Diagnostic Approach and Treatment of Lateral Hip Pain

Initial Diagnostic Workup

The American College of Radiology recommends starting with plain radiographs (AP pelvis and lateral hip views) to evaluate for femoroacetabular impingement, labral pathology, osteoarthritis, or bony abnormalities that commonly cause pain with lateral movements like side stepping 1, 3
Plain radiographs are mandatory as the first imaging study and should include both AP pelvis and lateral views to provide essential screening information and guide selection of subsequent imaging 1, 3

The American College of Radiology suggests proceeding directly to MRI of the hip (appropriateness rating 9/9) if radiographs are negative or equivocal, as standard MRI without contrast is sufficient for detecting soft tissue pathology including gluteal tendon tears, trochanteric bursitis, and early labral tears 1, 3, 5
MR arthrography with intra-articular gadolinium is the gold standard for suspected labral tears if clinical suspicion remains high after standard MRI, particularly in younger patients with mechanical symptoms 1, 3

The American Academy of Orthopaedic Surgeons recommends initiating hip-targeted exercise therapy immediately while awaiting imaging results, focusing on hip abductor strengthening (gluteus medius and minimus) with progressive loading over a minimum 3-month period 6, 4
The American Academy of Orthopaedic Surgeons suggests using oral NSAIDs when not contraindicated for symptomatic relief during the rehabilitation phase, with high-quality evidence supporting this recommendation 6, 4

The American College of Radiology and the American Academy of Orthopaedic Surgeons consider ultrasound-guided corticosteroid injection into the trochanteric bursa or peritendinous area if symptoms are severe enough to impair rehabilitation participation, with moderate recommendation and high-quality evidence 1, 6
Physical therapy referral is appropriate for supervised exercise prescription if self-directed exercise fails or if proper form and progression are uncertain, according to the American Academy of Orthopaedic Surgeons 6, 4

The American College of Radiology suggests that image-guided diagnostic injection (either intra-articular hip or peritrochanteric) definitively determines the source of pain if it remains uncertain after imaging, with a positive response to intra-articular injection confirming intra-articular pathology 1, 3, 5

Reassess at 4-6 week intervals using patient-reported outcome measures (Hip and Groin Outcome Score or International Hip Outcome Tool) and objective findings like single-leg stance ability and pain provocation tests, as recommended by Praxis Medical Insights 4
If no improvement occurs after 6-8 weeks of structured conservative management, reconsider the diagnosis or refer to orthopedics, according to Praxis Medical Insights 5, 4

Never skip plain radiographs and proceed directly to MRI, as this violates ACR guidelines and may miss important bony pathology like stress fractures or cam/pincer morphology, according to the American College of Radiology 1, 3, 5
Do not allow unstructured rest without exercise therapy, as passive rest alone produces inferior outcomes compared to progressive loading programs, as noted by Praxis Medical Insights 4
Avoid opioids entirely, as consensus guidelines strongly oppose opioid use for hip-related pain, according to the American Academy of Orthopaedic Surgeons and Praxis Medical Insights 6, 5, 4
Do not diagnose based on imaging alone, as incidental findings are common in asymptomatic individuals, so clinical correlation is essential, according to the British Journal of Sports Medicine and Praxis Medical Insights 7, 5
Screen for referred pain from lumbar spine and sacroiliac joints systematically, as these commonly masquerade as hip pain, as recommended by the American College of Radiology and Praxis Medical Insights 1, 5