What are the appropriate diagnosis and treatment options for a patient experiencing hip pain, possibly due to osteoarthritis?

Hip Pain: Diagnostic and Treatment Approach

Begin with plain radiographs (AP pelvis and frog-leg lateral hip views) as your first imaging test for any patient presenting with hip pain, regardless of suspected etiology. 1

Initial Diagnostic Workup

First-Line Imaging

• Obtain AP pelvis radiographs plus a lateral femoral head-neck view (frog-leg or Dunn view) before any other imaging modality. 1 This combination is superior to imaging the symptomatic hip alone, as it allows comparison and evaluation of pelvic alignment. 1
• For suspected osteoarthritis specifically, physical examination combined with plain radiographs may be sufficient and can match or exceed MRI accuracy. 1
• Radiographs effectively screen for fractures, arthritis, bone tumors, femoroacetabular impingement (FAI), and acetabular dysplasia. 1

Critical Exclusions Before Proceeding

Before categorizing hip-related pain, you must first exclude: 1

• Non-musculoskeletal causes (vascular, neurologic, intra-abdominal/pelvic pathology)
• Serious pathology (tumors, infections, slipped capital femoral epiphysis)
• Competing musculoskeletal conditions (lumbar spine referred pain, knee pathology)

When Radiographs Are Negative, Equivocal, or Nondiagnostic

For Suspected Soft Tissue Pathology (Tendonitis, Bursitis)

• Order MRI hip without IV contrast (rated 9/9 appropriateness) as the next test. 1 MRI is highly sensitive and specific for detecting soft tissue abnormalities including trochanteric bursitis, iliopsoas bursitis, abductor tendinosis or tears, and hamstring injuries. 1
• Ultrasound (rated 7/9 appropriateness) is an acceptable alternative for evaluating superficial soft tissue structures and can guide diagnostic/therapeutic injections. 1
• IV contrast is rarely needed for MRI in these cases. 1

For Suspected Labral Tear or Femoroacetabular Impingement

• MR arthrography is the diagnostic test of choice (rated 9/9 appropriateness). 1 Direct intra-articular injection of dilute gadolinium (1:200 in saline) provides superior visualization of labral tears and cartilage delamination. 1
• CT arthrography is an acceptable alternative (rated 7/9 appropriateness) when MRI is contraindicated. 1
• Standard MRI without contrast (rated 6/9 appropriateness) may suffice at 3 Tesla field strength but is less reliable than arthrography. 1

For Suspected Intra-Articular Pathology of Uncertain Origin

The diagnostic approach should combine patient symptoms, clinical signs, and diagnostic imaging—no single modality in isolation is sufficient. 1 The diagnostic capability of matching these three elements remains incompletely understood but represents current best practice. 1

Osteoarthritis-Specific Management

Pharmacologic Treatment Algorithm

1. Start with acetaminophen as first-line therapy. 2
2. Step up to NSAIDs (ibuprofen 1200-3200 mg daily in divided doses) if acetaminophen fails. 3, 2 Use the lowest effective dose for the shortest duration. 3
3. For ibuprofen dosing in osteoarthritis: 3
   • Initial dose: 400-800 mg three to four times daily
   • Maximum: 3200 mg/day (though 2400 mg/day is often equally effective with less risk)
   • Take with meals or milk if GI complaints occur
   • Therapeutic response typically seen within 2 weeks

Adjunctive Treatments

• Exercise reduces pain and disability and should be prescribed. 2
• Glucosamine plus chondroitin combination can be used for moderate to severe osteoarthritis. 2
• Intra-articular corticosteroid injections provide 4-8 weeks of relief for acute flare-ups. 2
• Hyaluronic acid injections are more expensive but provide longer symptom relief than corticosteroids. 2

Diagnostic Injections as a Tool

Image-guided anesthetic injections (with or without corticosteroids) serve as both diagnostic and therapeutic interventions. 1

• Intra-articular hip injection relieving pain confirms the joint as the pain source. 1
• Trochanteric injection relieving pain confirms trochanteric bursitis/tendinopathy. 1
• Iliopsoas injection relieving pain confirms iliopsoas pathology. 1
• All injections should be performed under imaging guidance (fluoroscopy, ultrasound, or CT). 1

Surgical Referral Indications

Refer for orthopedic evaluation when: 2

• Chronic pain and disability persist despite maximal medical therapy
• Imaging confirms surgically correctable pathology (FAI, labral tears, severe osteoarthritis)
• Total joint replacement should be considered for end-stage disease with refractory symptoms

Common Pitfalls to Avoid

• Do not order MRI as the first imaging test—radiographs must come first to guide subsequent imaging selection and provide comparison. 1
• Do not assume normal radiographs exclude significant pathology—labral tears, early cartilage damage, and soft tissue injuries require advanced imaging. 1
• Do not perform diagnostic injections before imaging—they are reserved for when a specific diagnosis is suspected. 1
• Do not use CT for soft tissue evaluation—it is insensitive compared to MRI and ultrasound. 1
• Do not exceed 3200 mg/day of ibuprofen, and recognize that doses above 2400 mg/day rarely provide additional benefit while increasing risk. 3