to have hip osteoarthritis (OA)?

Findings  The most useful findings for identifying patients with hip OA are squat causing posterior pain, groin pain on passive abduction or adduction, abductor weakness, and decreased passive hip adduction or internal rotation. Hip OA is unlikely in the presence of normal passive hip adduction.

Meaning  A number of simple range-of-motion tests can be used to identify patients with hip or groin pain that are most likely to have evidence of OA on hip radiographs.


Importance  Hip osteoarthritis (OA) is a common cause of pain and disability.

Objective  To identify the clinical findings that are most strongly associated with hip OA.

Data Sources  Systematic search of MEDLINE, PubMed, EMBASE, and CINAHL from inception until November 2019.

Study Selection  Included studies (1) quantified the accuracy of clinical findings (history, physical examination, or simple tests) and (2) used plain radiographs as the reference standard for diagnosing hip OA.

Data Extraction and Synthesis  Studies were assigned levels of evidence using the Rational Clinical Examination scale and assessed for risk of bias using the Quality Assessment of Diagnostic Accuracy Studies tool. Data were extracted using individual hips as the unit of analysis and only pooled when findings were reported in 3 or more studies.

Main Outcomes and Measures  Sensitivity, specificity, and likelihood ratios (LRs).

Results  Six studies were included, with data from 1110 patients and 1324 hips, of which 509 (38%) showed radiographic evidence of OA. Among patients presenting to primary care physicians with hip or groin pain, the affected hip showed radiographic evidence of OA in 34% of cases. A family history of OA, personal history of knee OA, or pain on climbing stairs or walking up slopes all had LRs of 2.1 (sensitivity range, 33%-68%; specificity range, 68%-84%; broadest LR range: 95% CI, 1.1-3.8). To identify patients most likely to have OA, the most useful findings were squat causing posterior pain (sensitivity, 24%; specificity, 96%; LR, 6.1 [95% CI, 1.3-29]), groin pain on passive abduction or adduction (sensitivity, 33%; specificity, 94%; LR, 5.7 [95% CI, 1.6-20]), abductor weakness (sensitivity, 44%; specificity, 90%; LR, 4.5 [95% CI, 2.4-8.4]), and decreased passive hip adduction (sensitivity, 80%; specificity, 81%; LR, 4.2 [95% CI, 3.0-6.0]) or internal rotation (sensitivity, 66%; specificity, 79%; LR, 3.2 [95% CI, 1.7-6.0]) as measured by a goniometer or compared with the contralateral leg. The presence of normal passive hip adduction was most useful for suggesting the absence of OA (negative LR, 0.25 [95% CI, 0.11-0.54]).

Conclusions and Relevance  Simple tests of hip motion and observing for pain during that motion were helpful in distinguishing patients most likely to have OA on plain radiography from those who will not. A combination of findings efficiently detects those most likely to have severe hip OA.

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Article Information

Corresponding Author: David Metcalfe, PhD, MRCS, Kadoorie Centre for Critical Care Research, Level 3, John Radcliffe Hospital, Headley Way, Oxford, OX3 9DU, United Kingdom (

Accepted for Publication: November 13, 2019.

Author Contributions: Dr Metcalfe had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Metcalfe, Perry, Claireaux, Costa.

Acquisition, analysis, or interpretation of data: Metcalfe, Perry, Claireaux, Simel, Zogg.

Drafting of the manuscript: Metcalfe, Perry, Claireaux, Costa.

Critical revision of the manuscript for important intellectual content: Metcalfe, Perry, Claireaux, Simel, Zogg.

Statistical analysis: Metcalfe, Claireaux, Simel, Zogg.

Administrative, technical, or material support: Claireaux.

Supervision: Perry, Claireaux, Simel, Costa.

Conflict of Interest Disclosures: Dr Perry reported receiving a National Institute for Health Research Clinician Scientist Award (CS-2014-14-012). Dr Simel reported receiving nonfinancial support from Veterans Health Affairs during the conduct of the study and personal fees from JAMAEvidence outside the submitted work. No other disclosures were reported.

Funding/Support: Dr Metcalfe was funded by a Royal College of Surgeons of England Fulbright Scholarship and a UCB-Oxford Prize Fellowship in Biomedical Research. Dr Simel’s work was supported by the Durham Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT) (CIN 13-410) at the Durham VA Health Care System.

Role of the Funder/Sponsor: The authors’ funding bodies did not have any role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Disclaimer: The views expressed are those of the authors and not necessarily those of the UK National Health Service, the NIHR, the UK Department of Health, the US Department of Veterans Affairs, or the US government. Dr Simel is a Section Editor for the Rational Clinical Examination series in JAMA but was not involved in the editorial review of or decision to publish this study.

Additional Contributions: We are grateful for comments on the manuscript from Brian H. Halstater, MD (Duke University, Durham, NC); Kim M. Huffman, MD, PhD (Durham Veterans Affairs Medical Center and Duke University, Durham, NC); Stephen P. Shaheen, MD (Duke University, Durham, NC); and Samuel S. Wellman, MD (Durham Veterans Affairs Medical Center and Duke University, Durham, NC). These contributors were not financially compensated. We are also grateful to Elinor Harriss, MSc (Bodleian Library, University of Oxford), for coordinating the initial literature search. She did not receive additional compensation outside of her role as a specialist librarian at the University of Oxford.

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