Official reprint from UpToDate®
www.uptodate.com ©2017 UpToDate, Inc. and/or its affiliates. All Rights Reserved.

Imaging evaluation of the painful hip in adults

Cecilia Matilda Jude, MD
Shahla Modarresi, MD
Section Editors
Robert H Shmerling, MD
Karl B Fields, MD
Deputy Editors
Monica Ramirez Curtis, MD, MPH
Susanna I Lee, MD, PhD


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 exams 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".)


The modalities available for evaluation of the hip include:

Plain film radiography — Plain film radiography of the hip 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) of the hip without contrast is most useful in the setting of trauma, for preoperative planning, and for evaluation and guiding percutaneous biopsy of tumors. Intravenous contrast is administered for evaluating a septic joint or a soft tissue abscess.

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:

Subscribers log in here

Literature review current through: Nov 2017. | This topic last updated: Jun 13, 2017.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2017 UpToDate, Inc.
  1. American College of Radiology. ACR Appropriateness Criteria: Chronic hip pain. First test. Available at: https://acsearch.acr.org/docs/69425/Narrative/ (Accessed on May 04, 2017).
  2. 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.
  3. Lee KS, Rosas HG, Phancao JP. Snapping hip: imaging and treatment. Semin Musculoskelet Radiol 2013; 17:286.
  4. Jacobson JA, Bedi A, Sekiya JK, Blankenbaker DG. Evaluation of the painful athletic hip: imaging options and imaging-guided injections. AJR Am J Roentgenol 2012; 199:516.
  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. Molière S, Dosch JC, Bierry G. Pelvic, acetabular and hip fractures: What the surgeon should expect from the radiologist. Diagn Interv Imaging 2016; 97:709.
  8. Hougaard K, Lindequist S, Nielsen LB. Computerised tomography after posterior dislocation of the hip. J Bone Joint Surg Br 1987; 69:556.
  9. Foulk DM, Mullis BH. Hip dislocation: evaluation and management. J Am Acad Orthop Surg 2010; 18:199.
  10. 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.
  11. Schultz E, Miller TT, Boruchov SD, et al. Incomplete intertrochanteric fractures: imaging features and clinical management. Radiology 1999; 211:237.
  12. Hegazi TM, Belair JA, McCarthy EJ, et al. Sports Injuries about the Hip: What the Radiologist Should Know. Radiographics 2016; 36:1717.
  13. 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.
  14. Verbeeten KM, Hermann KL, Hasselqvist M, et al. The advantages of MRI in the detection of occult hip fractures. Eur Radiol 2005; 15:165.
  15. 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.
  16. Feldman F, Staron RB. MRI of seemingly isolated greater trochanteric fractures. AJR Am J Roentgenol 2004; 183:323.
  17. 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.
  18. Poggi JJ, Callaghan JJ, Spritzer CE, et al. Changes on magnetic resonance images after traumatic hip dislocation. Clin Orthop Relat Res 1995; :249.
  19. 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.
  20. Martinoli C, Garello I, Marchetti A, et al. Hip ultrasound. Eur J Radiol 2012; 81:3824.
  21. Dawes AR, Seidenberg PH. Sonography of sports injuries of the hip. Sports Health 2014; 6:531.
  22. DeAngelis NA, Busconi BD. Assessment and differential diagnosis of the painful hip. Clin Orthop Relat Res 2003; :11.
  23. Matin P. Basic principles of nuclear medicine techniques for detection and evaluation of trauma and sports medicine injuries. Semin Nucl Med 1988; 18:90.
  24. 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.
  25. 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.
  26. 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.
