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Radiologic evaluation of the painful hip in adults

Authors
Cecilia Matilda Jude, MD
Shahla Modarresi, MD
Section Editors
Robert H Shmerling, MD
Karl B Fields, MD
Deputy Editor
Monica Ramirez Curtis, MD, MPH

INTRODUCTION

The hip is a stable, major weightbearing joint with significant mobility. Hip pain has different etiologies in adults and children. In adults, hip pain may be caused by intraarticular disorders such as avascular necrosis (AVN), arthritis, loose bodies, labral tears; periarticular pathology such as tendinitis and bursitis; or extraarticular conditions such as referred pain from lumbar spine, as well as sacroiliac joint and nerve entrapment syndromes.

Imaging modalities used to evaluate adults with hip pain and the appropriateness of particular studies in different clinical scenarios will be reviewed here. The history and physical examination, which are necessary to develop a differential diagnosis prior to the selection of imaging tests; a general review of imaging tests that are used in the evaluation of bone and joint pain; and imaging modalities used to evaluate the hip in children are presented separately. (See "Evaluation of the adult with hip pain" and "Imaging techniques for evaluation of the painful joint" and "Radiologic evaluation of the hip in infants, children, and adolescents".)

TYPES OF IMAGING STUDIES

The modalities available for evaluation of the hip include:

Plain film radiography — Plain film radiography is used in the initial evaluation of any cause of hip pain, including trauma and sports injuries, suspected avascular necrosis (AVN), arthritis, hip arthroplasty, infection, dysplasia, and tumor [1]. Plain film can also identify causes of referred hip pain, such as sacroiliitis. Plain film may not detect or accurately characterize some hip fractures and bone marrow edema associated with early AVN or early osteomyelitis.

Computerized tomography — Computerized tomography (CT) is most useful in the setting of trauma, for preoperative planning, and for evaluation and guiding percutaneous biopsy of tumors.

                                     

