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Radiographic; Hip Pain Diagnosis; X-rays; Magnetic Resonance Imaging; Ultrasound

Introduction

Hip pain can be a debilitating condition that significantly affects a person’s quality of life. Whether it stems from injury, degeneration, inflammation, or an underlying medical condition, accurate diagnosis is essential for effective treatment. In the quest to uncover the root causes of hip pain, medical professionals have developed a comprehensive toolbox of imaging techniques that range from traditional radiography to advanced cross-sectional modalities. This article explores the diverse array of tools available to diagnose hip pain and how they contribute to effective patient care [1].

The Traditional Approach: Radiography

X-rays: Radiography, commonly known as X-ray imaging, remains a fundamental tool for evaluating hip pain. X-rays provide a twodimensional view of the hip joint, allowing healthcare providers to assess bone structure, identify fractures, joint degeneration, and detect abnormalities like osteoarthritis [2].

Fluoroscopy: In some cases, fluoroscopy, a real-time X-ray imaging technique, may be employed to visualize joint movement and dynamic issues, such as impingement or instability.

Hip Pain Imaging: Need for Clinical Correlation

Imaging of the hip needs to be complementary to the clinical history and physical examination because it is well known that imaging findings do not always correlate with the presence of pain and vice versa.

Clinical tests are adapted to identify the source of pain as intraarticular or extra-articular. The flexion-abduction-external rotation (FABER) [3], internal range of motion with overpressure (IROP), and scour tests show sensitivity values in identifying individuals with intraarticular pathology ranging from 0.62 to 0.91.

In the next subheadings, we are going to describe the main indications and role of different imaging modalities (X-ray, magnetic resonance imaging (MRI), computed tomography (CT), ultrasound, and scintigraphy) in studying intra-articular causes of hip pain.

Advanced Imaging Modalities

Computed tomography (CT): CT scans offer a more detailed three-dimensional view of the hip joint, making them valuable for assessing complex fractures, tumors, and abnormalities that may not be apparent on X-rays [4].

Magnetic resonance imaging (MRI): MRI is a non-invasive technique that uses magnetic fields and radio waves to create highly detailed images of the hip joint, including the surrounding soft tissues, ligaments, and cartilage. It is especially useful for diagnosing conditions like labral tears, hip impingement, and inflammatory disorders.

Ultrasound: Ultrasonography can provide real-time images of the hip joint, making it a valuable tool for assessing soft tissue structures, such as tendons, ligaments, and muscles [5]. It is often used to diagnose conditions like bursitis and tendonitis.

Bone scintigraphy: This nuclear medicine technique involves injecting a small amount of radioactive material into the bloodstream, which accumulates in areas of increased bone activity [6]. It can help identify conditions like osteomyelitis or stress fractures.

Positron emission tomography (PET) scans: PET scans are used in conjunction with CT scans to detect areas of increased metabolic activity in the hip joint, which can be indicative of conditions like infections or certain types of tumors.

Magnetic resonance arthrography (MRA): MRA combines the benefits of MRI with the injection of a contrast agent into the hip joint to provide a more detailed assessment of structures like the labrum and articular cartilage [7].

Magnetic Resonance

Many pathological conditions of the hip are detected early by MRI due to its high soft tissue resolution and sensitivity. Its accuracy in studying acute hip pain in children has proved to be superior to ultrasound and plan film radiography. However, MRI accessibility and the need of sedation relegate its use to selected cases in which diagnosis is not clear with less demanding techniques. These include differentiating transient synovitis from a septic arthritis or osteomyelitis, diagnosis of inflammatory joint disease or bone tumors, and early detection and follow-up of Perthes disease [8].

MRI findings correlate with prognosis in LCPD. These include extent and distribution of epiphyseal necrosis, subchondral ossified nucleus fracture, involvement of the lateral pillar, and disturbance of physeal growth, including presence of transphyseal neovascularity or bridging.

Recent studies have been focused on the role of diffusion weighted MRI because it does not need contrast medium administration. ADC ratio of the femoral metaphysis was positively correlated with the Herring classification. ADC ratio superior to 1.63 indicates bad prognosis with 89% sensitivity and 58% specificity [9].

In adult patients, MRI is currently playing a definite role in the assessment of osteoarthritis. Although traditionally belonging to the arena of radiographs, the role of MRI has been stressed after the term femoral acetabular impingement was coined in 2003. Growing interest has been focused in accurate diagnosis of the acetabular and femoral morphological abnormalities that may lead to early osteoarthritis.

Tailoring the Diagnosis

The choice of imaging modality depends on the patient’s clinical presentation, the suspected underlying condition, and the physician’s judgment. Often, a combination of imaging techniques may be necessary to arrive at an accurate diagnosis [10]. For instance, a patient with chronic hip pain and suspected osteoarthritis may benefit from X-rays to assess joint space narrowing and bone spurs, followed by an MRI to evaluate soft tissue damage and cartilage integrity.

Conclusion

The diagnosis of hip pain has evolved significantly over the years, thanks to advancements in medical imaging technology. From traditional radiography to advanced cross-sectional modalities like MRI and CT scans, healthcare providers now have a diverse toolbox to investigate and understand the causes of hip pain comprehensively. The ability to visualize bone, soft tissues, and joints in intricate detail allows for more accurate diagnoses, leading to improved treatment outcomes and ultimately a better quality of life for those suffering from hip pain. The key to successful diagnosis lies in the judicious selection of the appropriate imaging modality, guided by the patient’s clinical presentation and symptoms.

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