Hip Pain: When Do You Need an X Ray or MRI?
Hip pain can have many different causes.
Hip osteoarthritis, greater trochanteric pain syndrome, gluteal tendinopathy, femoroacetabular impingement and labral problems can all produce pain around the hip.
Sometimes pain experienced around the hip is not actually coming from the hip joint at all.
This can understandably lead to the question:
Do I need an X ray or MRI for my hip pain?
Sometimes imaging is extremely useful.
But choosing the right investigation depends on what we think might be causing the symptoms and what question we need the scan to answer.
For one person, a weight bearing X ray may provide all the information required. Another may genuinely need an MRI. For many people, neither is necessary initially.
The starting point should usually be a good clinical assessment.
Table of Contents
What are the common causes of hip pain?
The location of hip pain can provide useful information, but it does not establish the diagnosis by itself.
Pain felt predominantly around the groin or front of the hip may be associated with the hip joint itself.
Pain over the outside of the hip may be more consistent with structures around the greater trochanter.
But there is considerable overlap.
Some of the conditions we might consider include:
Hip osteoarthritis
Hip osteoarthritis becomes increasingly common with age.
Symptoms can include groin or anterior hip pain, stiffness, reduced movement and difficulty with activities such as walking, putting on shoes and socks, getting out of a car or climbing stairs.
However, the presence of osteoarthritis on an X ray does not automatically mean that it is responsible for every symptom someone experiences.
Greater trochanteric pain syndrome
Greater trochanteric pain syndrome, often shortened to GTPS, typically causes pain around the outside of the hip.
People may find lying on that side uncomfortable and experience pain with walking, stairs, running or prolonged standing.
Gluteal tendinopathy is commonly involved and the condition was historically often labelled as trochanteric bursitis.
Femoroacetabular impingement
Femoroacetabular impingement, or FAI, is associated with the shape and interaction of the ball and socket of the hip.
It is often discussed in younger or more active adults with groin pain, particularly during activities involving greater amounts of hip flexion or rotation.
Importantly, simply having cam or pincer morphology on imaging does not mean somebody has symptomatic FAI.
Structural morphology needs to be considered alongside symptoms and clinical findings.
Hip labral problems
The labrum is a ring of tissue around the socket of the hip.
Labral abnormalities and tears can sometimes be associated with hip symptoms, particularly in younger and active populations.
But, as with many musculoskeletal imaging findings, seeing a labral tear does not automatically establish that it is the cause of someone's pain.
Muscular and tendon related pain
The hip flexors, adductors, hamstrings and other structures around the hip can also become painful.
These presentations often require no imaging initially and can frequently be assessed clinically.
Referred pain
The lumbar spine can refer symptoms towards the buttock and hip region.
This means that somebody can understandably believe they have a hip problem when the primary source of their symptoms may be elsewhere.
That is one reason jumping straight to imaging the painful area is not always the best starting point.
Can hip pain be diagnosed without a scan?
Very often, yes.
A clinical assessment can provide a considerable amount of information.
The history might consider:
Where the pain is located
How it started
Whether there was an injury
Age and activity levels
What movements provoke symptoms
Walking tolerance
Whether lying on the affected side is painful
Whether there is significant morning stiffness
Whether symptoms are associated with running or sport
Whether there is back pain
Whether symptoms occur at rest or at night
The physical examination can then assess hip movement, strength, functional tasks and specific movements or tests that help build the clinical picture.
The purpose is not necessarily to identify one structure with absolute certainty during the first appointment.
It is to establish the most likely diagnosis, consider important alternatives and determine whether further investigation would actually change management.
When is an X ray useful for hip pain?
X rays provide useful information about bone and joint structure.
They are particularly useful when hip osteoarthritis is suspected.
A weight bearing X ray can demonstrate features associated with osteoarthritis including joint space narrowing, osteophytes and other structural changes.
X rays can also provide information about hip morphology and other bony abnormalities where these are clinically relevant.
The important point is that an MRI is not automatically better simply because it provides more detailed images.
If the clinical question is:
Does this person have significant hip osteoarthritis?
an appropriate X ray may provide exactly the information required.
More detail is only useful when that additional information has clinical value.
When is an MRI useful for hip pain?
MRI provides much greater soft tissue detail.
It can help investigate structures including muscles, tendons, the labrum, cartilage and bone marrow.
That can make it extremely useful in selected presentations.
