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

Evaluation and Management of Hip Pain in Adults

Start with plain radiographs (AP pelvis and lateral hip views) as your initial imaging for all patients presenting with hip pain, regardless of whether the presentation is acute traumatic or chronic. 1

Initial Clinical Assessment

History and Physical Examination Focus

Localize the pain anatomically to guide your differential diagnosis 2:

• Anterior hip/groin pain: Suggests intra-articular pathology (osteoarthritis, labral tears, femoroacetabular impingement) or hip flexor injuries 2, 3
• Lateral hip pain: Most commonly greater trochanteric pain syndrome (gluteus medius tendinopathy/tear, bursitis, iliotibial band friction) 2, 3
• Posterior hip pain: Consider lumbar radiculopathy, piriformis syndrome, sacroiliac joint dysfunction, ischiofemoral impingement, or hamstring tendinopathy 2, 3

Determine acuity and mechanism 1, 4:

• Acute traumatic: Prioritize fracture and dislocation detection
• Chronic/atraumatic: Focus on degenerative, inflammatory, or soft tissue etiologies

Imaging Algorithm

Step 1: Initial Radiographs (All Patients)

Order AP pelvis with 15-degree internal hip rotation and cross-table lateral view of the affected hip 1. This rapid, portable imaging reduces morbidity by quickly identifying fractures and dislocations without moving the patient 1.

Step 2: If Radiographs Are Negative or Indeterminate

For Acute Traumatic Hip Pain with Suspected Fracture:

Obtain CT hip without IV contrast as the first-line next study 1. CT rapidly detects radiographically occult fractures and reduces fracture-related morbidity by enabling prompt treatment 1.

• If CT remains negative or equivocal but clinical suspicion persists, proceed to MRI hip without contrast 1
• MRI detects occult fractures, stress fractures, and osteonecrosis with high sensitivity 3

For Chronic Hip Pain:

The next imaging depends on your clinical suspicion 1:

• Suspected soft tissue pathology (tendonitis, bursitis): MRI hip without contrast OR ultrasound 1
• Suspected labral tear: MRI hip without contrast, MR arthrography, OR CT arthrography 1
  • MR arthrography is the diagnostic test of choice for labral tears 3
• Suspected femoroacetabular impingement: MR arthrography OR CT arthrography 1
• Suspected tendon/muscle/ligament injury: MRI hip without contrast is usually appropriate 1
  • MRI detected 100% of proximal hamstring avulsions versus only 58.3% for ultrasound 1

Step 3: After Positive Radiographs

For Confirmed Hip Fracture:

Obtain CT hip without contrast when you need fracture characterization for surgical planning 1. This helps assess fracture alignment and guides operative decision-making 1.

For Hip Dislocation:

Obtain repeat radiographs (AP and lateral) after reduction to confirm successful relocation 1. If there is an associated large posterior acetabular wall fracture or difficulty achieving reduction, obtain CT hip without contrast to evaluate for surgical fixation needs or intra-articular fragments 1.

For Suspected Infection with Arthritis:

Obtain MRI hip with or without IV contrast OR perform hip aspiration 1. Joint aspiration is the definitive method to exclude septic arthritis 1.

Special Diagnostic Considerations

When Hip Is Uncertain Pain Source

If the patient has concomitant low back, pelvic, or knee pathology and you need to determine if the hip is contributing 1:

• MRI hip without contrast is the best screening test after negative/equivocal radiographs or radiographs showing only mild osteoarthritis 1
• Image-guided anesthetic injection (with or without corticosteroid) can diagnostically exclude the hip as the pain source 1

Modalities to Avoid

Do not use bone scan for acute traumatic hip pain evaluation 1. There is insufficient evidence supporting its use in either initial imaging or as a next study after negative radiographs 1.

Avoid CT with IV contrast or CT without and with IV contrast for acute traumatic hip pain—there is no evidence supporting their use 1.

Key Clinical Pitfalls

• Cross-table lateral views are mandatory in trauma settings rather than frog-leg laterals, which risk fracture displacement 1
• Ultrasound has significant limitations for detecting complete tendon tears and deep structures like the ligamentum teres 1
• Plain radiographs alone may miss occult fractures, labral tears, and early osteonecrosis—maintain low threshold for advanced imaging when clinical suspicion is high 1, 3
• Consider early orthopedic referral for femoroacetabular impingement, labral tears, and gluteus medius tears, as these typically have good surgical outcomes 2