Which imaging modalities are recommended for the assessment of hip pain in adults, and when should they be utilized?

Recommended imaging modalities for assessment of hip pain in adults include:

• Plain X-ray: Generally the first-line imaging for suspected hip osteoarthritis or trauma, especially if there is a history of trauma or focal bony tenderness. It is used to exclude fractures or other bony abnormalities and to assess for osteoarthritis if atypical features are present ²,¹.
• Ultrasound: Can be used in secondary care for further assessment of greater trochanteric pain syndrome when diagnosis is uncertain or when guided corticosteroid injections are considered ¹.
• Magnetic Resonance Imaging (MRI): Recommended in secondary care when symptoms persist despite conservative management, or when diagnosis is unclear, to evaluate soft tissue structures, tendons, bursae, or to assess for inflammatory or infective causes ¹,⁵. MRI is also used for suspected axial spondyloarthritis if X-ray is inconclusive or inappropriate ⁶.
• Computed Tomography (CT): May be used in secondary care for complex cases or when MRI is contraindicated, to provide detailed bony anatomy, especially in suspected fractures or tuberculosis ¹,⁵.

Clinical circumstances for imaging utilization:

• Do not routinely use imaging to diagnose osteoarthritis in adults aged 45 or over with typical activity-related joint pain and short morning stiffness; diagnosis is clinical unless atypical features or alternative diagnoses are suspected ².
• Urgent referral and imaging are indicated for severe hip pain unresponsive to analgesia, persistent loss of function, suspicion of infection, malignancy, or pathological fracture ¹.
• Refer for imaging if hip pain persists beyond 3 months despite physiotherapy, or if symptoms are severe, irritable, stiff, or interfere with sleep and activities of daily living ¹.
• In suspected spondyloarthritis, plain X-ray of sacroiliac joints is first-line; if inconclusive or skeleton immature, MRI is recommended ⁶.
• In cases of suspected tuberculosis involving bone or joint, imaging with X-ray, CT, or MRI is used depending on site and availability, alongside biopsy or aspirate for diagnosis ⁵.