Diagnostic Imaging Pathways - Hip Pain (Non-Traumatic)
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This pathway provides guidance on the imaging of adult patients with new onset, non-traumatic hip pain.
Date reviewed: August 2013
Date of next review: 2017/2018
Published: October 2013
Quick User Guide
Move the mouse cursor over the PINK text boxes inside the flow chart to bring up a pop up box with salient points.
Clicking on the PINK text box will bring up the full text.
The relative radiation level (RRL) of each imaging investigation is displayed in the pop up box.
| SYMBOL | RRL | EFFECTIVE DOSE RANGE |
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None | 0 |
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Minimal | < 1 millisieverts |
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Low | 1-5 mSv |
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Medium | 5-10 mSv |
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High | >10 mSv |
Teaching Points
Teaching Points
- Initial clinical assessment is important
- Plain radiography is an appropriate first line investigation for those with severe pain and significant functional impairment
- MRI is generally the best investigation to further evaluate hip pain. MR arthrography can help diagnose labral tears
- Bone scan is useful in detecting wide-spread bone metastases. Nuclear medicine studies are also useful in suspected infected hip prostheses
- CT is useful in diagnosing osteoid osteoma
- Ultrasound is useful in selected indications such as bursitis and tendinopathy but is user dependent and insufficient for articular or osseous structures
xray
Plain Radiography
- Plain radiography is an appropriate initial investigation for those with persistent pain and significant functional impairment 1
- Plain radiography may detect gross fractures, tumours, advanced arthrosis and hip dysplasias, but does not detect early changes of joint space narrowing, subtle stress or insufficiency fractures, intra-articular structures or bone marrow changes 2
- Osteoarthritis (OA) is diagnosed most effectively by clinical criteria with the aid of radiographic findings. 3 Further imaging modalities are seldom needed for OA diagnosis 4
- Certain radiographic features may help to distinguish metastases from other conditions and aid in identification of the primary tumour. Overall plain radiographs have poor sensitivity for detection of bone metastases 5, 6
- Normal plain radiographs do not reliably exclude osteomyelitis as nearly 50% loss of bone density is required before a radiograph becomes abnormal 7
MRI
Magnetic Resonance Imaging (MRI) and MR Arthrography
- If initial radiographs are negative or non-diagnostic, if soft tissue injury is suspected or a high suspicion of osseous abnormality remains, further evaluation is best done with MRI
- High sensitivity and specificity for detection of 2,8-10
- Osseous and chondral lesions; e.g. fracture, avascular necrosis or stress injury
- Ligamental and muscle injuries; e.g. femoroacetabular impingement
- Osteomyelitis 11
- MRI can help predict clinical outcome in osteoarthritis 12
- MR arthrography is superior to conventional 1.5T MRI or CT arthrography in the diagnosis of labral tears, 13-17 but may not preclude arthroscopy when negative and high clinical suspicion remains. 18 Higher field (3T) MRI appears equivalent to MR arthrography and may preclude the need for invasive intraarticular contrast 16,19,20
- MR arthrography is highly specific but insensitive for detection of intraarticular loose bodies compared to arthroscopy 21
CT
Computed Tomography (CT) and CT Arthrography
- CT offers excellent delineation of cortical bone. It is considered an alternative to MRI in detection of occult hip fracture where MRI is contraindicated
- More accurate than MRI in detecting the characteristic nidus of osteoid osteoma, 22,23 although the use of dynamic gadolinium-enhanced MRI improves nidus conspicuity compared to CT 24
