What is the diagnosis and recommended management for a patient with right hip tenderness, limited range of motion, and a positive Faber test, but normal strength and no gross deformity?

Clinical Interpretation: Likely Intra-Articular Hip Pathology

This examination strongly suggests intra-articular hip pathology, most likely involving the hip labrum, iliopsoas tendinopathy, or early femoroacetabular impingement (FAI) syndrome, and requires immediate plain radiographs (AP pelvis and lateral femoral head-neck views) followed by MRI or MR arthrography if imaging is negative but clinical suspicion remains high. 1

Key Examination Findings and Their Significance

Positive Findings Indicating Intra-Articular Pathology

• Tenderness over anterior hip joint line is the most significant finding, indicating intra-articular pathology such as labral tears, cartilage damage, or synovitis 2, 3

• Positive FABER test (Flexion-Abduction-External Rotation) has 88% sensitivity for hip joint pathology in research studies, though the British Journal of Sports Medicine notes this test has limited diagnostic accuracy and should not be used in isolation 1, 2

• Positive resisted sit-up test suggests iliopsoas tendinopathy or anterior labral pathology, as the iliopsoas tendon crosses the anterior hip joint and can irritate the labrum 3, 4

Reassuring Findings

• Negative FADIR test (Flexion-Adduction-Internal Rotation) is notable because the British Journal of Sports Medicine recommends the FADIR test as the single most appropriate screening test for hip-related pain, despite its limitations 1

• Normal strength (5/5 in all planes) and normal range of motion (flexion 120°, extension 10°, ER 60°, IR 40°, abduction 50°, adduction 30°) suggest this is not advanced osteoarthritis or severe structural pathology 1

• Negative labral shear test reduces but does not eliminate the possibility of labral pathology, as special tests have substantial ability to rule in labral conditions in only one high-quality study 1

Recommended Diagnostic Algorithm

Step 1: Immediate Plain Radiographs

• Obtain AP pelvis and lateral femoral head-neck radiographs immediately as the first diagnostic step, per consensus guidelines from the British Journal of Sports Medicine 1, 5

• These radiographs will identify FAI morphology (cam or pincer lesions), acetabular dysplasia, early osteoarthritis, or other bony abnormalities 1

Step 2: Advanced Imaging if Radiographs Are Negative

• If plain films are non-diagnostic but clinical findings remain positive, proceed with MRI or MR arthrography to detect labral tears, cartilage damage, ligamentum teres pathology, and soft tissue abnormalities 1, 5

• The British Journal of Sports Medicine emphasizes that diagnosis should never be made on imaging alone—imaging must be combined with clinical symptoms and signs, as diagnostic imaging shows only small to moderate shifts in post-test probability for most hip conditions 1

• MR arthrography is rated 9/9 for suspected labral tears and provides superior visualization compared to standard MRI 5, 2

Step 3: Consider Diagnostic Injection

• Image-guided intra-articular hip injection with anesthetic and corticosteroid can provide both diagnostic confirmation (if pain resolves temporarily) and therapeutic benefit 6, 3

Initial Conservative Management

First-Line Treatment

• Initiate NSAIDs immediately for symptomatic relief (strong recommendation, high-quality evidence per the American Academy of Orthopaedic Surgeons) 7, 6

• Refer to physical therapy targeting hip muscle strengthening, particularly hip abductors, adductors, flexors, and rotators (moderate recommendation, high-quality evidence) 7, 6

Additional Conservative Options

• Consider intra-articular corticosteroid injection for symptomatic relief if conservative measures fail (moderate recommendation, high-quality evidence) 7, 6

Critical Pitfalls to Avoid

• Do not skip plain radiographs, even if MRI is ultimately needed, as radiographs provide essential baseline morphological information that guides treatment decisions 1, 5

• Do not rely on the positive FABER test alone to make a diagnosis, as the British Journal of Sports Medicine states that clinical special tests have very limited ability to confirm specific hip pathology and should not be used in isolation 1

• Do not assume the negative FADIR test rules out intra-articular pathology, as the combination of anterior joint line tenderness and positive FABER test maintains high clinical suspicion despite the negative FADIR 1, 2

• Do not ignore the spine and pelvis, as hip pain frequently coexists with or is referred from lumbar spine or sacroiliac joint pathology 5, 2

• Avoid opioids entirely for chronic hip pain (consensus recommendation) and do not use hyaluronic acid injections (strong recommendation, high-quality evidence) 7, 6

Most Likely Diagnoses Based on This Examination Pattern

1. Labral tear or labral pathology - anterior joint line tenderness with positive FABER and resisted sit-up tests are classic findings 2, 3

2. Iliopsoas tendinopathy - positive resisted sit-up test is highly specific for this condition 3, 4

3. Early FAI syndrome - though FADIR is negative, the anterior joint line tenderness and positive FABER suggest possible FAI, particularly if radiographs show cam or pincer morphology 1, 3