What imaging modalities can be used for left hip pain with a negative X-ray (X-ray)?

Imaging Options for Left Hip Pain with Negative X-ray

For patients with left hip pain and negative X-rays, MRI without contrast is the recommended next imaging study due to its superior sensitivity (99-100%) for detecting occult fractures and soft tissue pathology. 1, 2

Diagnostic Algorithm for Hip Pain with Negative X-rays

Acute Traumatic Hip Pain

1. First choice: MRI Hip Without Contrast

   • Near 100% sensitivity for occult fractures 1
   • Can detect both femoral and pelvic fractures (38% of patients with negative X-rays have pelvic fractures) 1
   • Can visualize soft tissue injuries and bone marrow edema 2
   • Allows for early diagnosis and treatment planning, reducing morbidity 1
   • Rapid protocols available (coronal STIR sequence has 99% sensitivity) 1

2. Alternative: CT Hip Without Contrast (if MRI contraindicated/unavailable)

   • Meta-analysis shows CT detects occult hip fractures in 24.1% of cases with negative X-rays 1
   • Can lead to management changes in 20% of cases 1
   • Less sensitive than MRI (CT sensitivity 79-94% vs MRI 99-100%) 1
   • Patients with negative CT but persistent clinical concern should still undergo MRI 1

3. Not recommended:

   • Bone scan (insufficient evidence) 1
   • Ultrasound (insufficient evidence, limited research) 1
   • CT with IV contrast (no evidence supporting use) 1

Chronic Hip Pain

1. First choice: MRI Hip Without Contrast

   • Best for evaluating:
     • Labral tears
     • Tendinopathy
     • Stress fractures
     • Osteonecrosis
     • Soft tissue injuries 1, 2

2. Alternative options based on specific clinical suspicion:

   • MR arthrography or CT arthrography: Superior for labral tears and impingement 1
   • Ultrasound: Useful for extra-articular soft tissue abnormalities (e.g., trochanteric bursitis) 1

Clinical Considerations

Importance of Prompt Diagnosis

• Delays in diagnosis increase complications, hospital stays, and mortality rates 2
• Early detection of occult fractures reduces immobility and risk of osteonecrosis 1

Common Pitfalls to Avoid

1. Relying solely on X-rays when clinical suspicion is high

   • X-rays miss approximately 10% of hip fractures 2
   • Negative X-rays alone cannot exclude fracture when clinical suspicion remains high 2

2. Overlooking pelvic fractures

   • Many patients with hip pain have concurrent pelvic fractures 1, 2
   • MRI can detect both hip and pelvic pathology in a single study 1

3. Failing to consider soft tissue causes of hip pain

   • MRI can identify labral tears, tendinopathy, and bursitis not visible on X-ray 3, 4
   • Intra-articular and extra-articular processes can be evaluated with MRI 3

4. Delaying advanced imaging

   • Early diagnosis improves outcomes by reducing immobility and allowing prompt treatment 1, 2
   • MRI-diagnosed hip fracture patients do not suffer more complications than those diagnosed by X-ray 5

MRI has revolutionized the diagnosis of hip pathology, allowing visualization of both osseous and soft tissue structures that are not apparent on conventional radiography 6, 7. For patients with hip pain and negative X-rays, MRI without contrast represents the most comprehensive next imaging step to guide appropriate treatment and improve patient outcomes.