Evaluation and Management of Hip and Back Pain in Young Adults

Initial Clinical Assessment

The British Journal of Sports Medicine recommends beginning with anteroposterior (AP) pelvis and lateral femoral head-neck radiographs as the initial imaging study, combined with a comprehensive clinical examination that includes screening for both hip and spine pathology, as imaging alone cannot establish the diagnosis 1, 2
The FADIR test (Flexion-Adduction-Internal Rotation) is the single most appropriate clinical screening test for hip-related pain in young adults, despite its limitations 1, 3
Spine and pelvis screening is essential because hip pain frequently coexists with or is referred from lumbar spine pathology 1, 2, 4
Documenting specific functional impairments related to military duties is important for assessing activity limitations 5

The International Hip-Related Pain Research Network consensus categorizes hip-related pain in young active adults into three conditions: FAI syndrome, acetabular dysplasia and/or hip instability, and other conditions (labral, chondral, ligamentum teres pathology without specific bony morphology) 2, 3, 4, 5

If radiographs are negative but clinical suspicion remains high, proceed with MRI without contrast as the next study, as it is highly sensitive for detecting intra-articular pathology, soft tissue abnormalities, and occult fractures 6, 7
MR arthrography is the diagnostic test of choice when labral pathology is suspected clinically, with a rating of 9/9 for suspected labral tears 7

The British Journal of Sports Medicine emphasizes that diagnosis should never be made based on imaging alone—imaging must be combined with clinical symptoms and signs, as diagnostic imaging shows only small to moderate shifts in post-test probability for most hip conditions 1, 2, 3

The Journal of the American College of Radiology recommends obtaining AP pelvis and lateral hip radiographs immediately, followed by performing the FADIR test and screening the spine/pelvis 2, 6, 7
If radiographs show FAI morphology or dysplasia AND positive clinical findings, consider conservative management first (physiotherapy) 5
If conservative treatment fails or surgery is being considered, obtain MRI or MR arthrography to identify labral, chondral, or ligamentum teres pathology 4, 5

The Journal of the American Academy of Orthopaedic Surgeons advises against skipping radiographs, even if MRI is ultimately needed, as radiographs provide essential baseline morphological information 6, 7, 8, 9
The British Journal of Sports Medicine warns against relying on imaging findings alone, as asymptomatic morphological variants (cam morphology, labral changes) are common and require clinical correlation 1, 2, 5