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Literature review current through: Nov 2016. | This topic last updated: Tue Jun 30 00:00:00 GMT+00:00 2015.
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References
Top
  1. American College of Radiology. ACR Appropriateness Criteria: Chronic hip pain - Initial evaluation for chronic hip pain. First test. Available at: http://www.acr.org/~/media/ACR/Documents/AppCriteria/Diagnostic/ChronicHipPain.pdf (Accessed on July 01, 2013).
  2. Cavalier R, Herman MJ, Pizzutillo PD, Geller E. Ultrasound-guided aspiration of the hip in children: a new technique. Clin Orthop Relat Res 2003; :244.
  3. Cardinal E, Buckwalter KA, Capello WN, Duval N. US of the snapping iliopsoas tendon. Radiology 1996; 198:521.
  4. Berquist TH. Diagnostic and therapeutic injections as an aid to musculoskeletal diagnosis. Semin Intervent Radiol 1993; 10:326.
  5. Cardone DA, Tallia AF. Diagnostic and therapeutic injection of the hip and knee. Am Fam Physician 2003; 67:2147.
  6. Savolaine ER, Ebraheim N. Assessment of femoral neck nonunion with multiplanar computed tomography reconstruction. Orthopedics 2000; 23:713.
  7. Calkins MS, Zych G, Latta L, et al. Computed tomography evaluation of stability in posterior fracture dislocation of the hip. Clin Orthop Relat Res 1988; 227:152.
  8. Hougaard K, Lindequist S, Nielsen LB. Computerised tomography after posterior dislocation of the hip. J Bone Joint Surg Br 1987; 69:556.
  9. May DA, Purins JL, Smith DK. MR imaging of occult traumatic fractures and muscular injuries of the hip and pelvis in elderly patients. AJR Am J Roentgenol 1996; 166:1075.
  10. Schultz E, Miller TT, Boruchov SD, et al. Incomplete intertrochanteric fractures: imaging features and clinical management. Radiology 1999; 211:237.
  11. Bogost GA, Lizerbram EK, Crues JV 3rd. MR imaging in evaluation of suspected hip fracture: frequency of unsuspected bone and soft-tissue injury. Radiology 1995; 197:263.
  12. Chung CB, Robertson JE, Cho GJ, et al. Gluteus medius tendon tears and avulsive injuries in elderly women: imaging findings in six patients. AJR Am J Roentgenol 1999; 173:351.
  13. Verbeeten KM, Hermann KL, Hasselqvist M, et al. The advantages of MRI in the detection of occult hip fractures. Eur Radiol 2005; 15:165.
  14. Craig JG, Moed BR, Eyler WR, van Holsbeeck M. Fractures of the greater trochanter: intertrochanteric extension shown by MR imaging. Skeletal Radiol 2000; 29:572.
  15. Feldman F, Staron RB. MRI of seemingly isolated greater trochanteric fractures. AJR Am J Roentgenol 2004; 183:323.
  16. Quinn SF, McCarthy JL. Prospective evaluation of patients with suspected hip fracture and indeterminate radiographs: use of T1-weighted MR images. Radiology 1993; 187:469.
  17. Poggi JJ, Callaghan JJ, Spritzer CE, et al. Changes on magnetic resonance images after traumatic hip dislocation. Clin Orthop Relat Res 1995; :249.
  18. Evans PD, Wilson C, Lyons K. Comparison of MRI with bone scanning for suspected hip fracture in elderly patients. J Bone Joint Surg Br 1994; 76:158.
  19. Martinoli C, Garello I, Marchetti A, et al. Hip ultrasound. Eur J Radiol 2012; 81:3824.
  20. Dawes AR, Seidenberg PH. Sonography of sports injuries of the hip. Sports Health 2014; 6:531.
  21. DeAngelis NA, Busconi BD. Assessment and differential diagnosis of the painful hip. Clin Orthop Relat Res 2003; :11.
  22. Matin P. Basic principles of nuclear medicine techniques for detection and evaluation of trauma and sports medicine injuries. Semin Nucl Med 1988; 18:90.
  23. Meislin R, Abeles A. Role of hip MR imaging in the management of sports-related injuries. Magn Reson Imaging Clin N Am 2005; 13:635.
  24. Gibbs NJ, Cross TM, Cameron M, Houang MT. The accuracy of MRI in predicting recovery and recurrence of acute grade one hamstring muscle strains within the same season in Australian Rules football players. J Sci Med Sport 2004; 7:248.