An MRI may be considered when:
The diagnosis remains uncertain after clinical assessment
Symptoms are persistent and behaving unexpectedly
A significant soft tissue injury is suspected
A labral or other intra articular problem is clinically relevant
A bone stress injury is suspected
The result would influence an injection or surgical decision
Other investigations have not adequately answered the clinical question
Again, persistent pain alone does not automatically mean that somebody needs an MRI.
The useful question is:
What are we looking for, and would finding it change what we do next?
Do you need a scan for hip osteoarthritis?
Not everybody with suspected hip osteoarthritis needs immediate imaging.
Hip osteoarthritis can often be suspected from the history and examination.
When imaging is required to confirm the extent of structural change or assist with treatment decisions, an X ray is generally the most useful initial investigation.
MRI is not routinely necessary simply to demonstrate osteoarthritis.
This is particularly relevant because MRI can identify numerous additional structural findings that may have little bearing on management.
If somebody has a typical clinical presentation, an X ray demonstrates significant osteoarthritis and the symptoms correspond with those findings, an MRI may add very little.
If the presentation does not fit, however, further investigation may occasionally be appropriate.
The imaging decision should follow the clinical question.
Do you need imaging for greater trochanteric pain syndrome?
Usually not initially.
Greater trochanteric pain syndrome and gluteal tendinopathy can often be diagnosed clinically.
The location and behaviour of symptoms alongside examination of hip strength, movement and load tolerance can provide useful information.
Ultrasound or MRI can demonstrate changes affecting the gluteal tendons and surrounding structures.
However, imaging findings do not always correlate neatly with symptoms.
Structural tendon abnormalities can be present in people without significant pain.
Imaging may become more useful when the diagnosis is uncertain, symptoms have not responded as expected or there is concern about a more significant tendon injury.
For most straightforward presentations, scanning everybody at the outset is unlikely to improve management.
Does hip impingement show on a scan?
This requires some nuance.
Imaging can identify bony morphology associated with femoroacetabular impingement, including cam and pincer morphology.
But having that shape does not necessarily mean it is causing pain.
Cam morphology, for example, can be present in people who are physically active and completely asymptomatic.
A diagnosis of femoroacetabular impingement syndrome therefore requires more than an abnormal looking scan.
Symptoms, clinical signs and imaging findings need to make sense together.
This distinction matters because otherwise somebody can be shown an anatomical variation and understandably conclude that their hip is structurally abnormal and needs fixing.
The clinical relevance of the finding is what matters.
Does a labral tear on MRI explain hip pain?
Not necessarily.
Labral abnormalities can be found on MRI in people without hip pain.
This does not mean labral tears are irrelevant.
In the right clinical presentation, a labral problem may be highly relevant.
But the MRI result needs to correspond with the person's symptoms and examination.
This is a recurring principle across musculoskeletal imaging.
An MRI is very good at showing anatomy.
It is not always capable of telling us which anatomical finding is responsible for pain.
That requires clinical correlation.
What about hip flexor and adductor pain?
Pain involving the hip flexors, adductors and other muscles around the hip can often be assessed without imaging.
The mechanism, location of symptoms and response to loading can provide useful diagnostic information.
Rehabilitation can then be based around gradually restoring strength and tolerance to the activities that provoke symptoms.
Imaging becomes more relevant when the diagnosis is uncertain, a significant injury is suspected or progress is not following the expected pattern.
A scan should not automatically be required simply because symptoms have been given a muscular or tendon related diagnosis.
When should a stress fracture be considered?
This is one situation where the imaging decision can become considerably more important.
A femoral neck stress fracture or bone stress injury is relatively uncommon compared with many other causes of hip pain, but missing one can have significant consequences.
The clinical picture matters.
A recent substantial increase in running or weight bearing activity, progressively worsening groin pain, pain with weight bearing and relevant individual risk factors may increase suspicion.
Early X rays can sometimes appear normal despite the presence of a stress injury.
Where clinical suspicion remains significant, MRI can therefore be particularly valuable.
This is a good example of why there cannot be one imaging rule for everyone with hip pain.
For one presentation, an MRI would add very little.
For another, obtaining appropriate imaging promptly could be extremely important.
Could hip pain actually be coming from your back?
Yes.
Pain arising from the lumbar spine can be experienced around the buttock, lateral hip or thigh.
Sometimes the distinction is relatively straightforward.
Sometimes it is not.
Hip and spinal problems also become more common as people get older, so it is entirely possible for imaging to demonstrate abnormalities in both areas.
That can create another problem.
If somebody has osteoarthritis on a hip X ray and degenerative changes on a lumbar MRI, which finding actually explains the symptoms?
The answer comes back to the clinical assessment.
