What is the appropriate evaluation and management plan for a 27-year-old active duty male with left hip and back pain?

Evaluation and Management of a 27-Year-Old Active Duty Male with Left Hip and Back Pain

Begin with anteroposterior (AP) pelvis and lateral femoral head-neck radiographs as the initial imaging study, combined with a comprehensive clinical examination that includes screening for both hip and spine pathology, as imaging alone cannot establish the diagnosis. 1

Initial Clinical Assessment

History and Physical Examination Focus

For this young, active duty patient, the clinical examination should specifically assess:

• Pain location and pattern: Determine if pain is anterior (groin), lateral, or posterior hip, as this guides differential diagnosis 2, 3
• FADIR test (Flexion-Adduction-Internal Rotation): This is the single most appropriate clinical screening test for hip-related pain in young adults, despite its limitations 1
• Spine and pelvis screening: Essential because hip pain frequently coexists with or is referred from lumbar spine pathology 1
• Activity limitations: Document specific functional impairments related to military duties 1

Important caveat: Other special tests (Thomas test, prone instability test) have very limited diagnostic utility and are not recommended for establishing the diagnosis 1

Initial Imaging Protocol

Radiographs are mandatory as the first imaging study and should include: 1

• AP pelvis view
• Lateral femoral head-neck view (Dunn view, frog-leg, or cross-table view)

These radiographs assess for:

• Femoroacetabular impingement (FAI) morphology (cam or pincer lesions) 1
• Acetabular dysplasia 1
• Early osteoarthritis 1
• Stress fractures or other bony pathology 3

Diagnostic Categories After Initial Evaluation

Based on the 2020 International Hip-Related Pain Research Network consensus, hip-related pain in young active adults categorizes into three conditions: 1

1. FAI syndrome
2. Acetabular dysplasia and/or hip instability
3. Other conditions (labral, chondral, ligamentum teres pathology without specific bony morphology)

Advanced Imaging Indications

When Radiographs Are Negative or Non-Diagnostic

If radiographs are negative but clinical suspicion remains high, proceed with MRI without contrast as the next study: 1

• MRI is highly sensitive for detecting intra-articular pathology, soft tissue abnormalities, and occult fractures 1, 3
• Particularly important if symptoms persist beyond initial evaluation, as occult fractures can be missed on plain films 1

For Suspected Labral Tears or FAI Syndrome

MR arthrography is the diagnostic test of choice when labral pathology is suspected clinically: 1, 3

• Rated as most appropriate (rating 9/9) for suspected labral tears 1
• CT arthrography is an acceptable alternative (rating 7/9) 1
• Standard MRI without contrast has lower sensitivity (rating 6/9) for labral pathology 1

For Extra-Articular Soft Tissue Pathology

MRI without contrast (rating 9/9) or ultrasound (rating 7/9) for suspected: 1

• Greater trochanteric pain syndrome/gluteus medius tendinopathy 2
• Iliopsoas bursitis or tendinopathy 1
• Hamstring injuries 1

Critical Diagnostic Principle

Never make the diagnosis based on imaging alone—imaging must be combined with clinical symptoms and signs. 1 This is emphasized because:

• Diagnostic imaging shows only small to moderate shifts in post-test probability for most hip conditions 1
• Incidental intra-articular findings are common in asymptomatic individuals 1
• The clinical utility of imaging is limited without corresponding clinical findings 1

Management Algorithm

1. Obtain AP pelvis and lateral hip radiographs immediately 1
2. Perform FADIR test and screen spine/pelvis 1
3. If radiographs show FAI morphology or dysplasia AND positive clinical findings: Consider conservative management first (physiotherapy) 1
4. If conservative treatment fails or surgery is being considered: Obtain MRI or MR arthrography to identify labral, chondral, or ligamentum teres pathology 1
5. If radiographs are negative but symptoms persist >2 days with worsening pain: Obtain MRI to rule out occult fracture 1

Common Pitfalls to Avoid

• Do not skip radiographs: Even if MRI is ultimately needed, radiographs provide essential baseline morphological information 1
• Do not order MRI arthrography as the first test: Standard radiographs must come first 1
• Do not rely on imaging findings alone: Asymptomatic morphological variants (cam morphology, labral changes) are common and require clinical correlation 1
• Do not ignore the spine: Back pain in this patient requires concurrent spine evaluation, as lumbar pathology commonly refers to the hip 1