ACR Appropriateness Criteria®
Clinical Condition: Chronic Hip Pain
Variant 1: X-ray negative, suspect osseous or surrounding soft-tissue abnormality, excluding osteoid osteoma
Radiologic Exam Procedure |
Appropriateness Rating |
Comments
|
Magnetic Resonance Imaging (MRI) |
Without contrast |
9 |
|
With intravenous (IV) contrast |
6 |
If required after review of noncontrast study. |
Ultrasound |
2 |
|
Computed tomography(CT) |
2 |
|
CT with intra-articular contrast |
2 |
|
Arthrography and aspiration |
2 |
|
Radionuclide scan |
1 |
|
Appropriateness Criteria Scale
1 2 3 4 5 6 7 8 9
1=Least appropriate 9=Most appropriate
|
Variant 2: X-ray negative, suspect osteonecrosis (ON). Includes circumstance in which hip is asymptomatic but ON is suspected due to known predisposing factors
Radiologic Exam Procedure |
Appropriateness Rating |
Comments
|
MRI |
Without contrast |
9 |
|
With IV contrast |
2 |
|
Ultrasound |
2 |
|
CT |
2 |
|
CT with intra-articular contrast |
2 |
|
Radionuclide scan |
2 |
|
Arthrography and aspiration |
2 |
|
Arthrography with anesthetic or anesthetic and steroid |
2 |
|
Appropriateness Criteria Scale
1 2 3 4 5 6 7 8 9
1=Least appropriate 9=Most appropriate
|
Variant 3: X-ray negative, suspect osteoid osteoma
Radiologic Exam Procedure |
Appropriateness Rating |
Comments
|
CT |
9 |
|
CT with intra-articular contrast |
2 |
|
MRI |
Without contrast |
2 |
|
With IV contrast |
2 |
|
Ultrasound |
2 |
|
Radionuclide scan |
2 |
|
Arthrography and aspiration |
2 |
|
Arthrography with anesthetic or anesthetic and steroid |
2 |
|
Appropriateness Criteria Scale
1 2 3 4 5 6 7 8 9
1=Least appropriate 9=Most appropriate
|
Variant 4: X-ray negative, suspect labral tear
Radiologic Exam Procedure |
Appropriateness Rating |
Comments
|
MRI |
With intra-articular contrast |
9 |
Use of high resolution in the future may obviate the need for contrast. |
Without IV contrast |
4 |
Use of high resolution in the future may obviate the need for contrast. |
With IV contrast |
1 |
|
Ultrasound |
2 |
|
CT |
2 |
|
CT with intra-articular contrast |
2 |
|
Radionuclide scan
|
2 |
|
Arthrography and aspiration |
2 |
|
Arthrography with anesthetic or anesthetic and steroid |
2 |
At the request of the referring physician who has indicated hip as source of pain. |
Appropriateness Criteria Scale
1 2 3 4 5 6 7 8 9
1=Least appropriate 9=Most appropriate
|
Variant 5: X-ray negative or mild osteoarthritis, suspect referred pain but wish to exclude hip
Radiologic Exam Procedure |
Appropriateness Rating |
Comments
|
Injection with anesthetic or anesthetic and steroid |
9 |
|
MRI |
Without contrast |
5 |
If another imaging study is indicated, MRI is the study of choice. |
With contrast |
2 |
|
Ultrasound |
2 |
|
CT |
2 |
|
CT with intra-articular contrast |
2 |
|
Radionuclide scan |
2 |
|
Arthrography and aspiration |
2 |
|
Appropriateness Criteria Scale
1 2 3 4 5 6 7 8 9
1=Least appropriate 9=Most appropriate
|
Variant 6: X-ray positive, arthritis uncertain type. Infection not a consideration
Radiologic Exam Procedure |
Appropriateness Rating |
Comments
|
MRI |
Without contrast |
2 |
|
With contrast |
2 |
Contrast rarely necessary. |
Ultrasound |
2 |
|
CT |
2 |
|
CT with intra-articular contrast |
2 |
|
Radionuclide scan |
2 |
|
Appropriateness Criteria Scale
1 2 3 4 5 6 7 8 9
1=Least appropriate 9=Most appropriate
|
Variant 7: X-ray positive, suggestive of pigmented villonodular synovitis or osteochondromatosis
Radiologic Exam Procedure |
Appropriateness Rating |
Comments
|
MRI |
Without contrast |
9 |
|
With contrast |
2 |
|
Ultrasound |
2 |
|
CT |
2 |
If MR is not available or contraindicated. |
CT with intra-articular contrast |
2 |
|
Radionuclide scan |
2 |
|
Arthrography and aspiration |
2 |
|
Arthrography with anesthetic or anesthetic and steroid |
2 |
|
Appropriateness Criteria Scale
1 2 3 4 5 6 7 8 9
1=Least appropriate 9=Most appropriate
|
Chronic hip pain is a perplexing clinical problem. Symptoms may be related to numerous etiologies, including trauma, neoplasms, and arthropathies. Pain may be due to osseous, intra-articular, periarticular, or soft-tissue pathology. Referred pain from the lumbar spine, sacroiliac joints, or knee may add to the potentially confusing clinical picture. Very few references deal specifically with this condition, although the imaging of specific disorders has been the subject of many articles.
