• American College of Radiology (ACR), Expert Panel on Musculoskeletal Imaging. Chronic hip pain. Reston (VA): American College of Radiology (ACR); 2003. 6 p. (ACR appropriateness criteria). [31 references]

This is the current release of the guideline.

It is a revision of a previously issued version (Chronic hip pain. American College of Radiology. ACR Appropriateness Criteria. Radiology 2000 Jun;215(Suppl):391-6).

All Appropriateness Criteria™ topics are reviewed annually and updated as appropriate.

Chronic hip pain

Diagnosis

Family Practice
Internal Medicine
Nuclear Medicine
Orthopedic Surgery
Radiology

Health Plans
Hospitals
Managed Care Organizations
Physicians
Utilization Management

To evaluate the appropriateness of initial radiologic examinations for patients with chronic hip pain

Patients with chronic hip pain

1. Magnetic resonance imaging (MRI) (with or without contrast)
2. Ultrasound
3. Computed tomography (CT)
4. Computed tomography with intra-articular contrast
5. Radionuclide scan
6. Arthrography and aspiration
7. Arthrography with anesthetic or anesthetic and steroid
8. Injection with anesthetic or anesthetic and steroid

Utility of radiologic examinations in differential diagnosis

Searches of Electronic Databases

The guideline developer performed literature searches of recent peer-reviewed medical journals, primarily using the National Library of Medicine's MEDLINE database. The developer identified and collected the major applicable articles.

The total number of source documents identified as the result of the literature search is not known.

Weighting According to a Rating Scheme (Scheme Not Given)

Not stated

Systematic Review with Evidence Tables

One or two topic leaders within a panel assume the responsibility of developing an evidence table for each clinical condition, based on analysis of the current literature. These tables serve as a basis for developing a narrative specific to each clinical condition.

Expert Consensus (Delphi)

Since data available from existing scientific studies are usually insufficient for meta-analysis, broad-based consensus techniques are needed to reach agreement in the formulation of the Appropriateness Criteria. Serial surveys are conducted by distributing questionnaires to consolidate expert opinions within each panel. These questionnaires are distributed to the participants along with the evidence table and narrative as developed by the topic leader(s). Questionnaires are completed by the participants in their own professional setting without influence of the other members. Voting is conducted using a scoring system from 1-9, indicating the least to the most appropriate imaging examination or therapeutic procedure. The survey results are collected, tabulated in anonymous fashion, and redistributed after each round. A maximum of three rounds is conducted and opinions are unified to the highest degree possible. Eighty (80) percent agreement is considered a consensus. If consensus cannot be reached by this method, the panel is convened and group consensus techniques are utilized. The strengths and weaknesses of each test or procedure are discussed and consensus reached whenever possible.

Not applicable

A formal cost analysis was not performed and published cost analyses were not reviewed.

Internal Peer Review

Criteria developed by the Expert Panels are reviewed by the American College of Radiology (ACR) Committee on Appropriateness Criteria and the Chair of the ACR Board of Chancellors.

ACR Appropriateness Criteria®

Clinical Condition: Chronic Hip Pain

Variant 1: X-ray negative, suspect osseous or surrounding soft-tissue abnormality, excluding osteoid osteoma

Variant 2: X-ray negative, suspect osteonecrosis (ON). Includes circumstance in which hip is asymptomatic but ON is suspected due to known predisposing factors

Variant 3: X-ray negative, suspect osteoid osteoma

Variant 4: X-ray negative, suspect labral tear

Variant 5: X-ray negative or mild osteoarthritis, suspect referred pain but wish to exclude hip

Variant 6: X-ray positive, arthritis uncertain type. Infection not a consideration

Variant 7: X-ray positive, suggestive of pigmented villonodular synovitis or osteochondromatosis

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.

None provided

The recommendations are based on analysis of the current literature and expert panel consensus.

Appropriate selection of radiologic exam procedures to evaluate patients with chronic hip pain

None identified

An American College of Radiology (ACR) Committee on Appropriateness Criteria and its expert panels have developed criteria for determining appropriate imaging examinations for diagnosis and treatment of specified medical condition(s). These criteria are intended to guide radiologists, radiation oncologists, and referring physicians in making decisions regarding radiologic imaging and treatment. Generally, the complexity and severity of a patient's clinical condition should dictate the selection of appropriate imaging procedures or treatments. Only those exams generally used for evaluation of the patient's condition are ranked. Other imaging studies necessary to evaluate other co-existent diseases or other medical consequences of this condition are not considered in this document. The availability of equipment or personnel may influence the selection of appropriate imaging procedures or treatments. Imaging techniques classified as investigational by the U.S. Food and Drug Administration (FDA) have not been considered in developing these criteria; however, study of new equipment and applications should be encouraged. The ultimate decision regarding the appropriateness of any specific radiologic examination or treatment must be made by the referring physician and radiologist in light of all the circumstances presented in an individual examination.

An implementation strategy was not provided.

Living with Illness

Effectiveness

• American College of Radiology (ACR), Expert Panel on Musculoskeletal Imaging. Chronic hip pain. Reston (VA): American College of Radiology (ACR); 2003. 6 p. (ACR appropriateness criteria). [31 references]

Not applicable: The guideline was not adapted from another source.

1998 (revised 2003)

American College of Radiology - Medical Specialty Society

The American College of Radiology (ACR) provided the funding and the resources for these ACR Appropriateness Criteria®.

ACR Appropriateness Criteria™ Committee, Expert Panel on Musculoskeletal Imaging

Names of Panel Members: John B. Kneeland, MD, Principal Author, University of Pennsylvania Hospital, Philadelphia, Pa; Murray K. Dalinka, MD, Panel Chair, University of Pennsylvania Hospital, Philadelphia, Pa; Naomi Alazraki, MD, VA Medical Center, Emory University, Atlanta, Ga; Richard H. Daffner, MD, Allegheny General Hospital, Pittsburgh, Pa; Arthur A. DeSmet, MD, University of Wisconsin, Madison, Wis; George Y. El-Khoury, MD, University of Iowa Hospitals and Clinics, Iowa City, Iowa; B.J. Manaster, MD, PhD, University of Colorado Health Science Center, Denver, Colo; Helene Pavlov, MD, Hospital for Special Surgery, New York, NY; David A. Rubin, MD, Mallinckrodt Institute of Radiology, St. Louis, Mo; Lynne S. Steinbach, MD, University of California, San Francisco, Calif; Murali Sundaram, MD, Mayo Clinic, Rochester, Minn; Barbara N. Weissman, MD, Brigham & Women’s Hospital, Boston, Mass; Robert H. Haralson III, MD, Southeast Orthopedics, Knoxville, Tenn, American Academy of Orthopaedic Surgeons

Not stated

This is the current release of the guideline.

It is a revision of a previously issued version (Chronic hip pain. American College of Radiology. ACR Appropriateness Criteria. Radiology 2000 Jun;215(Suppl):391-6).

All Appropriateness Criteria™ topics are reviewed annually and updated as appropriate.

None available

None available

This summary was completed by ECRI on May 6, 2001. The information was verified by the guideline developer as of June 29, 2001. This NGC summary was updated by ECRI on November 12, 2004. The information was verified by the guideline developer on December 21, 2004.