Right Anterior Hip Pain with Locking: Treatment Approach
Start with plain radiographs (AP pelvis and frog-leg lateral views) immediately, followed by MR arthrography if radiographs are negative or equivocal, as locking strongly suggests an intra-articular mechanical problem—most likely a labral tear or loose body—that may require arthroscopic surgery. 1
Initial Diagnostic Workup
Obtain plain radiographs first in all cases of hip pain with mechanical symptoms like locking 1. The locking sensation indicates a mechanical obstruction within the joint, which narrows your differential to intra-articular pathology 2, 3.
- Order AP pelvis view plus frog-leg lateral of the symptomatic hip to identify cam or pincer morphology (femoroacetabular impingement), loose bodies, osteoarthritis, or acetabular dysplasia 1, 2
- Look specifically for: cam deformity at the femoral head-neck junction, pincer lesions with acetabular overcoverage, joint space narrowing, and any calcified loose bodies 1, 2
Advanced Imaging When Radiographs Are Non-Diagnostic
If radiographs are negative or equivocal, proceed directly to MR arthrography (rated 9/9 appropriateness by ACR) rather than standard MRI 1, 2. The locking symptom makes labral pathology highly likely, and MR arthrography is superior for detecting labral tears 1.
- MR arthrography uses intra-articular dilute gadolinium (1:200 solution) and is the established gold standard for diagnosing acetabular labral tears 1, 2
- Standard MRI without contrast (rated 6/9) is less sensitive for labral pathology, though high-resolution 3 Tesla MRI may approach arthrography accuracy 1
- CT arthrography (rated 7/9) is an alternative if MRI is contraindicated, providing excellent visualization of labral tears and loose bodies 1
Conservative Management Before Surgery
Begin physical therapy and oral NSAIDs while awaiting imaging results, as these have strong evidence for symptomatic hip pathology 1, 2.
- Oral NSAIDs should be used when not contraindicated (high quality evidence, strong recommendation from AAOS) 1
- Physical therapy could be considered for mild-to-moderate symptoms (high quality evidence, moderate recommendation) 1, 2
- Oral acetaminophen may be considered as an alternative to NSAIDs (consensus evidence) 1
Avoid hyaluronic acid injections entirely (high quality evidence, strong recommendation against use in hip OA) 1, 2
Do not use oral opioids for treatment (consensus recommendation against) 1, 2
Diagnostic Injection for Confirmation
Consider image-guided intra-articular corticosteroid injection (rated 8/9 appropriateness) if the pain source is unclear or if concurrent low back/pelvic pathology exists 1, 2.
- Intra-articular corticosteroids could be considered for symptomatic relief (high quality evidence, moderate recommendation) 1
- Pain relief after injection confirms intra-articular source and helps differentiate from referred pain 1, 2
- This can be performed simultaneously with MR or CT arthrography 1
Surgical Referral Indications
Refer to orthopedic surgery if imaging confirms labral tear, loose body, or femoroacetabular impingement, as these conditions with mechanical locking typically have good surgical outcomes 3, 4.
- Labral tears, FAI, and loose bodies causing mechanical symptoms are arthroscopically treatable 3, 4
- Early referral may improve outcomes when mechanical obstruction is present 3
Critical Pitfalls to Avoid
Do not skip plain radiographs and proceed directly to MRI—this violates established imaging algorithms and may miss important bony pathology 1, 2
Do not obtain only ipsilateral hip views—always include AP pelvis view to assess bilateral hip morphology and pelvic alignment 1
Screen for lumbar spine and sacroiliac pathology with directed examination, as referred pain can mimic anterior hip pain 2, 3
Do not diagnose based on imaging alone—correlation with physical examination findings (especially FADIR test for FAI/labral pathology) is essential 2