Where is the pain?
What provokes it?
How does the hip move?
What happens when the lumbar spine is examined?
Are there neurological findings?
Which diagnosis best explains the whole presentation?
Imaging can contribute to that reasoning.
It cannot replace it.
What if your hip scan shows something abnormal?
This is often where imaging creates as many questions as it answers.
Words such as:
Osteoarthritis
Labral tear
Cam morphology
Tendinopathy
Bursitis
can understandably sound concerning on a radiology report.
But an abnormal finding does not automatically require treatment.
The first question should be whether the finding actually corresponds with the symptoms.
The second is whether it changes management.
This is particularly important because structural changes become increasingly common as we get older and many imaging findings also exist in people without pain.
The purpose of imaging should therefore not simply be to find something abnormal.
It should be to provide clinically useful information.
What if your hip pain is not getting better?
Persistent hip pain deserves reassessment.
That does not automatically mean an MRI is the next step.
The diagnosis should first be reconsidered.
Does this genuinely appear to be hip osteoarthritis?
Could it be greater trochanteric pain syndrome?
Does the presentation fit femoroacetabular impingement syndrome?
Is a labral problem genuinely plausible?
Could the symptoms be coming from the lumbar spine?
Has a less common but important diagnosis been appropriately considered?
Has conservative management actually been optimised?
Would an X ray provide enough information?
Would an MRI change treatment?
Is there now a reason to consider an injection or orthopaedic opinion?
These are the decisions that matter.
This is also where the reasoning and balance involved in an Advanced Physiotherapy assessment can be particularly useful.
At Genuine Physio in Tadworth, near Kingswood, the aim is not simply to decide whether somebody needs a scan.
It is to establish the most likely diagnosis first and then determine whether imaging would add useful information.
Sometimes no imaging is required.
Sometimes an X ray is the most appropriate investigation.
Sometimes an MRI is important.
And sometimes the most useful next step is an injection or orthopaedic opinion.
The value is knowing which option fits the individual presentation.
Frequently Asked Questions
Do I need an MRI for hip pain?
Not necessarily. Many causes of hip pain can initially be assessed clinically. MRI becomes more useful when the diagnosis is uncertain, particular soft tissue or bone pathology is suspected, symptoms are not progressing as expected or the result would change management.
Is an X ray or MRI better for hip pain?
Neither is universally better. An X ray is often the most appropriate investigation when hip osteoarthritis is suspected. MRI provides considerably more information about soft tissues and bone marrow and is useful for particular clinical questions.
Does hip arthritis show on an X ray?
Yes. X rays can demonstrate structural changes associated with hip osteoarthritis and are generally the initial imaging investigation when osteoarthritis needs to be assessed.
Do you need an MRI for greater trochanteric pain syndrome?
Usually not initially. GTPS and gluteal tendinopathy can often be diagnosed clinically. Imaging may be useful where the diagnosis is uncertain or symptoms are not progressing as expected.
Does FAI always cause hip pain?
No. Cam and pincer morphology can exist without symptoms. A diagnosis of femoroacetabular impingement syndrome requires symptoms, appropriate clinical findings and relevant imaging rather than imaging morphology alone.
Does a labral tear always cause hip pain?
No. Labral abnormalities can occur in people without symptoms. A labral finding needs to be interpreted alongside the person's history and clinical examination.
Can hip pain come from your back?
Yes. The lumbar spine can refer pain around the buttock, hip and thigh. Clinical assessment can help establish whether symptoms are more likely to originate from the hip, spine or another structure.
Can a hip X ray be normal even if something is wrong?
Yes. X rays are particularly useful for assessing bone and joint structure but provide limited information about many soft tissues. Some conditions, including early bone stress injuries, may also not initially be apparent on X ray.
Should I get a scan if physiotherapy has not helped my hip pain?
Possibly, but lack of improvement should first prompt reassessment. The diagnosis and rehabilitation programme should be reviewed before deciding whether an X ray, MRI or another investigation would genuinely change management.
Unsure whether you need an X ray or MRI for hip pain?
If you have persistent hip pain and are unsure about the diagnosis or whether you need an X ray, MRI or another opinion, get in touch with Genuine Physio.
A detailed assessment can help establish the likely source of your symptoms, determine whether conservative management has been appropriately optimised and decide whether imaging would provide useful additional information.
If an injection or orthopaedic opinion is the more appropriate next step, that should be recognised too.
The goal is not simply to find something on a scan. It is to understand what is causing your hip pain and use imaging when it genuinely helps make a better decision.
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