Diagnostic Approach and Management of Hip Pain

Imaging Strategy

The American College of Radiology recommends beginning with plain radiographs of both the pelvis and hip, as these are the first-line imaging studies for evaluating chronic hip pain and are complementary to each other 1
X-ray pelvis and X-ray hip are both rated as "usually appropriate" (rating 9/9) for initial evaluation of chronic hip pain and should be obtained together as they provide complementary information 1
If radiographs are negative, equivocal, or nondiagnostic and extra-articular soft tissue pathology is suspected, MRI hip without IV contrast is the next appropriate study (rating 9/9) 1
Plain radiographs may be the only imaging necessary if they reveal common disorders such as osteoarthritis or can guide the next steps in the diagnostic pathway 2

The British Journal of Sports Medicine suggests initiating exercise-based treatment immediately while awaiting imaging results, as this is the cornerstone of management for hip-related pain with moderate-quality evidence 3, 4, 5
Exercise therapy should last for a minimum of 3 months 3, 4
Components of exercise therapy should include hip, trunk, and functional strengthening exercises focusing on resistance training 3
Exercise should be prescribed relative to symptom severity and irritability, with progressive loading as tolerated 3

The European League Against Rheumatism recommends starting with acetaminophen (paracetamol) up to 4 grams daily as first-line oral analgesic for mild-to-moderate pain, as it has the best efficacy and safety profile for long-term use 6
If acetaminophen provides inadequate relief, add or substitute NSAIDs at the lowest effective dose 6
For patients with gastrointestinal risk factors, use either non-selective NSAIDs plus gastroprotective agent, or a selective COX-2 inhibitor 6
Consider opioid analgesics (with or without acetaminophen) only if NSAIDs are contraindicated, ineffective, or poorly tolerated 6

The British Journal of Sports Medicine suggests discussing with the patient that pain does not necessarily correlate with structural damage 3, 4, 5
Explain the relationship between hip pain and structural findings, including that morphological abnormalities are common in asymptomatic individuals 3
Set realistic expectations regarding treatment timeline - meaningful improvement typically requires at least 3 months of consistent exercise therapy 3, 4
Emphasize that physical activity and exercise are recommended and will not harm the hip joint 4, 5
Use shared decision-making to align treatment with patient goals, whether reducing pain, improving function, or returning to specific activities 3, 4

Track outcomes using patient-reported outcome measures (PROMs), physical impairment measures, and psychosocial factors 4, 5
Reassess at regular intervals (typically 4-6 weeks initially) to determine if symptoms are improving with conservative management 6
Determine if additional imaging or interventions are needed based on radiographic findings 1
Referral to orthopedic surgery is warranted for refractory cases 6

Image-guided corticosteroid injection may be appropriate (rating 5/9) if rehabilitation is hindered by elevated symptom severity that is unresponsive to analgesics and NSAIDs 1, 6
Surgical consultation is indicated if there is radiographic evidence of hip OA with refractory pain and disability despite 3+ months of optimal conservative management 6