What could be causing pain on my right hip when I put pressure on my leg, and how should it be evaluated and treated?

Right Hip Pain with Weight-Bearing: Evaluation and Management

Start with anteroposterior (AP) pelvis and frog-leg lateral hip radiographs immediately to screen for fractures, arthritis, bone tumors, and structural abnormalities. 1, 2

Initial Diagnostic Approach

First-Line Imaging

• Plain radiographs are mandatory as the first imaging test and should include both AP pelvis view and lateral femoral head-neck view (frog-leg or Dunn view) of the symptomatic hip 1, 2
• Radiographs serve as an excellent screening tool for common disorders including osteoarthritis, fractures, femoroacetabular impingement (FAI) morphology, acetabular dysplasia, and bone tumors 1, 3
• A pelvis view is superior to isolated hip views as it allows bilateral comparison and may reveal pelvic pathology 1, 2

Clinical Examination Priorities

• Determine pain location: anterior hip pain suggests intra-articular pathology (labral tear, FAI, osteoarthritis), lateral pain suggests greater trochanteric pain syndrome (gluteus medius tendinopathy, bursitis), and posterior pain suggests referred lumbar spine pathology or deep gluteal syndrome 3
• Perform FADIR test (flexion, adduction, internal rotation): reproduction of anterolateral hip pain suggests FAI or labral pathology 4
• Assess for aggravating activities: prolonged sitting, getting in/out of car, pivoting movements suggest intra-articular pathology 4
• Screen the lumbar spine and pelvis, as hip pain is frequently referred from these structures 1

If Radiographs Are Negative, Equivocal, or Nondiagnostic

For Suspected Intra-Articular Pathology (Labral Tear, FAI, Occult Fracture)

• Order MRI hip without IV contrast as the next step (rated 9/9 appropriateness by ACR) 1, 2
• MRI is highly sensitive and specific for detecting labral tears, cartilage damage, occult fractures (including stress fractures), bone marrow edema, and avascular necrosis 1, 2, 5
• If labral tear or FAI is specifically suspected based on clinical examination, MR arthrography (direct intra-articular gadolinium injection) is superior to standard MRI for visualizing labral tears and acetabular cartilage delamination 1, 4
• High-resolution 3 Tesla MRI may obviate the need for arthrography in some cases 1

For Suspected Extra-Articular Soft Tissue Pathology

• MRI hip without contrast or ultrasound are both appropriate for evaluating greater trochanteric pain syndrome, gluteus medius/minimus tendinopathy or tears, iliopsoas bursitis, trochanteric bursitis, and hamstring injuries 1, 2
• Ultrasound is particularly useful for dynamic assessment of snapping hip syndrome and for guiding diagnostic/therapeutic injections 1, 6

For Diagnostic Confirmation

• Image-guided intra-articular hip joint injection with anesthetic (rated 8/9 appropriateness by ACR) can confirm whether pain originates from the hip joint itself versus surrounding structures or referred sources 2
• This is especially valuable when concurrent low back, pelvic, or knee pathology exists 2
• Trochanteric or iliopsoas bursal injections can help localize extra-articular pain sources 1

Common Differential Diagnoses by Pain Pattern

Anterior Hip Pain with Weight-Bearing

• Intra-articular causes: Labral tear, FAI (cam or pincer type), early osteoarthritis, occult femoral neck fracture, avascular necrosis 3, 4
• Extra-articular causes: Iliopsoas tendinopathy, hip flexor strain, athletic pubalgia 3

Lateral Hip Pain with Weight-Bearing

• Greater trochanteric pain syndrome: Gluteus medius/minimus tendinopathy or tear, trochanteric bursitis, iliotibial band friction 3

Posterior Hip Pain

• Referred pain from lumbar spine (most common), deep gluteal syndrome with sciatic nerve entrapment, ischiofemoral impingement, hamstring tendinopathy 3

Critical Pitfalls to Avoid

• Never diagnose hip pathology based on imaging alone—diagnosis must combine symptoms, clinical signs, and imaging findings 1
• Do not proceed directly to advanced imaging without obtaining plain radiographs first, as this misses the opportunity to identify obvious structural abnormalities and wastes resources 1, 2
• Failing to obtain both pelvis and hip views may miss important bilateral or pelvic pathology 2
• Incidental intra-articular findings (labral tears, cartilage defects) are common in asymptomatic individuals—correlation with clinical presentation is essential 1
• Occult femoral neck fractures can present with normal initial radiographs—if pain worsens or persists beyond 2-3 days with weight-bearing, obtain urgent MRI as these may require surgical intervention 2
• Diagnostic imaging has limited ability to confirm a specific condition as the cause of pain (small to moderate post-test probability shifts at best), so comprehensive clinical examination remains paramount 1

What NOT to Do

• Do not use nuclear medicine bone scan, PET imaging, or CT without contrast for initial evaluation of hip pain with negative radiographs (rated 1/9 appropriateness by ACR) 2
• Do not perform peripheral nerve blocks of the obturator nerve for chronic hip pain, as this is experimental/investigational with insufficient evidence 2
• Do not rely on special clinical tests alone (Thomas test, prone instability test, ligamentum teres tear test) as they have very limited or insufficient diagnostic accuracy for ruling hip disease in or out 1