- CT arthrography is equivalent to MR arthrography in demonstrating articular cartilage lesions, and appears useful in diagnosing labral tears and other intra-articular hip pathology where MRI and MR arthrography is contraindicated or unavailable 14,25,26
US
Ultrasound
- Inexpensive and useful in specific indications. Ultrasound allows dynamic evaluation of tendons and muscles and identification of hip effusions as well as bursal and soft tissue collections
- However, it is user-dependent, insufficient for deeper articular or osseous structures and overall has a limited role in hip imaging 2
- Useful in the evaluation of greater trochanteric bursitis and gluteal tendon tears in the hands of an experienced user 27
NM
Bone Scan
- Use has mostly been replaced by MRI in the evaluation of focal hip pathology, but bone scintigraphy may be used as an alternative where MRI is contraindicated
- Useful for screening the entire skeleton to assess for systemic involvement of osseous and joint pathology, such as metastases, 5,6 or infection
- Some nuclear medicine scans may be helpful to assess suspected infected hip prostheses, where metallic implants may produce local artefacts and decrease imaging quality on MRI 28
References
References
Date of literature search: April 2013
The search methodology is available on request. Email
References are graded from Level I to V according to the Oxford Centre for Evidence-Based Medicine, Levels of Evidence. Download the document
- Glaves J. The use of radiological guidelines to achieve a sustained reduction in the number of radiographic examinations of the cervical spine, lumbar spine and knees performed for GPs. Clin Radiol. 2005;60(8):914-20. (Level II/III evidence)
- Lazarus ML. Imaging of Femoroacetabular Impingement and Acetabular Labral Tears of the Hip. Dis Mon. 2012;58(9):495-542. (Review article)
- Kinds MB, Welsing PMJ, Vignon EP, Bijlsma JWJ, Viergever MA, Marijnissen ACA, et al. A systematic review of the association between radiographic and clinical osteoarthritis of hip and knee. Osteoarthritis Cartilage. 2011;19(7):768-78. (Level II evidence)
- Menashe L, Hirko K, Losina E, Kloppenburg M, Zhang W, Li L, et al. The diagnostic performance of MRI in osteoarthritis: a systematic review and meta-analysis. Osteoarthritis Cartilage. 2012;20(1):13-21. (Level I evidence)
- Schaffer DL, Pendergrass HP. Comparison of enzyme, clinical, radiographic, and radionuclide methods of detecting bone metastases from carcinoma of the prostate. Radiology. 1976;121(2):431-4. (Level III evidence)
- Roberts JG, Gravelle IH, Baum M, Bligh AS, Leach KG, Hughes LE. Evaluation of radiography and isotopic scintigraphy for detecting skeletal metastases in breast cancer. Lancet (London, England). 1976;1(7953):237-9. (Level II evidence)
- Pineda C, Espinosa R, Pena A. Radiographic imaging in osteomyelitis: the role of plain radiography, computed tomography, ultrasonography, magnetic resonance imaging, and scintigraphy. Semin Plast Surg. 2009;23(2):80-9. (Review article)
- Khurana B, Okanobo H, Ossiani M, Ledbetter S, Al Dulaimy K, Sodickson A. Abbreviated MRI for patients presenting to the emergency department with hip pain. AJR Am J Roentgenol. 2012;198(6):W581-8. (Level II evidence)
- Beltran J, Herman LJ, Burk JM, Zuelzer WA, Clark RN, Lucas JG, et al. Femoral head avascular necrosis: MR imaging with clinical-pathologic and radionuclide correlation. Radiology. 1988;166(1 Pt 1):215-20. (Level II evidence)
- Shin AY, Morin WD, Gorman JD, Jones SB, Lapinsky AS. The superiority of magnetic resonance imaging in differentiating the cause of hip pain in endurance athletes. Am J Sports Med. 1996;24(2):168-76. (Level III evidence)
- Pineda C, Vargas A, Rodríguez AV. Imaging of osteomyelitis: current concepts. Infect Dis Clin North Am. 2006;20(4):789-825. (Review article)
