Hip Pain in Young Adults: When It's Not Just a Strain

Persistent hip and groin pain in a young adult is one of the most under-diagnosed presentations in orthopedic clinic. Patients are routinely told they have a “strain” and sent away with rest and anti-inflammatories — and many continue to limp through their work, training, and family life for two or three years before someone finally looks more carefully. The reality is that there is a well-recognised set of conditions that cause persistent hip pain in young adults, most of them treatable when identified correctly. This article describes what to look for, when to push for imaging, and what the modern treatment pathways look like.

The conditions to know about

The principal causes of persistent hip pain in young adults are:

• Femoroacetabular impingement (FAI) with or without labral tear — see our detailed article on FAI for treatment.
• Hip dysplasia — a shallow socket that overloads the labrum and cartilage. Often missed on plain X-rays unless the radiographer measures the lateral centre-edge angle.
• Avascular necrosis (AVN) — particularly in patients with risk factors such as steroid exposure or heavy alcohol use.
• Labral tear without FAI — usually from a single traumatic event.
• Athletic pubalgia (“sports hernia”) — a soft-tissue injury at the pubic symphysis, often mimicking groin pain.
• Adductor tendinopathy — overuse pain in the groin tendon.
• Hip flexor tendinopathy — iliopsoas-related anterior hip pain.
• Stress fractures — of the femoral neck, particularly in runners and military recruits.
• Inflammatory arthritis — ankylosing spondylitis and related conditions can present with hip pain.

The history that matters

A focused history can rule in or out most of these in one consultation:

• Where is the pain — anterior groin (intra-articular), lateral hip (greater trochanter), posterior (sacroiliac, sciatica)?
• What makes it worse — prolonged sitting (FAI), running (stress fracture), kicking and twisting (labral tear), inactivity (inflammatory)?
• Is there a mechanical component — catching, locking, giving way?
• Are there risk factors — adolescent high-level sport, steroid exposure, family history, autoimmune disease?
• Is the pain progressive or has it plateaued?

The examination

A handful of specific tests give a great deal of information: the FADIR (flexion–adduction–internal rotation) test for FAI, the FABER test for sacroiliac and intra-articular sources, the Stinchfield test for hip flexor pathology, the squeeze test for adductor pathology, and gait observation for compensation patterns.

When to image

Any young adult with hip or groin pain that has not improved with 6 weeks of conservative care deserves imaging. A standing pelvis X-ray is the first step but rarely the last — many conditions are radiographically silent and require MRI for diagnosis. MRI arthrogram is the gold standard for labral pathology. A bone scan or MRI is essential when stress fracture is suspected.

Treatment principles

Most of these conditions follow a stepped approach. Targeted physiotherapy comes first — usually addressing core stability, gluteal strength, and movement patterns. Activity modification is often required. Diagnostic and therapeutic injections have a role. Surgical options depend on the specific diagnosis — hip arthroscopy for FAI and labral tears, peri-acetabular osteotomy for selected dysplasia, core decompression for early AVN, hip replacement for arthritis.

What patients should not accept

“It’s probably just a strain — rest it” after six months of pain is not an answer. Hip pain that has not improved with proper rehabilitation deserves a careful diagnostic assessment by an orthopedic surgeon familiar with young-adult hip conditions. The cost of a one-hour consultation and an MRI is small compared to two years of unnecessary disability.