Evaluation of Hip Pain
Begin by performing the FADIR (flexion adduction internal rotation) test—a negative test effectively rules out hip disease in young and middle-aged active adults, while imaging should never be interpreted in isolation but always combined with clinical symptoms and examination findings. 1
Initial Clinical Assessment
Physical Examination Priority
- Perform the FADIR test first as it has the strongest evidence for ruling out hip pathology when negative (consensus recommendation score 9/9) 1, 2
- A negative FADIR test helps exclude hip disease and should redirect your evaluation toward alternative diagnoses such as lumbar spine pathology, sacroiliac joint dysfunction, or other competing musculoskeletal conditions 2, 3
- Critical caveat: A positive FADIR test is non-specific and may indicate FAI syndrome, labral tear, acetabular dysplasia, hip instability, or other intra-articular pathology—it does not confirm any single diagnosis 4
Anatomic Localization of Pain
- Anterior hip/groin pain: Most commonly intra-articular pathology including labral tears, FAI syndrome (younger adults), or osteoarthritis (older adults) 5, 6
- Lateral hip pain: Typically greater trochanteric pain syndrome, gluteus medius tendinopathy/tear, or iliotibial band friction 5, 6
- Posterior hip pain: Consider lumbar radiculopathy, deep gluteal syndrome with sciatic nerve entrapment, piriformis syndrome, sacroiliac joint dysfunction, or hamstring tendinopathy 5, 6
Mandatory Exclusions Before Proceeding
First exclude serious pathology and competing conditions before categorizing hip-related pain 1:
- Non-musculoskeletal conditions: tumors, infections 1, 4
- Serious hip pathology: stress fractures, slipped capital femoral epiphysis (SCFE) 1, 3, 4
- Competing musculoskeletal conditions: lumbar spine pathology, sacroiliac joint dysfunction 1, 2, 3
Imaging Algorithm
Initial Imaging (All Patients with Suspected Hip Pathology)
Order AP pelvis and lateral femoral head-neck radiographs as your first-line imaging (consensus recommendation score 9/9) 1, 2, 3
- These views assess for osseous morphology, dysplasia, degenerative changes, and bony abnormalities 3, 4
- Plain radiographs are sufficient to diagnose most hip complaints when combined with history and examination 6, 7
Advanced Imaging (When Indicated)
Proceed to MRI/MRA or CT when three-dimensional morphological assessment is needed or to evaluate intra-articular structures (labrum, cartilage, ligamentum teres) 1, 2
- For suspected labral tears specifically: MR arthrography is superior to CT arthrography and non-contrast MRI 2, 4
- MRI is valuable for detecting occult fractures, stress fractures, and osteonecrosis 6
- Imaging must always be combined with symptoms and clinical signs—never used in isolation (consensus recommendation score 9/9) 1
Critical Imaging Pitfall
Beware of incidental findings: Labral tears, chondral lesions, and ligamentum teres pathology are common on imaging in asymptomatic individuals 1, 2, 4
- Finding these abnormalities does not confirm they are the pain source 2, 4
- This is why the comprehensive approach (symptoms + clinical signs + imaging) is mandatory 1
Diagnostic Classification Framework
After excluding serious pathology, categorize hip-related pain into one of three conditions 1:
- Femoroacetabular impingement (FAI) syndrome 1, 4
- Acetabular dysplasia and/or hip instability 1, 3
- Other conditions without specific bony morphology: isolated labral tears, chondral conditions, ligamentum teres pathology 1, 3
Initial Management Approach
Conservative Treatment
Prescribed physiotherapy with education should be part of initial treatment for hip-related pain 2, 4
Diagnostic and Therapeutic Injections
Ultrasound-guided intra-articular anesthetic injections serve dual purposes 2, 4, 5:
- Diagnostic: Symptom improvement confirms intra-articular pathology as the pain source 4
- Therapeutic: Provides pain relief 2
Age-Specific Considerations
Young and Middle-Aged Active Adults
- Primary considerations: FAI syndrome, labral tears, acetabular dysplasia, hip instability 1, 2
- The consensus guidelines specifically target this population 1
Older Adults
- Osteoarthritis becomes the predominant intra-articular cause 5, 6
- Still perform the same systematic evaluation to avoid missing alternative diagnoses 6, 7
When Conservative Management Fails
If symptoms persist after 4 weeks of conservative management, proceed with comprehensive laboratory evaluation 8:
- Complete blood count with differential 8
- Erythrocyte sedimentation rate 8
- Arthritic panel (rheumatoid factor, antinuclear antibody, C-reactive protein) 8
- Consider nuclear bone scan or indium-111 labeled white blood cell scan depending on suspected etiology 8
Surgical Referral Considerations
Early referral may improve outcomes for conditions with good surgical results 5: