Understanding hip pain and the diagnostic tools available to make a diagnosis
The hip joint is classified as a Ball and Socket joint. It is the articulation point between the head of the femur and the acetabulum of the pelvis, which supports the weight of the upper body while allowing stability and motion of the lower extremities (1). Pain in the hip joint can originate for many reasons, such as Tendinitis, Overuse injury, Tight muscles in the buttocks, hip, or spinal muscles, to name a few (2).
Hip pain can affect all ages, but approximately 14% of the population over the age of 60 reports hip pain.
To make an accurate diagnosis of hip pain can be challenging (3). Factors such as distant osteoligamentous, tendinous, nervous, myofascial, and muscular anatomy must be taken into consideration before a diagnosis can be made.
The differential diagnosis of hip pain is broad, and without the accurate diagnosis, the correct and appropriate treatment plan cannot be established.
Hip pain can be divided into intra-articular (within the hip joint) and extra-articular (surrounding structures) pathology. A thorough clinical history must be taken, and a full physical examination must be done before the patient is sent for diagnostic evaluations (4). Hip pain can also be categorized according to origin in the following compartments: lateral, anterior, or posterior.
Figure 1: Localization of hip pain. (A) Posterior view. (B) Anterior view. (6)
Pain in the Anterior compartment can be due to various reasons, including meralgia paresthetica, sport’s hernia, femoral neck fracture/stress fracture, femoroacetabular impingement, hip labral tears, iliopsoas bursitis (internal snapping hip syndrome), osteoarthritis of the hip, osteonecrosis of the hip, transient synovitis and septic arthritis, etc. (4).
Pain originating from the Lateral compartment can be a result of external snapping hip, greater trochanteric bursitis or greater trochanteric pain syndrome (4).
Posterior compartment hip pain occurs due to gluteal tear/avulsion, iliac crest avulsion, hamstring muscle strain or avulsion, ischial apophysis avulsion, ischiofemoral impingement, piriformis syndrome or sacroiliac joint dysfunction (4).
There a few diagnostic tools available to lead the physician to the correct diagnosis. The following diagnostic tools are used to evaluate the hip and pelvic region, specifically:
X-ray of the pelvis and hip is used to exclude an acute fracture, dislocation, or stress fracture (5).
Ultrasound of the hip, or rather musculoskeletal ultrasound of the hip, can be used for both diagnostic and therapeutic purposes.
- Diagnosis: Assessment of soft tissue structures such as tendinopathy, tendon/muscle tears, ligamentous sprains, enteropathies, growth plate injuries, fractures, bursitis, effusions, synovitis, labral tears, and snapping hip syndrome.
- Therapeutic: Guide injections, aspirations, and biopsies (4).
MRI/MR Arthrography is a high-performance imaging tool able to assist with cases where the plain radiograph results are not diagnostic.
Magnetic Resonance Imaging (MRI) aid in the detection of traumatic occult fractures, stress fractures, osteonecrosis of the femoral head and labral tears (5,6). MR Arthrography is a study where intra-articular injection of contrast medium is used. The process takes place in two steps: first, an intra-articular injection is made under ultrasound or fluoroscopic guidance and second, the patient goes for an MRI scan. The contrast medium then aids in visualizing structures and pathology.
The diagnosis of hip pain remains challenging.
Hip pain can be treated in many ways, some being non-invasive, whilst others carry slightly more risk. Your healthcare practitioner will advise you on the best possible treatment route.
Keystone Medical aims to assist practitioners and patients in making accurate and fast diagnoses. The imaging modalities discussed above can also be used to monitor the effectiveness and progress of treatment (3).
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- Gold M, Munjal A, Varacallo M. Anatomy, Bony Pelvis and Lower Limb, Hip Joint. [Updated 2020 Aug 12]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK470555/
- Harvard Health Publishing (Internet). United States: Harvard Health Medical School; 2018. Think that hip pain is bursitis? Think again; (updated 2020 July 6; cited 2018 July 1); (3 of pages/screens. Available from: https://www.health.harvard.edu/pain/think-that-hip-pain-is-bursitis-think-again
- Battaglia PJ, D’Angelo K, Kettner NW. Posterior, Lateral, and Anterior Hip Pain Due to Musculoskeletal Origin: A Narrative Literature Review of History, Physical Examination, and Diagnostic Imaging. J Chiropr Med. 2016;15(4):281-293. doi:10.1016/j.jcm.2016.08.004
- Dawes AR, Seidenberg PH. Sonography of sports injuries of the hip. Sports Health. 2014;6(6):531-538. doi:10.1177/1941738114552801
- JOHN J. WILSON, MD, MS, and MASARU FURUKAWA, MD, MS, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin Am Fam Physician. 2014 Jan 1;89(1):27-34.
- Figure 2 Available from https://www.aafp.org/afp/2014/0101/p27.html)