What are the treatment options for hip pain with popping and a feeling of instability?

Hip Pain with Popping and Instability: Diagnostic and Treatment Approach

For hip pain with popping and a feeling of instability, begin with plain radiographs (AP pelvis and frog-leg lateral hip views), followed by MRI without contrast if radiographs are negative or equivocal, to categorize the condition into FAI syndrome, acetabular dysplasia/hip instability, or other soft tissue pathology—then proceed with conservative management (physical therapy, NSAIDs) before considering surgical intervention for refractory cases. 1

Initial Diagnostic Workup

Imaging Algorithm

Plain radiographs are the mandatory first step:

• Obtain AP view of the pelvis and frog-leg lateral view of the symptomatic hip 1, 2
• These serve as an excellent screening tool to identify bony morphology abnormalities, arthritis, fractures, and tumors 1, 2
• Assess for cam morphology (elevated alpha angle), acetabular dysplasia (decreased center-edge angle), and other structural abnormalities 1

If radiographs are negative, equivocal, or nondiagnostic:

• MRI hip without IV contrast is the next appropriate study (rated 9/9 by ACR) 1, 2
• MRI evaluates both intra-articular structures (labrum, cartilage, ligamentum teres) and extra-articular soft tissues (tendons, bursae, muscles) 1
• For suspected labral tears specifically, MR arthrography with intra-articular dilute gadolinium provides superior visualization compared to standard MRI 1, 3

Clinical Examination Priorities

Key physical examination findings to document:

• Positive FADIR test (flexion-adduction-internal rotation) suggests FAI syndrome or labral pathology 1
• Pain with internal rotation of the hip indicates intra-articular pathology 4
• Assess for capsular laxity with traction views or provocative maneuvers 5, 6
• Screen for lumbar spine and pelvic pathology as potential sources of referred pain 1

Critical pitfall: Never make a diagnosis based on imaging alone—incidental intra-articular findings are common in asymptomatic individuals 1

Categorization After Imaging

The 2020 British Journal of Sports Medicine consensus recommends categorizing hip-related pain into three groups: 1

1. FAI (Femoroacetabular Impingement) Syndrome:

   • Cam or pincer morphology on radiographs with positive FADIR test 1
   • Often coexists with labral and chondral pathology 1

2. Acetabular Dysplasia and/or Hip Instability:

   • Decreased acetabular coverage, increased femoral torsion, or soft tissue laxity 1, 7
   • May present with vague symptoms of "giving way" or unsteadiness 5, 6
   • Popping sensation may indicate capsular laxity or labral pathology 1, 4

3. Other Soft Tissue Conditions:

   • Labral tears, chondral lesions, ligamentum teres pathology without specific bony morphology 1
   • Greater trochanteric pain syndrome, iliopsoas tendinopathy, or snapping hip syndrome 1, 4

Conservative Management (First-Line Treatment)

For mild-to-moderate symptomatic hip pathology, initiate conservative treatment: 1

• Physical therapy is supported with high-quality evidence (moderate strength recommendation) 1
• Oral NSAIDs should be used when not contraindicated (strong recommendation) 1
• Oral acetaminophen may be considered as an alternative (consensus recommendation) 1
• Intra-articular corticosteroid injections could be considered for symptomatic relief (high-quality evidence, moderate strength) 1

Avoid these interventions:

• Intra-articular hyaluronic acid injections should NOT be used (strong recommendation against) 1
• Oral opioids should NOT be used for treatment (consensus recommendation against) 1

Diagnostic Injections for Unclear Cases

When the pain source remains uncertain after imaging:

• Image-guided intra-articular hip injection with anesthetic and corticosteroid is rated 8/9 (usually appropriate) by ACR 2
• This provides both diagnostic confirmation that pain originates from the hip joint and therapeutic benefit 2
• Particularly useful when concurrent low back, pelvic, or knee pathology exists 2

Avoid peripheral nerve blocks of the obturator nerve—these are experimental/investigational with insufficient evidence 2

Surgical Considerations

Proceed to surgical evaluation if conservative management fails:

• For FAI syndrome with labral tears: Arthroscopic techniques allow minimally invasive access for labral repair or debridement 3, 4
• For hip instability: Arthroscopic or open capsular plication can address capsular laxity 5, 6
• For acetabular dysplasia: Periacetabular osteotomy or other bony procedures may be necessary 7

Prognostic considerations:

• Untreated labral tears may lead to progressive cartilage damage and osteoarthritis 3
• FAI syndrome, labral tears, and gluteus medius tendon tears typically have good surgical outcomes when appropriately treated 4
• Early referral for surgical evaluation may improve patient outcomes in refractory cases 4

Common Pitfalls to Avoid

• Failing to obtain both pelvis and hip radiographic views may miss important pathology 1, 2
• Proceeding directly to advanced imaging without plain radiographs is not recommended 1, 2
• Diagnosing based on imaging alone without correlating with clinical examination findings 1
• Missing referred pain from lumbar spine or pelvis—always screen these areas 1, 4
• Using hyaluronic acid injections or opioids for treatment 1