How should I evaluate and manage hip pain?

Evaluation and Management of Hip Pain

Begin by obtaining AP pelvis and lateral femoral head-neck radiographs combined with a focused clinical assessment that categorizes pain location (anterior, lateral, or posterior) and patient age, as imaging alone cannot diagnose the source of hip pain 1.

Initial Clinical Assessment

Pain Location Classification

Systematically categorize hip pain by anatomical location, as this directly correlates with underlying pathology 2:

• Anterior hip pain: Consider intra-articular causes (FAI syndrome, labral tears, osteoarthritis in older adults), hip flexor injuries, or referred pain from abdomen/pelvis
• Lateral hip pain: Most commonly greater trochanteric pain syndrome (gluteus medius tendinopathy/tear, bursitis, iliotibial band friction)
• Posterior hip pain: Evaluate for lumbar spine pathology, deep gluteal syndrome with sciatic nerve entrapment, ischiofemoral impingement, or hamstring tendinopathy

Key History Elements

Document onset pattern (sudden vs insidious), specific motions or positions that reproduce pain, predisposing activities, and effect of weight-bearing 3. For young and middle-aged active adults, inquire about sports participation and functional goals 4.

Diagnostic Imaging Strategy

Initial Imaging

Order AP pelvis radiographs plus lateral femoral head-neck views (Dunn, frog-leg, or cross-table view) as your first-line imaging 1. This reveals underlying hip morphology relevant to the pain presentation.

Advanced Imaging Indications

Proceed to MRI/MRA or CT arthrogram when 1:

• Three-dimensional morphological assessment is needed
• Evaluating intra-articular structures (labrum, cartilage, ligamentum teres)
• Plain radiographs and conservative therapy prove ineffective 3

Critical Imaging Caveat

Never diagnose hip pain based on imaging alone 1. Diagnostic imaging shows only very small to substantial post-test probability shifts for FAI syndrome and acetabular dysplasia, and small to moderate shifts at best for labral/chondral pathology. Incidental findings are common in asymptomatic individuals and require appropriate clinical sensitivity.

Clinical Examination Limitations

Most special clinical tests have very limited diagnostic utility 1:

• FADIR test and other special tests cannot confirm FAI syndrome with adequate post-test probability
• ROM, muscle performance tests lack diagnostic accuracy for hip-related pain conditions
• Do not rely on these tests to diagnose the pain source

Diagnostic Categories After Imaging

Classify hip disease in young and middle-aged active adults into 1:

1. FAI syndrome
2. Acetabular dysplasia and/or hip instability
3. Other conditions (soft-tissue pathology without specific bony morphology, including labral/chondral/ligamentum teres conditions)

Note that labral and chondral conditions frequently coexist with FAI syndrome and acetabular dysplasia.

Management Approach

Conservative Treatment Foundation

For young and middle-aged active adults with hip-related pain 4:

Implement physiotherapist-led treatment targeting specific impairments:

• Address lower hip and trunk muscle strength deficits
• Improve dynamic balance and single-leg squat alignment
• Correct gait alterations
• Enhance jumping, deceleration, and cutting movement abilities

Monitoring Treatment Response

Use validated patient-reported outcome measures 4:

• Copenhagen Hip and Groin Outcome Score (HAGOS)
• International Hip Outcome Tool (IHOT)

Combine with physical impairment measures: ROM, hip muscle strength, movement quality, and functional task performance.

Physical Activity Prescription

Recommend continued physical activity and sport participation 4. Develop sport-specific goals collaboratively with patients and implement strategies to achieve return to activity. Progress from strength and cardiovascular fitness to basic athletic movements, then gradually introduce sports-specific high-level tasks (running, high-speed movements, twisting, turning).

Injection Therapy

Consider ultrasound-guided anesthetic injections to aid diagnosis of intra-articular pain sources 2.

Surgical Referral Considerations

Pursue early referral and advanced imaging for 2:

• Femoroacetabular impingement
• Labral tears
• Gluteus medius tendon tears

These conditions typically have good surgical outcomes, making timely specialist evaluation beneficial for patient outcomes.

Age-Specific Considerations

In older adults, osteoarthritis becomes the predominant intra-articular cause 2. Management should emphasize exercise therapy and manual therapy for pain and mobility deficits associated with hip osteoarthritis 5.