What are the appropriate steps to diagnose and manage hip pain?

Diagnostic and Management Approach to Hip Pain

Radiographs of the pelvis and hip should be the first imaging test ordered for the evaluation of patients with chronic hip pain, followed by targeted advanced imaging based on radiographic findings and clinical suspicion. 1

Initial Evaluation

• Begin with a focused history to determine the location of pain (anterior, lateral, or posterior), which helps narrow the differential diagnosis 2
• Perform a targeted physical examination including:
  • Range of motion assessment 1
  • FADIR test (flexion, adduction, internal rotation) - a negative test helps rule out hip disease 1
  • Assessment for gait abnormalities, locking or snapping 1
  • Evaluation of pain patterns (worse at night, relieved by activity) 1

Imaging Algorithm

First-Line Imaging

• Obtain radiographs of the pelvis and hip as the initial imaging study for all patients with hip pain 1
  • Include anteroposterior (AP) view of the pelvis and frog-leg lateral view of the symptomatic hip 1, 3
  • These views can identify common disorders such as osteoarthritis, dysplasia, femoroacetabular impingement (FAI), and bone tumors 1

Second-Line Imaging (if radiographs are negative, equivocal, or nondiagnostic)

For suspected extra-articular soft tissue abnormality (e.g., tendinitis, bursitis):

• MRI hip without IV contrast (rated 9/9 for appropriateness) 1
• Ultrasound (rated 7/9 for appropriateness) - particularly useful for evaluating superficial structures like abductor tendons, trochanteric bursitis, and guiding injections 1

For suspected labral tear or femoroacetabular impingement:

• MR arthrography (rated 9/9 for appropriateness) 1
• CT arthrography (rated 7/9 for appropriateness) - alternative if MRI is contraindicated 1
• High-resolution 3T MRI without contrast may be sufficient in some cases 1

Diagnostic Injections

• Image-guided anesthetic/corticosteroid injections can be both diagnostic and therapeutic 1
• Consider injections when:
  • Need to differentiate the source of pain (intra-articular vs. extra-articular) 1
  • Relief with intra-articular injection suggests joint pathology 1
  • Relief with trochanteric injection suggests greater trochanteric pain syndrome 1
  • Relief with iliopsoas injection suggests iliopsoas pathology 1

Management Based on Diagnosis

Intra-articular Pathology

• Common causes: osteoarthritis (older adults), labral tears or FAI (younger adults) 2, 4
• Management:
  • Physical therapy may improve symptoms in some cases 4
  • Arthroscopic intervention for labral tears and FAI with good surgical outcomes 2, 4

Lateral Hip Pain

• Most commonly caused by greater trochanteric pain syndrome 2, 3
• Management:
  • Ultrasound-guided corticosteroid injection can be therapeutic 1
  • Physical therapy focusing on hip abductor strengthening 5

Posterior Hip Pain

• Consider lumbar spine pathology, deep gluteal syndrome, ischiofemoral impingement 2, 3
• Management:
  • MRI to evaluate for lumbar radiculopathy if suspected 3
  • Targeted physical therapy based on specific diagnosis 5

Common Pitfalls to Avoid

• Relying solely on imaging findings without correlating with clinical symptoms - diagnostic utility of imaging is limited when used in isolation 1
• Failure to consider referred pain from lumbar spine, sacroiliac joints, or knee 1
• Overlooking extra-articular causes of hip pain, which are common 2
• Delaying appropriate referral for conditions with good surgical outcomes (FAI, labral tears, gluteus medius tears) 2

Special Considerations

• In elderly patients, osteoarthritis is more common, but other serious conditions like fractures must be excluded 6
• In athletes and young adults, consider labral tears and FAI as common causes of hip pain 4
• When evaluating chronic hip pain with negative radiographs, MRI is the preferred next test to screen for significant pathology 1