How should bilateral hip pain without a known injury be evaluated and managed?

Bilateral Hip Pain Without Known Injury: Evaluation and Management

Initial Imaging

Obtain an anteroposterior (AP) pelvis radiograph and a lateral femoral head-neck view (Dunn, frog-leg/Lauenstein, or cross-table) as the first imaging study for every patient presenting with bilateral hip pain. 1

• These plain films provide essential information on bony morphology and can identify fractures, dislocations, and structural abnormalities even in the absence of known trauma. 1
• The AP pelvis view is a core component and allows bilateral comparison. 1
• The lateral femoral head-neck view complements the AP view and is essential for assessing bony morphology. 1

Clinical Examination Priorities

Actively screen for extra-hip sources of pain before attributing symptoms to the hip joint itself. 1

• Lumbar spine pathology, intra-abdominal/pelvic conditions, and other musculoskeletal disorders must be excluded. 1, 2
• Posterior hip pain may represent lumbar radiculopathy, sacroiliac joint dysfunction, or piriformis syndrome. 2, 3
• Anterior hip pain includes referred pain from intra-abdominal or intrapelvic causes. 2
• Perform the FADIR (flexion-adduction-internal rotation) test; a negative result helps rule out intra-articular hip disease in young and middle-aged active adults. 1

Differential Diagnosis by Pain Location

Bilateral Anterior Hip and Groin Pain

• Intra-articular pathology: femoroacetabular impingement (FAI) syndrome, labral tears, or early osteoarthritis. 2, 3
• Extra-articular causes: hip flexor injuries, athletic pubalgia, or "sports hernia." 4
• Referred pain from intra-abdominal or pelvic sources. 2

Bilateral Lateral Hip Pain

• Greater trochanteric pain syndrome (gluteus medius tendinopathy or tear, bursitis, iliotibial band friction). 2

Bilateral Posterior Hip Pain

• Lumbar spinal pathology with bilateral radiculopathy. 2, 3
• Sacroiliac joint dysfunction. 4, 3
• Deep gluteal syndrome with sciatic nerve entrapment. 2

Advanced Imaging Pathways

When Plain Radiographs Are Normal or Inconclusive

For suspected soft-tissue injury (tendon, muscle, ligament):

• MRI without contrast is the preferred next-step imaging. 1
• MRI detects 100% of proximal hamstring avulsions, compared with only 58.3% detection by ultrasound. 1
• Do not use ultrasound for acute tendon or muscle injuries due to insufficient evidence. 1

For suspected intra-articular pathology (labrum, cartilage):

• Employ MRI or magnetic resonance arthrography (MRA), or CT arthrography, when detailed assessment of the labrum, cartilage, or ligamentum teres is required. 1
• Recognize that labral and chondral abnormalities are frequently present in asymptomatic individuals; imaging findings must be correlated with clinical presentation. 1

For suspected occult fracture or stress fracture:

• Use non-contrast CT as the first advanced imaging modality when a fracture is suspected but plain films are negative. 1
• If CT remains negative or equivocal and clinical suspicion persists, proceed to non-contrast MRI. 1

Patient-Reported Outcome Measures and Monitoring

Use the Copenhagen Hip and Groin Outcome Score (HAGOS) or International Hip Outcome Tool (IHOT) questionnaires to monitor treatment response. 5

• Measures of physical impairment such as ROM, hip muscle strength, movement quality, and functional task performance should also be assessed. 5
• Accurate monitoring quantifies the benefits of treatment on the individual patient. 5

Management Approach

Physiotherapist-Led Treatment

Physical activity (which may include sport) is recommended for people with hip-related pain. 5

• In collaboration with the patient, develop sport or activity-specific goals and implement strategies to achieve these goals. 5
• Treatment should target strength, dynamic balance, single leg squat alignment, gait alterations, and ability to jump, decelerate, and perform cutting movements. 5
• Initially focus on strength, cardiovascular fitness, basic athletic movements, and ability to tolerate load, then gradually introduce sports-specific high-level tasks. 5

Shared Decision-Making and Education

Discuss patient expectations, use shared decision-making, and provide education about their condition, treatment choices, possible benefits and harms of each option, and likely outcomes. 5

• Determine the health literacy of the individual patient and tailor information accordingly. 5

Key Pitfalls to Avoid

• Do not rely on ultrasound for acute tendon or muscle injuries; MRI provides markedly higher detection rates. 1
• Do not over-interpret incidental intra-articular findings, as many such abnormalities are present in asymptomatic people. 1
• Do not skip plain radiographs; they remain the essential first imaging step regardless of suspected pathology. 1
• Do not make a definitive diagnosis based solely on imaging; imaging must be interpreted together with the patient's history and physical examination results. 1
• Do not ignore lumbopelvic stiffness, which places increased stress on the hip to achieve necessary flexion. 6
• Do not overlook concurrent pathology at the pubic symphysis and sacroiliac joint, which may exist concurrently through aberrant muscle forces. 6