  25. Cross TM, Gibbs N, Houang MT, Cameron M. Acute quadriceps muscle strains: magnetic resonance imaging features and prognosis. Am J Sports Med 2004; 32:710.
  26. Czerny C, Hofmann S, Neuhold A, et al. Lesions of the acetabular labrum: accuracy of MR imaging and MR arthrography in detection and staging. Radiology 1996; 200:225.
  27. American College of Radiology. ACR Appropriateness Criteria: Chronic hip pain - Radiographs negative, equivocal, or nondiagnostic. Suspect labral tear with or without clinical findings consistent with or suggestive of femoroacetabular impingement. Available at: http://www.acr.org/~/media/ACR/Documents/AppCriteria/Diagnostic/ChronicHipPain.pdf (Accessed on July 01, 2013).
  28. Reiman MP, Mather RC 3rd, Hash TW 2nd, Cook CE. Examination of acetabular labral tear: a continued diagnostic challenge. Br J Sports Med 2014; 48:311.
  29. Tian CY, Wang JQ, Zheng ZZ, Ren AH. 3.0 T conventional hip MR and hip MR arthrography for the acetabular labral tears confirmed by arthroscopy. Eur J Radiol 2014; 83:1822.
  30. Czerny C, Hofmann S, Urban M, et al. MR arthrography of the adult acetabular capsular-labral complex: correlation with surgery and anatomy. AJR Am J Roentgenol 1999; 173:345.
  31. Leunig M, Werlen S, Ungersböck A, et al. Evaluation of the acetabular labrum by MR arthrography. J Bone Joint Surg Br 1997; 79:230.
  32. Toomayan GA, Holman WR, Major NM, et al. Sensitivity of MR arthrography in the evaluation of acetabular labral tears. AJR Am J Roentgenol 2006; 186:449.
  33. Wettstein M, Dienst M. [Hip arthroscopy for femoroacetabular impingement]. Orthopade 2006; 35:85.
  34. Leunig M, Beck M, Dora C, Ganz R. [Femoroacetabular impingement: trigger for the development of coxarthrosis]. Orthopade 2006; 35:77.
  35. Beck M, Kalhor M, Leunig M, Ganz R. Hip morphology influences the pattern of damage to the acetabular cartilage: femoroacetabular impingement as a cause of early osteoarthritis of the hip. J Bone Joint Surg Br 2005; 87:1012.
  36. Beaulé PE, Zaragoza E, Motamedi K, et al. Three-dimensional computed tomography of the hip in the assessment of femoroacetabular impingement. J Orthop Res 2005; 23:1286.
  37. Bredella MA, Stoller DW. MR imaging of femoroacetabular impingement. Magn Reson Imaging Clin N Am 2005; 13:653.
  38. Tannast M, Siebenrock KA, Anderson SE. Femoroacetabular impingement: radiographic diagnosis--what the radiologist should know. AJR Am J Roentgenol 2007; 188:1540.
  39. James SL, Ali K, Malara F, et al. MRI findings of femoroacetabular impingement. AJR Am J Roentgenol 2006; 187:1412.
  40. Schapira D. Transient osteoporosis of the hip. Semin Arthritis Rheum 1992; 22:98.
  41. Hayes CW, Conway WF, Daniel WW. MR imaging of bone marrow edema pattern: transient osteoporosis, transient bone marrow edema syndrome, or osteonecrosis. Radiographics 1993; 13:1001.
  42. Kaplan SS, Stegman CJ. Transient osteoporosis of the hip. A case report and review of the literature. J Bone Joint Surg Am 1985; 67:490.
  43. Balakrishnan A, Schemitsch EH, Pearce D, McKee MD. Distinguishing transient osteoporosis of the hip from avascular necrosis. Can J Surg 2003; 46:187.
  44. Vande Berg BC, Malghem JJ, Lecouvet FE, et al. Idiopathic bone marrow edema lesions of the femoral head: predictive value of MR imaging findings. Radiology 1999; 212:527.
  45. Watson RM, Roach NA, Dalinka MK. Avascular necrosis and bone marrow edema syndrome. Radiol Clin North Am 2004; 42:207.
  46. Smith SW, Fehring TK, Griffin WL, Beaver WB. Core decompression of the osteonecrotic femoral head. J Bone Joint Surg Am 1995; 77:674.
  47. Tooke SM, Nugent PJ, Bassett LW, et al. Results of core decompression for femoral head osteonecrosis. Clin Orthop Relat Res 1988; :99.
