What is the initial evaluation and management of hip pain?

Initial Evaluation and Management of Hip Pain

The initial evaluation of hip pain should start with radiographs, including anteroposterior (AP) pelvis and lateral femoral head-neck views, followed by appropriate physical examination tests and targeted treatment based on the identified cause. 1

Diagnostic Approach

History and Physical Examination

• Location of pain - Categorize as:

  • Anterior (intra-articular causes like labral tears, FAI, OA)
  • Lateral (typically greater trochanteric pain syndrome)
  • Posterior (sciatic nerve entrapment, hamstring issues) 2

• Red flag symptoms requiring immediate attention:

  • Fever
  • Severe pain
  • Inability to bear weight
  • Night pain
  • Unexplained weight loss 1

• Key physical examination tests:

  • FADIR test (Flexion, Adduction, Internal Rotation) - negative result helps rule out hip disease 1
  • Internal rotation - reproduction of pain suggests intra-articular pathology 3
  • Gait assessment - antalgic gait may indicate advanced disease 3

Initial Imaging

• First-line imaging: AP pelvis and lateral femoral head-neck radiographs 1, 3

  • Evaluates for osteoarthritis, fractures, dysplasia, and bony morphology

• Advanced imaging (when indicated):

  • MRI without contrast (99-100% sensitivity): For occult fractures, soft tissue injuries, osteonecrosis, tendinopathy, labral tears 1
  • MR arthrography: Superior for labral tears and femoroacetabular impingement 1
  • Ultrasound: For extra-articular soft tissue abnormalities (tendinitis, bursitis) 1
  • CT scan: When 3D morphological assessment is needed 3, 1

Important caveat: Imaging should never be used in isolation but combined with patient symptoms and clinical signs 3, 1

Initial Management Based on Diagnosis

For Osteoarthritis

1. NSAIDs (high quality evidence, strong recommendation) - first-line when not contraindicated 3
2. Acetaminophen (consensus evidence) - may be considered when NSAIDs are contraindicated 3
3. Physical therapy (high quality evidence, moderate recommendation) - for mild-to-moderate symptomatic hip OA 3

For Soft Tissue Causes

• Ultrasound-guided injections may be both diagnostic and therapeutic 1
• Activity modification based on specific diagnosis
• Targeted physical therapy for specific conditions (e.g., gluteus medius strengthening for greater trochanteric pain syndrome) 2

For Intra-articular Pathology in Younger Adults

• Consider early referral for conditions with good surgical outcomes:
  • Femoroacetabular impingement
  • Labral tears
  • Gluteus medius tendon tears 2

Clinical Categorization

Hip pain may be further categorized after initial evaluation into:

1. Femoroacetabular impingement syndrome
2. Acetabular dysplasia and/or hip instability
3. Other conditions causing hip-related pain (including soft tissue conditions) 3

Important Considerations

• Avoid diagnostic pitfalls:

  • Don't dismiss clinical suspicion based solely on negative radiographs 1
  • Consider referred pain from lumbar spine or sacroiliac joint 1, 2
  • Remember that incidental findings on imaging are common in asymptomatic individuals 3, 1

• When to refer:

  • Presence of red flag symptoms
  • Failed conservative management (NSAIDs, acetaminophen, PT)
  • Young or middle-aged adults with suspected labral tears or FAI 2
  • Patients with significant functional limitations 3

Early and accurate diagnosis is critical for preventing complications, reducing hospital stays, and improving outcomes, particularly for serious conditions like occult fractures, infections, or tumors 1.