ACR Appropriateness Criteria®

Clinical Condition: Chronic Hip Pain

Variant 1: Initial evaluation for chronic hip pain. First test.

Note: Abbreviations used in the tables are listed at the end of the "Major Recommendations" field.

Variant 2: Radiographs negative, suspect osseous or surrounding soft-tissue abnormality, excluding osteoid osteoma.

Note: Abbreviations used in the tables are listed at the end of the "Major Recommendations" field.

Variant 3: Radiographs negative, suspect osteonecrosis. Includes circumstance in which hip is asymptomatic but osteonecrosis is suspected due to known predisposing factors.

Note: Abbreviations used in the tables are listed at the end of the "Major Recommendations" field.

Variant 4: Radiograph negative. Suspect osteoid osteoma.

Note: Abbreviations used in the tables are listed at the end of the "Major Recommendations" field.

Variant 5: Radiographs negative, suspect labral tear with or without clinical findings consistent with or suggestive of femoroacetabular impingement.

Note: Abbreviations used in the tables are listed at the end of the "Major Recommendations" field.

Variant 6: Radiographs negative or mild osteoarthritis. Suspect referred pain but wish to exclude hip.

Note: Abbreviations used in the tables are listed at the end of the "Major Recommendations" field.

Variant 7: Radiographs positive, arthritis uncertain type. Infection not a consideration.

Note: Abbreviations used in the tables are listed at the end of the "Major Recommendations" field.

Variant 8: Radiographs positive, suggestive of pigmented villonodular synovitis or osteochondromatosis.

Note: Abbreviations used in the tables are listed at the end of the "Major Recommendations" field.

Summary of Literature Review

Chronic hip pain and/or groin 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 chronic hip pain, 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) can be very useful for reducing the potentially long list of differential diagnoses. 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 primary bone tumors. Whether the radiographs 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.

MRI is frequently performed after initial radiographs to detect osseous, articular, or soft-tissue abnormalities. It is both highly sensitive and specific for detecting many abnormalities involving the hip or surrounding soft tissues and should in general be the first imaging technique used following radiographs. Osteonecrosis (ON) is probably the most common cause of chronic hip pain for which MRI is routinely used and the disorder for which the appearance and accuracy of MRI have been most thoroughly demonstrated in the literature.

Some investigators suggest that proton MRI spectroscopy may be a potential tool for predicting the risk for development of ON. 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 radiographs.

Other causes of chronic painful hip for which MR has been used with considerable success include radiographically occult fractures, acute and chronic soft-tissue injuries, infection and inflammation, and tumors. Intravenous Gd-chelate agents are used to differentiate between joint fluid and synovitis. Generally, if the arthritis has an atypical appearance on radiographs, MRI may be helpful for further characterization and the intravenous contrast is rarely needed. The only exceptions to the use of MRI as the primary technique following radiographs are cases of suspected osteoid osteoma, for which computed tomography (CT) should be performed. One study reported that osteoid osteoma can be successfully imaged by dynamic contrast-enhanced MRI. However, the opinion of this expert panel is that the MRI without and/or with intravenous contrast is generally not widely utilized and most of time not needed in the diagnosis of osteoid osteoma and should be performed under discretion of radiologist if additional information is believed could be gained. For evaluating labral tears MR arthrography should probably be used. Direct MR arthrography with the intra-articular injection of a dilute (1:200) solution of Gd-chelate in saline has been established as a reliable technique for diagnosing of acetabular labral tears that are frequently associated with femoroacetabular impingement syndrome. However, several investigators suggest that high-resolution MRI with 3T may improve the visualization of the acetabular labrum and the hyaline articular cartilage, which may obviate the need for intra-articular contrast.

Other investigators have obtained satisfactory results in detecting labral and hyaline cartilage lesions with high-resolution MRI of the hip at 1.5T without intra-articular contrast. Hip cartilage abnormalities can also be successfully evaluated by high-resolution CT arthrography. Three-dimensional CT is an accurate tool to quantify the femoral head-neck concavity, providing a noninvasive assessment of hips at risk of femoroacetabular impingement. CT is also useful in evaluating hip dysplasia. Radiotracer uptake in the superior or superomedial aspect of the acetabular rim on skeletal scintigraphy has been reported as a characteristic feature of a labral tear. Absence of this pattern carries a high negative predictive value for the diagnosis.

Indirect MR arthrography, in which Gd-chelate contrast is administered by intravenous (IV) injection and diffuses into the joint space through the synovium, has been proposed as an alternative to direct MR arthrography for detecting 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 assessing the hyaline articular cartilage and the acetabular labrum of the hip is uncertain.

Diagnostic and therapeutic joint injections, which can be performed readily at the time of an MRI arthrogram or as dedicated procedures, are useful tools 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. Sonography-guided iliopsoas bursal/peritendinous injections may be useful in determining the cause of hip pain.

In the presence of normal radiographs, and in the absence of ready access to MRI, a bone scan may be a useful technique. Radionuclide bone scans are effective for detecting or excluding subtle osseous abnormalities.

Other techniques such as fluoroscopic motion studies (with or without intra-articular contrast) and ultrasound (US) are useful to evaluate articular and peri-articular conditions such as snapping iliopsoas tendon. In one study, real-time US 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 and Recommendations

Imaging of chronic hip pain is a broad subject, and the imaging assessment of numerous disorders has been described in the literature. Clinical data play an important role in patients with chronic hip pain. 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. Direct MR arthrography should be performed if acetabular labral tear is suspected, including patients with clinical evidence of femoroacetabular impingement. Use of higher field MRI (3T) may obviate the need for intra-articular contrast. Other imaging techniques as well as image-guided aspiration have selected roles to play in certain disorders.

Anticipated Exceptions

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