What is the initial management approach for a patient presenting with right hip pain and a positive left FABER test?

Right Hip Pain with Positive Left FABER Test: Sacroiliac Joint Pathology

A positive FABER test on the left side causing right hip pain indicates sacroiliac (SI) joint pathology on the right side, not hip joint pathology. This is a critical diagnostic distinction that changes your entire management approach.

Understanding the Clinical Presentation

The FABER test (Flexion, Abduction, External Rotation) is being misinterpreted in this scenario. When performing a left FABER test that produces pain in the right hip/SI region, you are stressing the right sacroiliac joint, not the left hip joint 1.

Key Diagnostic Points:

• A positive FABER test causing ipsilateral hip pain suggests intra-articular hip pathology (88% of patients with true hip pathology have positive ipsilateral FABER tests) 1
• A positive FABER test causing contralateral pain points to SI joint dysfunction or referred pain from the pelvis/spine 2, 3
• The British Journal of Sports Medicine emphasizes that comprehensive clinical examination must include screening for spine and pelvic conditions that present with hip-related pain 2

Initial Management Algorithm

Step 1: Confirm the Pain Source

• Perform a right-sided FABER test to determine if right hip pain occurs with ipsilateral testing (suggesting true hip pathology) 1
• Examine the lumbar spine and pelvis systematically, as these are common sources of referred pain to the hip region 2, 3
• Assess for SI joint tenderness with direct palpation and provocative maneuvers (Gaenslen's test, FABER test, compression test) 4

Step 2: Obtain Appropriate Imaging

Start with anteroposterior (AP) pelvis and lateral femoral head-neck radiographs to evaluate both hip joints and pelvic alignment 2, 5. This is the consensus recommendation for any patient presenting with hip-related pain, regardless of the clinical suspicion 2.

• Plain radiographs assess for hip osteoarthritis, femoroacetabular impingement morphology, acetabular dysplasia, and fractures 2, 5
• Imaging should never be used in isolation—diagnosis requires integration of symptoms, clinical signs, and imaging findings 2

Step 3: Advanced Imaging if Indicated

If radiographs are negative but clinical suspicion remains high for hip pathology, obtain MRI of the hip without contrast 5, 3. However, given the presentation of contralateral FABER pain, consider:

• MRI of the lumbar spine and pelvis if SI joint or spinal pathology is suspected 3, 4
• MRI is superior for detecting soft tissue pathology, labral tears, and early osteonecrosis 5
• Image-guided diagnostic injection (either hip intra-articular or SI joint) can definitively determine the pain generator 5, 3

Conservative Management Approach

For Suspected SI Joint Dysfunction:

• Physical therapy focused on pelvic stabilization and core strengthening 6
• NSAIDs for symptomatic relief 6, 7
• Consider SI joint injection with corticosteroid if conservative measures fail after 6-8 weeks 5

For Confirmed Hip Pathology (if right FABER is also positive):

• Refer to Physical Medicine and Rehabilitation (PMR) for individualized physical therapy programs before considering surgical options 6
• The American Academy of Orthopaedic Surgeons strongly recommends physical therapy as evidence-based treatment for mild-to-moderate hip pathology 6
• Intra-articular corticosteroid injection can provide both diagnostic confirmation and therapeutic benefit 6, 5

Critical Pitfalls to Avoid

Do not assume this is primary hip joint pathology without confirming the pain source. The contralateral FABER pain pattern is atypical for intra-articular hip disease 1.

Do not proceed directly to advanced imaging without plain radiographs first. This violates consensus guidelines and may miss important bony pathology 2, 5.

Do not diagnose based on imaging alone. Incidental findings are common in asymptomatic individuals—clinical correlation is essential 2. Diagnostic imaging shows only small to moderate shifts in post-test probability for hip pathology 2.

Screen for lumbar and pelvic pathology systematically. Hip-related pain requires comprehensive examination including the spine and pelvis, as these commonly refer pain to the hip region 2, 3, 4.

Avoid opioids for chronic hip or SI joint pain. Consensus recommendations oppose opioid use for symptomatic hip osteoarthritis 5.