What are the examination, treatment, and medication options for patients presenting with hip pain?

Hip Pain: Examination, Treatment, and Medication

Initial Diagnostic Approach

Radiography of the pelvis and hip must be the first imaging test for any patient presenting with hip pain, regardless of acuity or suspected etiology. 1, 2, 3

First-Line Imaging Protocol

• Obtain an anteroposterior (AP) view of the pelvis with approximately 15 degrees of internal hip rotation, plus a cross-table lateral view (or frog-leg lateral for non-traumatic cases) of the symptomatic hip 2, 3
• The pelvis view allows critical comparison with the contralateral side, which may reveal pathology missed on single-hip views 2
• Never proceed directly to advanced imaging without obtaining plain radiographs first—this wastes resources and may delay diagnosis 1

Clinical Examination Framework

Before imaging, categorize hip pain by anatomic location to guide differential diagnosis 4:

Anterior hip pain may indicate:

• Intra-articular pathology (labral tear, femoroacetabular impingement in younger adults; osteoarthritis in older adults) 4
• Hip flexor injuries 4
• Referred pain from intra-abdominal or intrapelvic sources 4

Lateral hip pain most commonly indicates:

• Greater trochanteric pain syndrome (gluteus medius tendinopathy/tear, bursitis, iliotibial band friction) 4

Posterior hip pain may indicate:

• Lumbar spine pathology (referred pain) 4
• Deep gluteal syndrome with sciatic nerve entrapment 4
• Ischiofemoral impingement or hamstring tendinopathy 4

Critical Exclusions Before Proceeding

First exclude non-musculoskeletal and serious pathology (tumors, infections, slipped capital femoral epiphysis) and competing musculoskeletal conditions (lumbar spine pathology) before categorizing hip disease 1

Advanced Imaging: When and What to Order

If Radiographs Are Negative or Equivocal

For suspected soft tissue abnormality (tendonitis, bursitis):

• MRI hip without IV contrast (rating 9/9 - usually appropriate) 1, 3
• Ultrasound is an acceptable alternative (rating 7/9) for evaluating specific superficial structures 1

For suspected labral tear or femoroacetabular impingement:

• MR arthrography is the preferred method (rating 9/9) 1, 3
• CT arthrography is an acceptable alternative (rating 7/9) 1

For suspected occult fracture (especially in trauma or persistent pain):

• MRI without IV contrast has near 100% sensitivity for proximal femoral fracture detection 2, 3

For evaluating articular cartilage:

• MRI hip without IV contrast (rating 9/9) or MR arthrography (rating 9/9) 1

Diagnostic Injections

Image-guided anesthetic ± corticosteroid injection into the hip joint (rating 8/9) can determine if pain originates from the hip joint itself versus surrounding structures or referred sources 1, 3

• This is particularly useful when concurrent low back, pelvic, or knee pathology exists 1
• Provides both diagnostic information and potential therapeutic benefit 3

What NOT to Order

Nuclear medicine bone scans, PET imaging, and CT without contrast are NOT appropriate for chronic hip pain evaluation (rating 1/9) 1, 3

Treatment Approach

Conservative Management for Osteoarthritis

For mild-to-moderate symptomatic hip osteoarthritis, the treatment hierarchy is:

1. Oral NSAIDs (when not contraindicated) - strong recommendation 1

   • NSAIDs have been shown comparable to aspirin and indomethacin for controlling disease activity with fewer gastrointestinal and nervous system adverse effects 5
   • Use at the lowest effective dose for the shortest duration needed 5
   • Critical warning: NSAIDs increase risk of serious cardiovascular thrombotic events, myocardial infarction, and stroke, which can be fatal and increases with longer use 5
   • Never use NSAIDs immediately before or after coronary artery bypass graft surgery 5
   • NSAIDs can cause ulcers and bleeding in the stomach and intestines at any time, which can occur without warning and may be fatal 5

2. Oral acetaminophen (when not contraindicated) - consensus option 1

   • May be considered for symptomatic hip osteoarthritis 1

3. Physical therapy - moderate recommendation 1

   • Could be considered for mild-to-moderate symptomatic hip osteoarthritis 1

4. Intra-articular corticosteroid injection - moderate recommendation 1

   • Could be considered for symptomatic hip osteoarthritis 1
   • Should be performed under imaging guidance 3

What NOT to Use

Intra-articular hyaluronic acid injections should NOT be used for hip osteoarthritis - strong recommendation against 1

Surgical Considerations

For end-stage osteoarthritis refractory to conservative measures:

• Total hip arthroplasty is appropriate 1
• Either formal physical therapy or unsupervised home exercise is supported after THA (moderate recommendation) 1

For femoroacetabular impingement, labral tears, and gluteus medius tendon tears:

• These conditions typically have good surgical outcomes, so advanced imaging and/or early referral may improve patient outcomes 4

Critical Integration Principle

Never rely on imaging alone for diagnosis—the diagnostic utility of clinical examination or imaging in isolation is limited 1, 2, 3

• Diagnosis requires integration of patient symptoms, clinical signs, and diagnostic imaging findings 1, 2
• Multiple hip conditions may coexist in the same patient 1

Common Pitfalls to Avoid

• Failing to obtain both pelvis and hip views may miss associated pelvic fractures or contralateral pathology that alters treatment decisions 2
• Delaying MRI when occult fracture is suspected (especially if pain worsens or persists beyond 2-3 days) may indicate an occult femoral neck fracture requiring urgent surgical intervention 3
• Using peripheral nerve blocks (such as obturator nerve blocks) for chronic hip pain diagnosis—these are experimental/investigational with insufficient evidence 3
• Combining NSAIDs with aspirin is not recommended as aspirin increases naproxen excretion rates and data are inadequate to show benefit over aspirin alone, while increasing adverse event frequency 5