  27. 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.
  28. 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 May 04, 2017).
  29. 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.
  30. 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.
  31. 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.
  32. Leunig M, Werlen S, Ungersböck A, et al. Evaluation of the acetabular labrum by MR arthrography. J Bone Joint Surg Br 1997; 79:230.
  33. 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.
  34. Wettstein M, Dienst M. [Hip arthroscopy for femoroacetabular impingement]. Orthopade 2006; 35:85.
  35. Leunig M, Beck M, Dora C, Ganz R. [Femoroacetabular impingement: trigger for the development of coxarthrosis]. Orthopade 2006; 35:77.
  36. 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.
  37. 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.
  38. Bredella MA, Stoller DW. MR imaging of femoroacetabular impingement. Magn Reson Imaging Clin N Am 2005; 13:653.
  39. Tannast M, Siebenrock KA, Anderson SE. Femoroacetabular impingement: radiographic diagnosis--what the radiologist should know. AJR Am J Roentgenol 2007; 188:1540.
  40. James SL, Ali K, Malara F, et al. MRI findings of femoroacetabular impingement. AJR Am J Roentgenol 2006; 187:1412.
  41. 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 impingement. Available at: https://acsearch.acr.org/docs/69425/Narrative/ (Accessed on May 04, 2017).
  42. Asadipooya K, Graves L, Greene LW. Transient osteoporosis of the hip: review of the literature. Osteoporos Int 2017.
  43. 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.
  44. 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.
  45. 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.
  46. 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.
  47. Balakrishnan A, Schemitsch EH, Pearce D, McKee MD. Distinguishing transient osteoporosis of the hip from avascular necrosis. Can J Surg 2003; 46:187.
  48. 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.
  49. Watson RM, Roach NA, Dalinka MK. Avascular necrosis and bone marrow edema syndrome. Radiol Clin North Am 2004; 42:207.
  50. Calori GM, Mazza E, Colombo A, et al. Core decompression and biotechnologies in the treatment of avascular necrosis of the femoral head. EFORT Open Rev 2017; 2:41.
  51. American College of Radiology. ACR appropriateness criteria: Osteonecrosis of the hip. Available at: https://acsearch.acr.org/docs/69420/Narrative/ (Accessed on May 04, 2017).
  52. Karantanas AH, Drakonaki EE. The role of MR imaging in avascular necrosis of the femoral head. Semin Musculoskelet Radiol 2011; 15:281.
  53. Manenti G, Altobelli S, Pugliese L, Tarantino U. The role of imaging in diagnosis and management of femoral head avascular necrosis. Clin Cases Miner Bone Metab 2015; 12:31.
  54. Mont MA, Zywiel MG, Marker DR, et al. The natural history of untreated asymptomatic osteonecrosis of the femoral head: a systematic literature review. J Bone Joint Surg Am 2010; 92:2165.
  55. 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.
  56. Hu LB, Huang ZG, Wei HY, et al. Osteonecrosis of the femoral head: using CT, MRI and gross specimen to characterize the location, shape and size of the lesion. Br J Radiol 2015; 88:20140508.
  57. Stoica Z, Dumitrescu D, Popescu M, et al. Imaging of avascular necrosis of femoral head: familiar methods and newer trends. Curr Health Sci J 2009; 35:23.
  58. Fink B, Assheuer J, Enderle A, et al. Avascular osteonecrosis of the acetabulum. Skeletal Radiol 1997; 26:509.
  59. 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.
  60. Yamamoto T, Iwamoto Y, Schneider R, Bullough PG. Histopathological prevalence of subchondral insufficiency fracture of the femoral head. Ann Rheum Dis 2008; 67:150.