- Hunter DJ, Zhang W, Conaghan PG, Hirko K, Menashe L, Li L, et al. Systematic review of the concurrent and predictive validity of MRI biomarkers in OA. Osteoarthritis Cartilage. 2011;19(5):557-88. (Level I evidence)
- Toomayan GA, Holman WR, Major NM, Kozlowicz SM, Vail TP. Sensitivity of MR arthrography in the evaluation of acetabular labral tears. AJR Am J Roentgenol. 2006;186(2):449-53. (Level II evidence)
- Perdikakis E, Karachalios T, Katonis P, Karantanas A. Comparison of MR-arthrography and MDCT-arthrography for detection of labral and articular cartilage hip pathology. Skeletal Radiol. 2011;40(11):1441-7. (Level II evidence)
- Chan YS, Lien LC, Hsu HL, Wan YL, Lee MS, Hsu KY, et al. Evaluating hip labral tears using magnetic resonance arthrography: a prospective study comparing hip arthroscopy and magnetic resonance arthrography diagnosis. Arthroscopy. 2005;21(10):1250. (Level II evidence)
- Smith TO, Hilton G, Toms AP, Donell ST, Hing CB. The diagnostic accuracy of acetabular labral tears using magnetic resonance imaging and magnetic resonance arthrography: a meta-analysis. Eur Radiol. 2011;21(4):863-74. (Level II evidence)
- Burgess RM, Rushton A, Wright C, Daborn C. The validity and accuracy of clinical diagnostic tests used to detect labral pathology of the hip: a systematic review. Man Ther. 2011;16(4):318-26. (Level II evidence)
- Reurink G, Jansen SPL, Bisselink JM, Vincken PWJ, Weir A, Moen MH. Reliability and validity of diagnosing acetabular labral lesions with magnetic resonance arthrography. J Bone Joint Surg Am. 2012;94(18):1643-8. (Level II evidence)
- Sundberg TP, Toomayan GA, Major NM. Evaluation of the acetabular labrum at 3.0-T MR imaging compared with 1.5-T MR arthrography: preliminary experience. Radiology. 2006;238(2):706-11. (Level IV evidence)
- Mintz DN, Hooper T, Connell D, Buly R, Padgett DE, Potter HG. Magnetic resonance imaging of the hip: detection of labral and chondral abnormalities using noncontrast imaging. Arthroscopy. 2005;21(4):385-93. (Level II evidence)
- Neckers AC, Polster JM, Winalski CS, Krebs VE, Sundaram M. Comparison of MR arthrography with arthroscopy of the hip for the assessment of intra-articular loose bodies. Skeletal Radiol. 2007;36(10):963-7. (Level II evidence)
- Assoun J, Richardi G, Railhac JJ, Baunin C, Fajadet P, Giron J, et al. Osteoid osteoma: MR imaging versus CT. Radiology. 1994 Apr;191(1):217-23. (Level III evidence)
- Davies M, Cassar-Pullicino VN, Davies AM, McCall IW, Tyrrell PN. The diagnostic accuracy of MR imaging in osteoid osteoma. Skeletal Radiol. 2002;31(10):559-69. (Level III evidence)
- Liu PT, Chivers FS, Roberts CC, Schultz CJ, Beauchamp CP. Imaging of osteoid osteoma with dynamic gadolinium-enhanced MR imaging. Radiology. 2003;227(3):691-700. (Level IV evidence)
- Ha YC, Choi JA, Lee YK, Kim JY, Koo KH, Lee GY, et al. The diagnostic value of direct CT arthrography using MDCT in the evaluation of acetabular labral tear: with arthroscopic correlation. Skeletal Radiol. 2013;42(5):681-8. (Level II evidence)
- Christie-Large M, Tapp MJ, Theivendran K, James SL. The role of multidetector CT arthrography in the investigation of suspected intra-articular hip pathology. Br J Radiol. 2010;83(994):861-7. (Level III evidence)
- Westacott DJ, Minns JI, Foguet P. The diagnostic accuracy of magnetic resonance imaging and ultrasonography in gluteal tendon tears--a systematic review. Hip Int. 2011;21(6):637-45. (Level II evidence)
- Prandini N, Lazzeri E, Rossi B, Erba P, Parisella M, Signore A. Nuclear medicine imaging of bone infections. Nucl Med Commun. 2006;27(8):633-44. (Level II evidence)
Information for Consumers
Information for Consumers
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Contrast Medium (Gadolinium versus Iodine) Iodine-Containing Contrast Medium Magnetic Resonance Imaging (MRI) Radiation Risk of Medical Imaging During Pregnancy Radiation Risk of Medical Imaging for Adults and Children |
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