What x-ray views are best for evaluating hip pain in a patient, considering their medical history and potential conditions such as osteoarthritis or previous hip replacements?

Standard X-ray Views for Hip Pain

For initial evaluation of hip pain, obtain an anteroposterior (AP) view of the pelvis with 15 degrees of internal hip rotation combined with a cross-table lateral view of the symptomatic hip. 1, 2

Initial Imaging Protocol

Essential Views

• AP pelvis radiograph is mandatory as the foundation of hip imaging because it allows simultaneous visualization of both hips for side-to-side comparison and detects concomitant pelvic fractures (sacrum, pubic rami) that frequently accompany hip pathology 1, 2
• Cross-table lateral view of the affected hip completes the orthogonal imaging required for accurate diagnosis and treatment planning 1, 2
• Position the hip with 15 degrees of internal rotation on the AP view to properly align the femoral neck parallel to the imaging plane and minimize visibility of the lesser trochanter 1, 2, 3

Technical Specifications

• Center the femoral neck in the scan field with the lesser trochanter barely visible when proper internal rotation is achieved 2
• Use positioning devices secured with straps to prevent movement during image acquisition 2

Clinical Context Determines Approach

Acute Hip Pain (Trauma/Fall)

• AP pelvis + cross-table lateral is the definitive initial imaging choice because it rapidly detects fractures and dislocations while allowing portable acquisition without moving the patient 1, 2
• This combination identifies approximately 90% of proximal femoral fractures on initial imaging 1
• Never use frog-leg lateral views in trauma settings as they risk displacing occult fractures; always use cross-table laterals 2

Chronic Hip Pain or Suspected Osteoarthritis

• Start with AP pelvis radiograph as first-line imaging before considering advanced modalities 1, 3, 4
• Add a lateral view (frog-leg lateral or false profile view acceptable in non-trauma settings) to complete the standard series 3, 5, 4
• The false profile view (Lequesne's view) is particularly valuable for assessing osteoarthritis 4

Suspected Femoroacetabular Impingement or Labral Pathology

• Begin with AP pelvis and lateral femoral head-neck radiographs to assess bony morphology 1
• These views help identify structural abnormalities associated with FAI syndrome and guide decisions about advanced imaging 1

Critical Pitfalls to Avoid

• Never order isolated hip views without the pelvis—this eliminates the ability to compare with the contralateral side and misses associated pelvic pathology that occurs frequently alongside hip disease 1, 2
• Failing to obtain orthogonal views (both AP and lateral) leads to missed diagnoses and altered treatment decisions, particularly for fracture classification 1, 2
• Approximately 10% of proximal femoral fractures are not visible on initial radiographs, so maintain high clinical suspicion and proceed to MRI without contrast if radiographs are negative but clinical concern persists 1, 2

When Advanced Imaging Is Needed

MRI Without Contrast

• Reserved for cases where radiographs are negative or equivocal but clinical suspicion remains high 1
• Most appropriate for detecting occult fractures, stress fractures, osteonecrosis, and evaluating articular cartilage 1, 5
• Rated as "usually appropriate" (score 9/9) for chronic hip pain with negative radiographs when evaluating cartilage 1

MR Arthrography

• The diagnostic test of choice for suspected labral tears, rated "usually appropriate" (score 9/9) 1, 5
• Also highly rated (9/9) for evaluating articular cartilage when radiographs are non-diagnostic 1

CT Arthrography

• Alternative to MR arthrography for labral evaluation, rated "usually appropriate" (score 7/9) 1
• Useful when MRI is contraindicated 1

Summary Algorithm

1. All hip pain: Start with AP pelvis (15° internal rotation) + cross-table lateral of symptomatic hip 1, 2
2. If acute trauma: Use only cross-table lateral, never frog-leg 2
3. If chronic pain with negative radiographs: Proceed to MRI without contrast for most conditions 1
4. If suspected labral tear: Proceed to MR arthrography 1, 5