  61. Jackson SM, Major NM. Pathologic conditions mimicking osteonecrosis. Orthop Clin North Am 2004; 35:315.
  62. Agarwal KK, Mukherjee A, Sharma P, et al. Incremental value of 99mTc-MDP hybrid SPECT/CT over planar scintigraphy and SPECT in avascular necrosis of the femoral head. Nucl Med Commun 2015; 36:1055.
  63. Conaghan P. Is MRI useful in osteoarthritis? Best Pract Res Clin Rheumatol 2006; 20:57.
  64. Sugimoto H, Takeda A, Hyodoh K. Early-stage rheumatoid arthritis: prospective study of the effectiveness of MR imaging for diagnosis. Radiology 2000; 216:569.
  65. American College of Radiology. ACR Appropriateness Criteria: Chronic hip pain. Radiographs suggestive of pigmented villonodular synovitis or osteochondromatosis. Available at: https://acsearch.acr.org/docs/69425/Narrative/ (Accessed on May 04, 2017).
  66. Steinmetz S, Rougemont AL, Peter R. Pigmented villonodular synovitis of the hip. EFORT Open Rev 2016; 1:260.
  67. Startzman A, Collins D, Carreira D. A systematic literature review of synovial chondromatosis and pigmented villonodular synovitis of the hip. Phys Sportsmed 2016; 44:425.
  68. Murphey MD, Vidal JA, Fanburg-Smith JC, Gajewski DA. Imaging of synovial chondromatosis with radiologic-pathologic correlation. Radiographics 2007; 27:1465.
  69. Murphey MD, Rhee JH, Lewis RB, et al. Pigmented villonodular synovitis: radiologic-pathologic correlation. Radiographics 2008; 28:1493.
  70. Klauser AS, Martinoli C, Tagliafico A, et al. Greater trochanteric pain syndrome. Semin Musculoskelet Radiol 2013; 17:43.
  71. Expert Panel on Musculoskeletal Imaging:, Beaman FD, von Herrmann PF, et al. ACR Appropriateness Criteria(®) Suspected Osteomyelitis, Septic Arthritis, or Soft Tissue Infection (Excluding Spine and Diabetic Foot). J Am Coll Radiol 2017; 14:S326.
  72. Koulouris G, Morrison WB. MR imaging of hip infection and inflammation. Magn Reson Imaging Clin N Am 2005; 13:743.
  73. Lee YJ, Sadigh S, Mankad K, et al. The imaging of osteomyelitis. Quant Imaging Med Surg 2016; 6:184.
  74. Palestro CJ. Radionuclide imaging of osteomyelitis. Semin Nucl Med 2015; 45:32.
  75. Maj L, Gombar Y 3rd, Morrison WB. MR imaging of hip infection and inflammation. Magn Reson Imaging Clin N Am 2013; 21:127.
  76. American College of Radiology. ACR Appropriateness Criteria: Primary bone tumors. Available at: https://acsearch.acr.org/docs/69421/Narrative/ (Accessed on May 04, 2017).
  77. American College of Radiology. ACR Appropriateness Criteria: Soft-tissue masses. Available at: https://acsearch.acr.org/docs/69434/Narrative/ (Accessed on May 04, 2017).
  78. Miller TT. Imaging of hip arthroplasty. Semin Musculoskelet Radiol 2006; 10:30.
  79. American College of Radiology. ACR Appropriateness Criteria: Imaging after total hip arthroplasty. Available at: https://acsearch.acr.org/docs/3094200/Narrative/ (Accessed on May 04, 2017).
  80. Ostlere S, Soin S. Imaging of prosthetic joints. Imaging 2003; 15:270.
  81. Buckwalter KA, Parr JA, Choplin RH, Capello WN. Multichannel CT Imaging of Orthopedic Hardware and Implants. Semin Musculoskelet Radiol 2006; 10:86.
  82. Fritz J, Lurie B, Miller TT, Potter HG. MR imaging of hip arthroplasty implants. Radiographics 2014; 34:E106.
  83. White LM, Kim JK, Mehta M, et al. Complications of total hip arthroplasty: MR imaging-initial experience. Radiology 2000; 215:254.
  84. 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.
  85. Petchprapa CN, Rosenberg ZS, Sconfienza LM, et al. MR imaging of entrapment neuropathies of the lower extremity. Part 1. The pelvis and hip. Radiographics 2010; 30:983.
  86. Martinoli C, Miguel-Perez M, Padua L, et al. Imaging of neuropathies about the hip. Eur J Radiol 2013; 82:17.
Topic Outline