What causes intermittent sharp right hip pain when walking?

Right Front Hip Pain When Walking: Differential Diagnosis

Intermittent sharp right anterior hip pain when walking is most commonly caused by intra-articular pathology (labral tears, femoroacetabular impingement, or early osteoarthritis), iliopsoas tendinopathy, or greater trochanteric pain syndrome, and requires plain radiographs as the initial diagnostic test. 1, 2, 3

Initial Diagnostic Approach

Start with AP pelvis and frog-leg lateral hip radiographs to exclude osseous pathology, arthritis, fractures, or structural abnormalities. 1, 2, 4 This is the American College of Radiology's first-line recommendation for any hip pain presentation. 1, 4

Most Likely Diagnoses Based on Location

Anterior Hip Pain (Groin/Front of Hip)

The anterior location strongly suggests one of three categories:

Intra-articular causes:

• Labral tears - Sharp, catching pain with walking, often with clicking or locking sensations 3, 5
• Femoroacetabular impingement (FAI) - Sharp pain with hip flexion and internal rotation during gait 3, 5
• Early osteoarthritis - More common in middle-aged and older adults, though can present with intermittent sharp pain 6, 3

Extra-articular causes:

• Iliopsoas tendinopathy - Sharp pain over the anterior hip/groin, worsened by hip flexion during walking 2, 5
• Hip flexor strain - Sharp pain with active hip flexion, history of sudden onset or overuse 3, 5

Next Steps After Radiographs

If Radiographs Are Negative or Equivocal:

Obtain MRI hip without IV contrast (rated 9/9 by ACR as "usually appropriate"). 1, 4 This evaluates:

• Labral tears 4, 5
• Cartilage damage 1, 5
• Tendon pathology (iliopsoas, hip flexors) 2, 4
• Occult fractures 4
• Soft tissue inflammation 4, 3

Alternative: Ultrasound can evaluate iliopsoas tendon and trochanteric bursa, particularly useful for guiding diagnostic injections. 2, 4

If Labral Tear or FAI Specifically Suspected:

MR arthrography is superior to standard MRI for detecting labral pathology and is rated 9/9 by ACR. 1, 4

Diagnostic Injection Strategy

Image-guided anesthetic injection into the hip joint (rated 8/9 by ACR) helps differentiate intra-articular from extra-articular pain sources when diagnosis remains unclear. 1, 4 This provides both diagnostic information and potential therapeutic benefit. 4

For suspected iliopsoas pathology, ultrasound-guided corticosteroid injection into the iliopsoas bursa can be both diagnostic and therapeutic. 2

Critical Pitfalls to Avoid

• Never skip plain radiographs - Proceeding directly to advanced imaging misses fractures, tumors, and arthritis that change management. 1, 4
• Don't obtain only hip views - AP pelvis is essential to evaluate the contralateral hip, sacroiliac joints, and pubic symphysis. 1, 4
• Avoid nuclear medicine scans or PET imaging for this presentation - They are rated 1/9 (usually not appropriate) by ACR and provide inferior soft tissue evaluation. 1, 4
• Consider referred pain - Lumbar spine pathology, sacroiliac joint dysfunction, and athletic pubalgia can all present as anterior hip pain. 3, 5 If hip imaging is unrevealing, consider lumbar spine evaluation. 4

Age-Specific Considerations

Younger, active adults: Think labral tears, FAI, and iliopsoas tendinopathy first. 3, 5 These have good surgical outcomes when diagnosed early, so consider early referral if confirmed. 3

Middle-aged and older adults: Osteoarthritis becomes more likely, though labral tears and tendinopathy still occur. 6, 3

Adolescents: Consider apophyseal avulsion (especially if acute onset with "pop" sensation) or slipped capital femoral epiphysis. 6, 7

Conservative Management While Awaiting Imaging

For suspected iliopsoas pathology: Activity modification, physical therapy focusing on hip flexor stretching and hip stabilizer strengthening, and NSAIDs for 4-6 weeks before considering injections. 2