Diagnostic Approach for Obese 45-Year-Old with Diabetes and New Onset Hip Pain

Initial Evaluation and Imaging

The American College of Radiology recommends starting with anteroposterior (AP) pelvis and frog-leg lateral hip radiographs for all patients with hip pain, regardless of age or comorbidities 1, 2, 3
Initial imaging should include plain radiographs to identify joint space narrowing, cam or pincer morphology, femoral head collapse or sclerosis, acetabular dysplasia, fractures, or bone tumors 1, 2, 6, 7

Osteonecrosis (avascular necrosis) of the femoral head is a significant risk factor in diabetic patients, presenting with insidious onset hip/groin pain without trauma 1
Osteoarthritis is a major risk factor in obese and aging patients, typically presenting with anterior hip/groin pain exacerbated by activity 4, 5
Femoroacetabular impingement (FAI) syndrome can occur in this age group, presenting with anterior hip/groin pain 6, 7

If radiographs are negative or equivocal, obtain MRI hip without IV contrast, which is superior for detecting osteonecrosis, occult fractures, bone marrow edema, and soft tissue pathology 1, 2, 3
Consider MR arthrography if labral tear or FAI syndrome is strongly suspected clinically, providing superior visualization of labral tears compared to standard MRI 8, 3
Image-guided intra-articular hip injection with anesthetic and corticosteroid can provide both diagnostic confirmation and therapeutic benefit 2, 8

Assess diabetes control by checking HbA1c, as poorly controlled diabetes increases the risk of osteonecrosis and diabetic myonecrosis 4, 5
Document BMI, as obesity increases the risk of osteoarthritis and may affect surgical outcomes if intervention is needed 4, 5
Avoid opioids for chronic hip pain, following the consensus recommendation against opioid use for symptomatic hip osteoarthritis 4, 5