What is the appropriate workup for a patient presenting with bilateral hip pain?

Workup for Bilateral Hip Pain

The appropriate workup for bilateral hip pain should begin with radiographs of the pelvis and both hips, followed by MRI without contrast if radiographs are negative, equivocal, or nondiagnostic. 1

Initial Evaluation

First-Line Imaging

• Plain radiographs:
  • Anteroposterior (AP) view of the pelvis 1
  • Lateral femoral head-neck view of each hip (e.g., Dunn view, frog-leg/Lauenstein view) 1
  • These views provide essential information about:
    • Osteoarthritis
    • Femoroacetabular impingement (FAI)
    • Hip dysplasia
    • Fractures
    • Bone tumors
    • Joint space narrowing

Physical Examination Focus

• Location of pain (anterior, lateral, posterior)
• FADIR test (flexion, adduction, internal rotation) - recommended as the most appropriate clinical screening test for hip-related pain 1
• Range of motion assessment
• Gait evaluation
• Tenderness over greater trochanter (for trochanteric pain syndrome)
• Lumbar spine and sacroiliac joint examination (for referred pain)

Secondary Evaluation (Based on Radiograph Results)

If Radiographs Are Normal or Nondiagnostic:

1. MRI without IV contrast (rated 9/9 for appropriateness) 1

   • Best for evaluating:
     • Soft tissue abnormalities
     • Labral tears
     • Cartilage damage
     • Tendinopathies (iliopsoas, gluteus medius)
     • Bursitis
     • Bone marrow edema

2. Ultrasound (rated 7/9 for appropriateness for soft tissue pathology) 1

   • Useful for:
     • Abductor tendinosis/tears
     • Trochanteric bursitis
     • Iliopsoas tendinopathy
     • Guiding injections

If Specific Conditions Are Suspected:

1. For suspected labral tear or femoroacetabular impingement:

   • MR arthrography (rated 9/9 for appropriateness) 1
   • CT arthrography (rated 7/9) as an alternative 1

2. For suspected cartilage damage:

   • MRI without contrast or MR arthrography (both rated 9/9) 1

3. For suspected inflammatory or infectious process:

   • MRI with and without contrast (rated 9/9) 1
   • Consider joint aspiration if infection is suspected

Special Considerations

When Hip Pain May Be Referred:

• If concurrent low back, pelvic, or knee pathology exists:
  • MRI hip without contrast (rated 9/9) 1
  • Consider image-guided diagnostic injection (rated 8/9) 1
  • Evaluate lumbar spine with appropriate imaging if radicular symptoms present 2

For Older Adults:

• Focus on osteoarthritis evaluation
• Physical examination and radiography may be sufficient for diagnosis (reasonable sensitivity and specificity) 1

For Younger Adults:

• Higher suspicion for:
  • Labral tears
  • Femoroacetabular impingement
  • Athletic injuries
  • Early advanced imaging may be warranted 3

Common Pitfalls to Avoid

1. Relying solely on imaging findings:

   • Diagnostic imaging should never be used in isolation but combined with symptoms and clinical signs 1
   • Incidental findings are common in asymptomatic individuals 1

2. Missing referred pain sources:

   • Hip pain may originate from lumbar spine, sacroiliac joints, or knee 1, 2
   • Consider broader evaluation when hip imaging is normal

3. Inadequate radiographic views:

   • Single view radiographs may miss important findings
   • Both AP pelvis and lateral femoral head-neck views are necessary 1

4. Premature invasive procedures:

   • Diagnostic injections should not be performed until a diagnosis is suspected 1
   • Aspiration and injection are diagnostic tools, not first-line approaches

5. Overlooking bilateral nature:

   • When pain is bilateral, consider systemic conditions:
     • Inflammatory arthropathies
     • Transient osteoporosis of pregnancy 4
     • Osteonecrosis with bilateral involvement

By following this systematic approach to the workup of bilateral hip pain, clinicians can efficiently diagnose the underlying cause and develop an appropriate treatment plan to improve patient outcomes and quality of life.