  48. American College of Radiology. ACR ppropriateness Criteria: Avascular necrosis (osteonecrosis) of the hip. Available at: http://www.acr.org/~/media/ACR/Documents/AppCriteria/Diagnostic/AvascularNecrosisOsteonecrosisHip.pdf (Accessed on July 01, 2013).
  49. Meyer SJ, Vahey TN. Imaging algorithm for avascular necrosis of the hip. Rheum Dis Clin North Am 1991; 17:799.
  50. Shih TT, Su CT, Chiu LC, et al. Evaluation of hip disorders by radiography, radionuclide scanning and magnetic resonance imaging. J Formos Med Assoc 1993; 92:737.
  51. Lee MJ, Corrigan J, Stack JP, Ennis JT. A comparison of modern imaging modalities in osteonecrosis of the femoral head. Clin Radiol 1990; 42:427.
  52. Tervonen O, Mueller DM, Matteson EL, et al. Clinically occult avascular necrosis of the hip: prevalence in an asymptomatic population at risk. Radiology 1992; 182:845.
  53. Khanna AJ, Yoon TR, Mont MA, et al. Femoral head osteonecrosis: detection and grading by using a rapid MR imaging protocol. Radiology 2000; 217:188.
  54. Kopecky KK, Braunstein EM, Brandt KD, et al. Apparent avascular necrosis of the hip: appearance and spontaneous resolution of MR findings in renal allograft recipients. Radiology 1991; 179:523.
  55. Glickstein MF, Burk DL Jr, Schiebler ML, et al. Avascular necrosis versus other diseases of the hip: sensitivity of MR imaging. Radiology 1988; 169:213.
  56. Beltran J, Burk JM, Herman LJ, et al. Avascular necrosis of the femoral head: early MRI detection and radiological correlation. Magn Reson Imaging 1987; 5:431.
  57. Gardeniers J. A new international classification of osteonecrosis of the ARCO (Association Research Circulation Osseous) Committee. ARCO News 1992; 4:41.
  58. Mitchell MD, Kundel HL, Steinberg ME, et al. Avascular necrosis of the hip: comparison of MR, CT, and scintigraphy. AJR Am J Roentgenol 1986; 147:67.
  59. Iida S, Harada Y, Shimizu K, et al. Correlation between bone marrow edema and collapse of the femoral head in steroid-induced osteonecrosis. AJR Am J Roentgenol 2000; 174:735.
  60. Radke S, Kirschner S, Seipel V, et al. Magnetic resonance imaging criteria of successful core decompression in avascular necrosis of the hip. Skeletal Radiol 2004; 33:519.
  61. Mitchell DG, Steinberg ME, Dalinka MK, et al. Magnetic resonance imaging of the ischemic hip. Alterations within the osteonecrotic, viable, and reactive zones. Clin Orthop Relat Res 1989; :60.
  62. Fink B, Assheuer J, Enderle A, et al. Avascular osteonecrosis of the acetabulum. Skeletal Radiol 1997; 26:509.
  63. Shimizu K, Moriya H, Akita T, et al. Prediction of collapse with magnetic resonance imaging of avascular necrosis of the femoral head. J Bone Joint Surg Am 1994; 76:215.
  64. Ohzono K, Saito M, Takaoka K, et al. Natural history of nontraumatic avascular necrosis of the femoral head. J Bone Joint Surg Br 1991; 73:68.
  65. Nishii T, Sugano N, Ohzono K, et al. Significance of lesion size and location in the prediction of collapse of osteonecrosis of the femoral head: a new three-dimensional quantification using magnetic resonance imaging. J Orthop Res 2002; 20:130.
  66. Beltran J, Knight CT, Zuelzer WA, et al. Core decompression for avascular necrosis of the femoral head: correlation between long-term results and preoperative MR staging. Radiology 1990; 175:533.
  67. Imhof H, Breitenseher M, Trattnig S, et al. Imaging of avascular necrosis of bone. Eur Radiol 1997; 7:180.
  68. Yamamoto T, Iwamoto Y, Schneider R, Bullough PG. Histopathological prevalence of subchondral insufficiency fracture of the femoral head. Ann Rheum Dis 2008; 67:150.
  69. Jackson SM, Major NM. Pathologic conditions mimicking osteonecrosis. Orthop Clin North Am 2004; 35:315.
  70. Kim KY, Lee SH, Moon DH, Nah HY. The diagnostic value of triple head single photon emission computed tomography (3H-SPECT) in avascular necrosis of the femoral head. Int Orthop 1993; 17:132.
