How should I evaluate and manage a patient presenting with hip pain?

Evaluation and Management of Hip Pain

Initial Imaging: Always Start with Radiographs

Radiography of the pelvis and hip must be the first imaging test ordered for any patient presenting with hip pain, whether acute or chronic. 1, 2

• Obtain an anteroposterior (AP) view of the pelvis with approximately 15 degrees of internal hip rotation, plus a cross-table lateral view of the affected hip 1, 2
• The pelvis view is essential because it allows comparison with the contralateral side, which is crucial for accurate diagnosis 2
• For acute trauma, use cross-table lateral rather than frog-leg lateral views to avoid risk of fracture displacement 1, 2
• Radiographs serve as an excellent screening tool that guides selection of additional imaging when needed, regardless of whether findings are normal or abnormal 2

Clinical Assessment: Localize the Pain Anatomically

The location of pain determines your differential diagnosis and subsequent workup 3:

Anterior Hip and Groin Pain

• Suggests intra-articular pathology such as femoroacetabular impingement (FAI), labral tears, or osteoarthritis in older adults 3, 4
• Perform the FADIR test (flexion-adduction-internal rotation): flex hip to 90°, adduct toward opposite shoulder, and internally rotate 5
• A negative FADIR test effectively rules out intra-articular hip pathology in young and middle-aged adults 5
• A positive FADIR test indicates need for advanced imaging but is not specific to any single diagnosis 5

Lateral Hip Pain

• Most commonly caused by greater trochanteric pain syndrome, including gluteus medius tendinopathy, bursitis, or iliotibial band friction 3, 6
• Ultrasound is excellent for evaluating periarticular soft tissue structures like trochanteric bursitis 1, 7

Posterior Hip Pain

• Consider lumbar spine pathology, deep gluteal syndrome with sciatic nerve entrapment, ischiofemoral impingement, or hamstring tendinopathy 3, 6
• Always exclude non-musculoskeletal and serious pathology (tumors, infections, slipped capital femoral epiphysis) before categorizing hip disease 1

Advanced Imaging: When and What to Order

After Negative or Equivocal Radiographs in Acute Trauma

• MRI without IV contrast is the next study, with near 100% sensitivity for detecting radiographically occult proximal femoral fractures 2, 7
• Delays in fracture diagnosis beyond 12 hours significantly increase 30-day mortality risk 1

After Negative or Equivocal Radiographs in Chronic Pain

For suspected intra-articular pathology (labral tears, FAI):

• MR arthrography is the gold standard with the highest appropriateness rating (9/9) for detecting labral tears and impingement 1, 7, 4
• CT arthrography is an alternative if MRI is contraindicated 1

For suspected extra-articular soft tissue abnormalities (tendonitis, bursitis):

• MRI without IV contrast receives the highest rating (9/9) and is most sensitive for detecting tendonitis and other soft tissue pathology 1, 7
• Ultrasound is also appropriate for periarticular structures with a rating of 7/9 7

For suspected infection:

• MRI with IV contrast increases reader confidence and better delineates abscesses 7
• Hip aspiration may be needed when infection is a consideration 1

For cartilage evaluation:

• Both MRI without IV contrast and MR arthrography receive the highest rating (9/9) 7

Critical Pitfalls to Avoid

• Never rely on imaging alone—diagnosis requires integration of symptoms, clinical signs, and imaging findings 1, 2, 5
• Never skip the pelvis view—hip radiographs alone may miss associated pelvic fractures that alter treatment decisions 2
• Never stabilize the pelvis inadequately during FADIR testing—compensatory pelvic tilting creates false-positive findings 5
• Never assume labral tears or chondral lesions seen on imaging are symptomatic—these findings are frequently present in asymptomatic individuals 5
• Never order MRI with and without IV contrast routinely—it receives lower appropriateness ratings and adds unnecessary time and cost 7

Diagnostic Injection for Unclear Cases

• Image-guided anesthetic injection with or without corticosteroid is appropriate to exclude the hip as the source of pain when there is coexisting low back, pelvic, or knee pathology with negative or equivocal radiographs 1, 3
• Ultrasound-guided anesthetic injections can aid in confirming an intra-articular cause of pain 3

When to Refer

• Early referral is warranted for FAI, labral tears, and gluteus medius tendon tears because these conditions typically have good surgical outcomes 3
• Refer when advanced imaging confirms surgically correctable pathology in appropriate candidates 3