Clinical data is essential for selecting the most appropriate imaging techniques in patients with chronic hip pain. Range of motion, gait abnormalities, locking or snapping, duration of symptoms, and pain patterns (e.g., worse at night, increased with exercise, relieved by aspirin, etc.) can be very useful for reducing the potentially long list of differential diagnoses. Routine radiographs should be obtained first in most, if not all, cases and may provide specific information for common disorders such as osteoarthritis (OA) or less common disorders such as pigmented villonodular synovitis (PVNS) and primary bony tumors. Whether the plain films are normal or not, they are often of considerable value for the selection of additional techniques and for comparison with studies such as magnetic resonance imaging (MRI) examinations and radionuclide bone scans.
Magnetic resonance imaging is frequently performed after initial radiographs to detect osseous, articular, or soft-tissue abnormalities. MRI is both highly sensitive and specific for the detection of many abnormalities involving the hip or surrounding soft tissues and should in general be the first imaging technique employed following plain films. Osteonecrosis (ON) is probably the most common cause of chronic hip pain for which MRI is routinely employed and the disorder for which the appearance and accuracy of MRI have been most thoroughly demonstrated in the literature. Despite all of the work with the MRI of ON, several controversies have arisen, including the relationship of size of the lesion to progression to collapse and the efficacy of treatment and the potential confusion of the MRI appearance of ON with transient bone marrow edema syndrome or subchondral fractures . MRI can also accurately detect ON in the asymptomatic, contralateral hip in those cases in which ON of the other hip has been diagnosed by plain film.
Other causes of chronic painful hip for which MR has been used with considerable success include radiographically occult acute and stress fractures, acute and chronic soft-tissue injuries, and tumors. The only exceptions to the use of MR as the primary technique following plain films are cases of suspected osteoid osteoma, for which computed tomography (CT) should be performed and labral tears for which MR arthrography should probably be employed. Direct MR arthrography employing the intra-articular injection of a dilute (1:200) solution of Gd-chelate in saline has been established as a reliable technique for the diagnosis of acetabular labral tears, although several investigators (Potter H, Stoller D, Beltran J—personal communication) have more recently suggested that the use of small-field of view (FOV) (e.g., 18–20 cm) images in conjunction with very-high-resolution matrices (512 x 384) obtained with a fast-spin-echo sequence (FSE) may obviate the need for intra-articular contrast. These same investigators have also suggested that the use of the same high-resolution FSE images may be of value in detecting the loss of articular cartilage resulting from OA much earlier than can be seen with plain films.
Indirect MR arthrography, in which Gd-chelate contrast is administered by IV injection and diffuses into the joint space through the synovium, has been proposed as an alternative to direct MR arthrography for the detection of intra-articular disorders. It is faster and easier to perform than direct arthrography and does not require fluoroscopy. It suffers from less consistent enhancement of the joint space as well as inability to distend the joint capsule. Its value in the assessment of intra-articular disorders of the hip is uncertain. The use of IV Gd-chelate contrast has also been proposed as a means to differentiate between joint fluid and pannus in the knee in patients with inflammatory arthritis, although its value in the hip for this purpose has not been addressed.
Diagnostic and therapeutic joint injections, which can be performed readily at the time of an MR arthrogram or as dedicated procedures, are a useful tool for confirming the location of pain and in some cases helping in its control for a short period. Joint aspiration is also critical in diagnosing the presence of infection or crystal disease. Local articular and extra-articular injections can define the symptomatic site and exclude referred symptoms. Intra-articular injection of a small amount of iodinated contrast medium under fluoroscopic guidance is used to confirm needle position. Sonography can also be used to localize fluid collections for aspiration.
In the presence of normal radiographs, and in the absence of ready access to MR imaging capability, a bone scan may be a useful technique. Radionuclide bone scans are effective for detection of subtle osseous pathology and, when negative, are useful in excluding bone or ligament/tendon attachment abnormalities.
Other techniques such as fluoroscopic motion studies (with or without intra-articular contrast) and ultrasound are useful to evaluate articular and periarticular conditions such as snapping iliopsoas tendon. In one study, real-time ultrasound was used to evaluate the snapping iliopsoas tendon. This method is noninvasive, which is an advantage compared with injection of the tendon sheath and fluoroscopic evaluation.
Summary
Imaging of chronic hip pain is a broad subject, and the imaging assessment of numerous disorders has been described in the literature. Clinical data plays an important role in patients with chronic hip pain. Plain radiographs should be obtained as the first imaging study and, in general, MRI should be obtained as the next imaging study except in cases of suspected osteoid osteoma or labral tear as discussed above. Other imaging techniques as well as image-guided aspiration have selected roles to play in certain disorders.