Diagnostic Approach to Posterior Right Hip Pain

Initial Evaluation and Diagnosis

The American Academy of Orthopaedic Surgeons recommends obtaining plain radiographs (AP pelvis and lateral hip views) immediately as the first diagnostic step for posterior right hip pain, as this presentation most likely represents either hip osteoarthritis, femoroacetabular impingement (FAI), or ischiofemoral impingement 1, 2
Hip osteoarthritis remains a strong consideration in patients over 50, despite atypical posterior pain location, with classic presentation including groin pain with internal rotation reproducing symptoms, but pain can radiate to the buttock 3, 1
Femoroacetabular impingement (FAI) should be considered, particularly posterior FAI, which can cause pain with external rotation and extension 2

The American Academy of Orthopaedic Surgeons recommends ordering AP pelvis and lateral femoral head-neck views bilaterally to rapidly identify hip osteoarthritis, FAI morphology, and ischiofemoral space narrowing 1, 2
If plain films are non-diagnostic but clinical suspicion remains high, obtain MRI of the hip without contrast to detect labral tears, early cartilage damage, bone marrow edema, and soft tissue pathology not visible on radiographs 1, 2

The American Academy of Orthopaedic Surgeons recommends initiating NSAIDs immediately (strong recommendation, high-quality evidence) for suspected hip osteoarthritis or FAI 5, 3, 1
Refer to physical therapy (moderate recommendation, high-quality evidence) for mild-to-moderate symptomatic hip OA, targeting hip muscle strengthening, particularly hip abductors, adductors, flexors, and rotators 3, 1, 2
Consider intra-articular corticosteroid injection for symptomatic relief (moderate recommendation, high-quality evidence) 5, 1, 2

Do not assume primary hip joint pathology without imaging confirmation, as referred pain from lumbar spine or SI joint can mimic hip pathology 1, 2
Do not proceed to advanced imaging without obtaining plain radiographs first, as this violates consensus guidelines and may miss important bony pathology 2, 4
Avoid opioids entirely for chronic hip pain (consensus recommendation) and do not use hyaluronic acid injections (strong recommendation, high-quality evidence) for symptomatic hip OA 2, 4, 5