  71. Stevens K, Tao C, Lee SU, et al. Subchondral fractures in osteonecrosis of the femoral head: comparison of radiography, CT, and MR imaging. AJR Am J Roentgenol 2003; 180:363.
  72. Conaghan P. Is MRI useful in osteoarthritis? Best Pract Res Clin Rheumatol 2006; 20:57.
  73. Sugimoto H, Takeda A, Hyodoh K. Early-stage rheumatoid arthritis: prospective study of the effectiveness of MR imaging for diagnosis. Radiology 2000; 216:569.
  74. American College of Radiology. ACR Appropriateness Criteria: Chronic hip pain - radiographs positive, suggestive of pigmented villonodular synovitis or osteochondromatosis. Available at: http://www.acr.org/~/media/ACR/Documents/AppCriteria/Diagnostic/ChronicHipPain.pdf (Accessed on July 01, 2013).
  75. Cotten A, Flipo RM, Chastanet P, et al. Pigmented villonodular synovitis of the hip: review of radiographic features in 58 patients. Skeletal Radiol 1995; 24:1.
  76. Kim SH, Hong SJ, Park JS, et al. Idiopathic synovial osteochondromatosis of the hip: radiographic and MR appearances in 15 patients. Korean J Radiol 2002; 3:254.
  77. Bhimani MA, Wenz JF, Frassica FJ. Pigmented villonodular synovitis: keys to early diagnosis. Clin Orthop Relat Res 2001; :197.
  78. Klauser AS, Martinoli C, Tagliafico A, et al. Greater trochanteric pain syndrome. Semin Musculoskelet Radiol 2013; 17:43.
  79. American College of Radiology. ACR Appropriateness Criteria: Chronic hip pain - radiographs negative, equivocal or nondiagnostic, suspect osseous or surrounding soft-tissue abnormality, excluding osteoid osteoma. Available at: http://www.acr.org/~/media/ACR/Documents/AppCriteria/Diagnostic/ChronicHipPain.pdf (Accessed on July 01, 2013).
  80. Koulouris G, Morrison WB. MR imaging of hip infection and inflammation. Magn Reson Imaging Clin N Am 2005; 13:743.
  81. Eisenberg RL, Margulis AR. Skeletal. In: What to order when: Pocket guide to diagnostic imaging, Lippincott Williams and Wilkens, Philadelphia 1999. p.288.
  82. Schauwecker DS. The scintigraphic diagnosis of osteomyelitis. AJR Am J Roentgenol 1992; 158:9.
  83. Morrison WB, Schweitzer ME, Bock GW, et al. Diagnosis of osteomyelitis: utility of fat-suppressed contrast-enhanced MR imaging. Radiology 1993; 189:251.
  84. American College of Radiology. ACR Appropriateness Criteria: Primary bone tumors. Available at: http://www.acr.org/~/media/ACR/Documents/AppCriteria/Diagnostic/PrimaryBoneTumors.pdf (Accessed on July 01, 2013).
  85. American College of Radiology. ACR Appropriateness Criteria: Soft tissue masses. Available at: http://www.acr.org/~/media/ACR/Documents/AppCriteria/Diagnostic/SoftTissueMasses.pdf (Accessed on July 01, 2013).
  86. Assoun J, Richardi G, Railhac JJ, et al. Osteoid osteoma: MR imaging versus CT. Radiology 1994; 191:217.
  87. Miller TT. Imaging of hip arthroplasty. Semin Musculoskelet Radiol 2006; 10:30.
  88. Ostlere S, Soin S. Imaging of prosthetic joints. Imaging 2003; 15:270.
  89. Buckwalter KA, Parr JA, Choplin RH, Capello WN. Multichannel CT Imaging of Orthopedic Hardware and Implants. Semin Musculoskelet Radiol 2006; 10:86.
  90. White LM, Kim JK, Mehta M, et al. Complications of total hip arthroplasty: MR imaging-initial experience. Radiology 2000; 215:254.
  91. Fang CS, Harvie P, Gibbons CL, et al. The imaging spectrum of peri-articular inflammatory masses following metal-on-metal hip resurfacing. Skeletal Radiol 2008; 37:715.
  92. Durrani Z, Winnie AP. Piriformis muscle syndrome: an underdiagnosed cause of sciatica. J Pain Symptom Manage 1991; 6:374.
  93. Wunderbaldinger P, Bremer C, Matuszewski L, et al. Efficient radiological assessment of the internal snapping hip syndrome. Eur Radiol 2001; 11:1743.
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