What are the treatment options for hip joint pain radiating into the groin upon movement?

Hip Joint Pain Radiating into Groin: Treatment Approach

Begin with plain radiographs (AP pelvis and frog-leg lateral hip views) as your first imaging test, then proceed to MRI hip without IV contrast if radiographs are negative or equivocal, and consider image-guided diagnostic injection to confirm the hip joint as the pain source. 1, 2

Initial Diagnostic Workup

First-Line Imaging

• Obtain plain radiographs of both the pelvis and hip as the mandatory first step (rated 9/9 "usually appropriate" by the American College of Radiology). 1, 2
• Include both anteroposterior pelvis view and frog-leg lateral view of the symptomatic hip to avoid missing pathology. 2
• Radiographs screen for common disorders including osteoarthritis, fractures, bone tumors, and femoroacetabular impingement. 1, 3

Clinical Examination Findings to Document

• Hip pain radiating to the groin typically indicates intra-articular hip pathology such as labral tears, femoroacetabular impingement, or osteoarthritis in older adults. 3, 4
• Test for restricted and painful hip quadrant compared to the contralateral side (most consistently positive finding). 4
• Perform FABER test (flexion, abduction, external rotation) - positive in 88% of patients with hip joint pathology. 4
• Consider that back pain may coexist with hip pathology in up to 50% of cases. 4

Second-Line Imaging Based on Initial Results

If Radiographs Are Negative or Equivocal

For suspected intra-articular pathology (labral tear, impingement):

• MR arthrography is the preferred test (rated 9/9 by the American College of Radiology). 1
• CT arthrography is an acceptable alternative (rated 7/9). 1
• Standard MRI hip without IV contrast is also appropriate (rated 6/9). 1

For suspected soft tissue abnormality (tendonitis):

• MRI hip without IV contrast is first choice (rated 9/9). 1, 2
• Ultrasound is a valuable alternative (rated 7/9). 1, 2

For evaluating articular cartilage:

• Both MRI hip without IV contrast and MR arthrography are equally appropriate (both rated 9/9). 1

Diagnostic Injection Protocol

• Image-guided anesthetic and corticosteroid injection into the hip joint is highly appropriate (rated 8/9) when diagnosis remains unclear or when concurrent low back, pelvic, or knee pathology exists. 1, 2
• This provides both diagnostic confirmation and therapeutic benefit. 2
• Helps differentiate hip joint pain from referred pain sources. 1, 2

Treatment Options

Conservative Management

NSAIDs for pain control:

• Ibuprofen 400-800 mg three to four times daily (maximum 3200 mg/day). 5
• Use the lowest effective dose for the shortest duration. 5
• For chronic conditions like osteoarthritis, therapeutic response typically seen within 2 weeks. 5
• Administer with meals or milk if gastrointestinal complaints occur. 5

Physical therapy:

• Active, supervised physical therapy is the initial treatment for adductor-related and pubic-related groin pain. 6
• Core strengthening and neuromuscular rehabilitation for inguinal-related pain. 6

Interventional Treatment

• Image-guided corticosteroid injection into the hip joint or surrounding structures (rated 8/9 for diagnostic and therapeutic purposes). 1
• Can be performed simultaneously with MR or CT arthrography. 1

Surgical Considerations

• Femoroacetabular impingement, labral tears, and gluteus medius tendon tears typically have good surgical outcomes. 3
• Early referral and advanced imaging may improve outcomes for these conditions. 3
• Hip arthroscopy is the definitive diagnostic and therapeutic procedure for intra-articular pathology. 4

Critical Pitfalls to Avoid

• Never proceed directly to advanced imaging without obtaining plain radiographs first - this is rated as "usually not appropriate" (1/9). 1, 2
• Do not obtain only hip views without pelvis views - both are complementary and necessary. 1, 2
• Do not dismiss hip pathology based on negative MRI alone - sensitivity is lower than specificity, with relatively high false negatives. 4
• Do not ignore concurrent lumbar spine pathology - referred pain from the spine, sacroiliac joints, or knee can confuse the clinical picture. 1
• Avoid peripheral nerve blocks of the obturator nerve - these are experimental/investigational with insufficient evidence. 2

Algorithm for Unclear Diagnosis

When pain source remains uncertain after imaging:

1. Perform image-guided diagnostic hip joint injection with anesthetic. 1, 2
2. If injection provides temporary relief, confirms hip joint as pain source. 2
3. If no relief, consider lumbar spine MRI for referred pain evaluation. 2
4. Consider hip arthroscopy if high clinical suspicion persists despite negative imaging. 4