What if the patient's symptoms are due to hip pathology, how would I diagnose and manage it?

Diagnosing and Managing Hip Pathology

To determine if a patient's symptoms are due to hip pathology, start with radiographs of the pelvis and hip as the first diagnostic step, followed by targeted advanced imaging based on clinical suspicion. 1

How to Identify Hip Pathology

Key Clinical Features to Look For:

• Pain Location:

  • Anterior hip pain: May indicate labral tears, femoroacetabular impingement (FAI), or osteoarthritis
  • Lateral hip pain: Often suggests greater trochanteric pain syndrome (including gluteus medius tendinopathy)
  • Posterior hip pain: Consider sciatic nerve entrapment, ischiofemoral impingement, or hamstring tendinopathy 2

• Physical Examination:

  • FADIR test (Flexion, Adduction, Internal Rotation): A negative test helps rule out hip disease 1
  • Assess for limited range of motion, especially internal rotation
  • Evaluate for pain with weight-bearing activities

Diagnostic Algorithm:

1. Initial Imaging:

   • AP pelvis and lateral femoral head-neck radiographs are the recommended first-line imaging 1
   • Look for:
     • Osseous abnormalities (FAI morphology, dysplasia)
     • Joint space narrowing (osteoarthritis)
     • Fractures or stress reactions

2. If Radiographs Are Negative/Equivocal but Symptoms Persist:

   • MRI without contrast: Best for evaluating soft tissue, cartilage, and bone marrow pathology 1
   • MR arthrography: Superior for labral tears and FAI syndrome 1
   • CT scan: When 3D morphological assessment is needed 1
   • Ultrasound: Useful for evaluating joint effusions, soft tissue collections, and periarticular pathology like trochanteric bursitis 1

3. Diagnostic Injection:

   • Image-guided anesthetic injection can help confirm the hip as the pain source, especially when symptoms might be referred from back, pelvis, or knee 1

Management Approach

For Confirmed Hip Pathology:

1. Conservative Management First:

   • 44% of patients with prearthritic, intra-articular hip disorders improve with conservative care alone 3

2. Treatment Options:

   • Exercise therapy: Provides long-term pain relief for tendinopathies and early osteoarthritis 4
   • Activity modification: Reduce activities that aggravate symptoms
   • NSAIDs: For pain and inflammation control 5
   • Image-guided injections: Corticosteroid injections for conditions like trochanteric bursitis 6

3. When to Consider Surgical Referral:

   • Persistent symptoms despite 3 months of conservative care
   • Positive response to diagnostic intra-articular injection
   • Surgically amenable lesion on advanced imaging (e.g., labral tear, FAI) 3
   • More active patients may benefit more from surgical intervention 3

Common Pitfalls to Avoid:

1. Misattribution of Symptoms: Hip pain can be referred from lumbar spine, sacroiliac joint, or intra-abdominal/pelvic sources 2

2. Incomplete Imaging: Radiographs alone may miss soft tissue pathology or early osteoarthritis 1

3. Overreliance on Imaging: Diagnostic imaging should always be combined with clinical symptoms and signs, not used in isolation 1

4. Missing Serious Pathology: Always exclude tumors, infections, stress fractures, and slipped capital femoral epiphysis before diagnosing more common hip conditions 1

5. Premature Surgery: A trial of conservative management should be considered before surgical intervention for prearthritic hip disorders 3

Remember that hip pathology in young and middle-aged adults typically falls into three categories: FAI syndrome, acetabular dysplasia/hip instability, or other conditions without distinct osseous morphology (including labral, chondral, and ligamentum teres pathology) 1.