Diagnosis and Management of Hip Pain with Mechanical Blockage and Occasional Lumbar Pain

Diagnostic Approach

The American College of Radiology recommends obtaining AP pelvis and lateral hip radiographs (Dunn, frog-leg, or cross-table) as the initial test in all cases of chronic hip pain, to evaluate for morphology cam or pincer (indicative of FAI), increased alpha angle and center-edge angle, acetabular dysplasia, and joint space narrowing 3, 4, 2
The British Journal of Sports Medicine suggests that a clinical presentation of hip pain with "catching" or mechanical blockage in a 35-year-old adult strongly suggests femoroacetabular impingement (FAI) syndrome with probable associated labral tear, requiring initial radiographic evaluation followed by magnetic resonance imaging (MRI) 1, 2

MRI without intravenous contrast or arthro-MRI is appropriate when labral tear is suspected with suggestive clinical findings of impingement, and is highly sensitive and specific for detecting intra-articular pathology (labrum, cartilage, ligamentum teres) and periarticular soft tissues 3, 2, 4
The American College of Radiology recommends using direct arthro-MRI with diluted gadolinium (1:200) for better visualization of labral tears 2

The test FADIR (flexion-adduction-internal rotation) is positive in patients with FAI, and is a key clinical finding to evaluate 1
The American College of Radiology suggests that a snapping hip (coxa saltans) can be evaluated with ultrasound, which can also guide aspirations/injections and evaluate the iliopsoas tendon in real-time during movement 4, 2

Image-guided intra-articular injection of anesthetic ± corticosteroid confirms the intra-articular origin of pain, and if pain is completely relieved, confirms that the hip is the source 4, 2, 5
The American College of Radiology recommends considering MRI or arthro-MRI before referring to orthopedic surgery if radiographs show FAI morphology and the FADIR test is positive 1, 5

The Annals of Internal Medicine suggests that if lumbar pain is non-specific (without radiculopathy, stenosis, or red flags), no initial spinal imaging is required 6, 7
The American College of Radiology recommends evaluating the thoracolumbar junction for pain and mobility restriction, as it can refer pain to the hip/groin area 6, 7