What is the most appropriate initial step in evaluating and managing a patient presenting with right hip pain?

Right Hip Pain: Initial Evaluation and Management

First Step: Obtain Plain Radiographs Immediately

Start with anteroposterior (AP) pelvis and lateral hip radiographs as your first diagnostic test—this is the foundation of hip pain evaluation and should never be skipped. 1, 2, 3

• Plain radiographs screen for common disorders including osteoarthritis, fractures, bone tumors, femoroacetabular impingement (FAI) morphology, acetabular dysplasia, and avascular necrosis 1, 4
• In many cases such as advanced osteoarthritis, radiographs may be the only imaging necessary 1
• The ACR rates plain radiographs as "usually appropriate" (rating 9/9) for chronic hip pain evaluation 1

Concurrent Clinical Assessment: Target Your Physical Examination

While ordering radiographs, perform a focused physical examination to localize the pain source and narrow your differential:

Anatomic Pain Localization

• Anterior hip/groin pain suggests intra-articular pathology (osteoarthritis, FAI, labral tears) 4
• Lateral hip pain indicates greater trochanteric pain syndrome 4
• Posterior hip/buttock pain points to piriformis syndrome, sacroiliac joint dysfunction, or lumbar radiculopathy 4

Critical Physical Examination Maneuvers

• Assess range of motion, particularly internal rotation—limited internal rotation with anterior pain strongly suggests FAI or early osteoarthritis 2
• Perform FABER test—contralateral pain indicates SI joint dysfunction rather than primary hip pathology 5
• Evaluate gait, provocative maneuvers, and check for locking or snapping 1
• Always examine the lumbar spine, sacroiliac joints, and knee as these commonly refer pain to the hip region 1, 5

Next Steps Based on Radiograph Results

If Radiographs Are Negative or Equivocal

Order MRI of the hip without IV contrast—this is rated 9/9 (usually appropriate) by the ACR for ongoing hip pain with negative radiographs. 3

• MRI detects soft tissue pathology, labral tears, early cartilage damage, bone marrow edema, occult fractures, and avascular necrosis not visible on plain films 2, 3
• MRI is superior to all other modalities for comprehensive soft tissue evaluation 3
• Do NOT order CT, bone scan, or PET imaging—these are rated 1/9 (usually not appropriate) and provide inadequate soft tissue detail 3

If Diagnosis Remains Unclear After MRI

Perform image-guided intra-articular hip injection with local anesthetic (with or without corticosteroid) to definitively confirm the hip joint as the pain generator. 2, 3

• This provides both diagnostic confirmation and therapeutic benefit 2
• The ACR rates diagnostic injection as 8/9 (usually appropriate) when concurrent spine, pelvic, or knee pathology exists 3

Initial Conservative Management

Once you've confirmed hip pathology:

First-Line Treatment

Refer to physical therapy immediately—this has high-quality evidence with moderate strength recommendation from the AAOS. 2

• Physical therapy is evidence-based treatment for mild-to-moderate hip pathology 5
• NSAIDs and acetaminophen provide symptomatic relief during rehabilitation 2, 6

Adjunctive Interventions

• Consider intra-articular corticosteroid injection for symptomatic relief (high-quality evidence, moderate strength recommendation) 2, 5
• Avoid hyaluronic acid injections—strong recommendation against use for hip osteoarthritis 2
• Avoid opioids entirely for chronic hip pain—consensus recommendations oppose their use 2, 5

Critical Pitfalls to Avoid

• Never diagnose based on imaging alone—incidental findings are extremely common in asymptomatic individuals; clinical correlation is essential 2, 5
• Never skip plain radiographs and proceed directly to advanced imaging—this violates consensus guidelines and may miss important bony pathology 5, 3
• Never assume primary hip joint pathology without imaging confirmation—referred pain from lumbar spine or SI joint commonly mimics hip pathology 2, 5
• Never fail to examine the spine and pelvis systematically—these are common sources of referred hip pain 1, 5