Diagnostic Approach to Hip Pain with Popping and Instability

Initial Diagnostic Workup

The American College of Radiology recommends plain radiographs as the first step in diagnosing hip pain, including AP view of the pelvis and frog-leg lateral view of the symptomatic hip, to identify bony morphology abnormalities, arthritis, fractures, and tumors 2, 3
The British Journal of Sports Medicine suggests assessing for cam morphology, acetabular dysplasia, and other structural abnormalities on radiographs 1
If radiographs are negative or equivocal, MRI hip without IV contrast is the next appropriate study, rated 9/9 by the American College of Radiology, to evaluate intra-articular structures and extra-articular soft tissues 2, 3
For suspected labral tears, MR arthrography with intra-articular dilute gadolinium provides superior visualization compared to standard MRI 2, 4

A positive FADIR test suggests FAI syndrome or labral pathology, according to the British Journal of Sports Medicine 1
Screening for lumbar spine and pelvic pathology is essential, as referred pain can be a potential source of hip pain, as recommended by the British Journal of Sports Medicine and the American College of Radiology 1, 2

The British Journal of Sports Medicine consensus recommends categorizing hip-related pain into three groups: FAI syndrome, acetabular dysplasia and/or hip instability, and other soft tissue conditions 1
FAI syndrome is characterized by cam or pincer morphology on radiographs with positive FADIR test, and often coexists with labral and chondral pathology, according to the British Journal of Sports Medicine 1

The American Academy of Orthopaedic Surgeons recommends physical therapy as the first-line treatment for mild-to-moderate symptomatic hip pathology, with high-quality evidence and moderate strength recommendation 5, 6
Oral NSAIDs should be used when not contraindicated, with strong recommendation, and oral acetaminophen may be considered as an alternative, according to the American Academy of Orthopaedic Surgeons 5, 6
Intra-articular corticosteroid injections could be considered for symptomatic relief, with high-quality evidence and moderate strength, as recommended by the American Academy of Orthopaedic Surgeons 5, 6

Image-guided intra-articular hip injection with anesthetic and corticosteroid is rated 8/9 by the American College of Radiology, providing both diagnostic confirmation and therapeutic benefit, especially when concurrent low back, pelvic, or knee pathology exists 3

Failing to obtain both pelvis and hip radiographic views may miss important pathology, as warned by the American College of Radiology and Praxis Medical Insights 2, 3
Proceeding directly to advanced imaging without plain radiographs is not recommended, according to the American College of Radiology and Praxis Medical Insights 2, 3
Diagnosing based on imaging alone without correlating with clinical examination findings is incorrect, as stated by the British Journal of Sports Medicine 1
Missing referred pain from lumbar spine or pelvis is a common pitfall, and screening these areas is essential, as recommended by the British Journal of Sports Medicine and the American College of Radiology 1, 2
Using hyaluronic acid injections or opioids for treatment is not recommended, with strong evidence against their use, as stated by the American Academy of Orthopaedic Surgeons 5, 6