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DOI: https://dx.doi.org/10.18535/jmscr/v5i3.126

MR Evaluation of Non-Traumatic Hip Pain

Authors
K Venkateshwar Reddy, Anu Kapoor
Department of Radiology Image Hospital, Hyderabad, Telangana-500083
Corresponding Author
Anu Kapoor
101, Lumbini Rockcastle, Road No 6, Banjara Hills, Hyderabad, Telangana-500034
Abstract
Background: Hip pain is a common yet non-specific symptom that may result from a number of articular as
well as extra articular conditions. Imaging plays an important role in evaluation of hip pain and MRI is often
most valuable imaging method in evaluating these cases.
Methods: This prospective observational study was carried out at Image Hospital, Hyderabad over a period
of one year. Patients with unilateral or bilateral non-traumatic hip pain were evaluated by plain radiographs
and MRI. Plain radiographs and MRI findings were reviewed and the final diagnosis was suggested based on
clinical, laboratory and imaging findings. Equivocal or nonspecific imaging findings were further confirmed
by cytology /histopathology wherever indicated.
Results: A total of 85 cases of non-traumatic hip pain were evaluated. A wide spectrum of conditions
including degenerative, ischemic, inflammatory/infective and neoplastic lesions were discovered as the cause
of hip pain.
Conclusion: Hip pain can arise from a wide variety of conditions and MRI is a very useful modality in
evaluation of these conditions.
Keywords: Hip, Pain, Imaging, Mri, Avascular Necrosis.

INTRODUCTION Imaging plays a pivotal role in evaluation of hip

Hip pain is a common clinical problem with a pain. Plain radiographs of the hip joint and pelvis
long list of possible etiologies. Symptoms are the first line of imaging but have limitation in
apparently originating from the hip may actually assessment of soft tissues and intra articular
arise from the periarticular structures, pelvis, structures. Ultrasound is a useful tool in
sacroiliac joint, lumbar spine or from distant sites differentiating intra articular from extra articular
like abdominal wall, retroperitoneum and pathology and helps in guiding diagnostic and
genitourinary tract. To determine the exact origin therapeutic interventional procedures. CT is useful
of hip pain can be quite challenging. Non- in evaluation of bone lesions but suffers from lack
traumatic hip pain may be unilateral or bilateral of soft tissue contrast.
and may further be categorizes as either anterior As of today, MRI is the modality of choice for
(groin) pain, lateral (trochanteric) or posterior evaluation of hip pain. It provides excellent soft
(gluteal) pain based on its location [1]. tissue resolution, multiplanar imaging and is

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without the risk of ionizing radiation. MRI is the (Siemens, Germany). A few cases referred from
modality of choice for imaging a vascular other hospitals with MRI performed on 1.5T
necrosis, radiographically occult fractures, scanner elsewhere were also included in the study.
marrow replacement disorders, musculoskeletal Bilateral hip protocol using Pelvic/body coil was
neoplasms, and various arthritides involving the employed in all cases with T1 weighted, T2
hip joint[2]. weighted and STIR images obtained in axial,
This study evaluated patients with non-traumatic coronal and sagittal planes. Intravenous contrast
hip pain using plain radiographs and MRI and (Gadolinium @ 0.1mmol/kg) was administered
assesses the role of MRI as an imaging tool in when thought necessary based on the MRI
these patients. findings.
Two radiologists evaluated all plain radiographs
MATERIAL AND METHODS and MRI studies independently. Final diagnosis
Patients referred to the orthopedic department of was based on clinical, laboratory and imaging
our hospital with non-traumatic hip pain were findings and further confirmed by cyto/
studied over a period of one year. histopathology where indicated.
Inclusion Criteria
 Patients presenting with unilateral or OBSERVATIONS & RESULTS
bilateral hip pain This prospective study included a total of 85
 Patients of all age groups and both sexes patients presenting with hip pain, out of which 64
Exclusion Criteria (75%) were males and 21(25%) females with their
 Patients with significant trauma. ages ranging between 12 to 75 years (mean-44
 Patients with previous history of hip years).
surgery. Of the 85 patients, 49 presented with unilateral hip
 Patients with cardiac pacemakers, pain and 36 with bilateral hip pain.Out of 85
ferromagnetic aneurysm clips, cochlear patients, 58 presented with anterior or groin pain,
implants and other ferromagnetic implants. 18 with posterior or gluteal pain and 9 with lateral
 Patients with claustrophobia. or trochanteric pain.
Plain radiographs of the pelvis and hip joints were A definite diagnosis could be made in 76 out of
obtained for all patients followed by MRI study the 85 cases with the following conditions as the
preformed on Magnetom Concerto 0.2 T scanner cause of hip pain.

Table – 1 Conditions Causing Hip Pain

Etiology No. Of Patients(N= 85) Percentage (%)
Avascular Necrosis 26 30
Infective Tubercular Arthritis 8 9.5
Osteomyelitis 3 3.5
Osteomyelitis With Septic Arthritis 2 2.3
Pyomyositis/Cellulitis 2 2.3
Osteoarthritis 9 11
Sacroiliitis 8 9.5
Neoplasia Primary 4 5
Metastasis 2 2.3
Malignant Fibrous Histiocytoma 1 1.2
Degenerative Disc Disease 6 7
Stress Fractures 3 3.5
Perthes Disease 2 2.3
Transient Osteoporosis Of Hip 1 1.2

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AGE DISTRIBUTION OF PATHOLOGICAL of the femoral head. Between 31-50 years the
CONDITIONS commonest cause of hip pain was avascular
Different age groups presented with different necrosis of femoral head and above 50 years
spectrum of disease. The most common cause of osteoarthritis was the commonest condition
hip pain in the age group of 10 to 30 years was causing hip pain.
infection followed closely by avascular necrosis

Table- 2 Age Distribution of Pathological Conditions

Age Group (Years) Etiology
10- 30 Infective, Avascular Necrosis.
31-50 Avascular Necrosis
51-70 Osteoarthritis
A total of 49 patients presented with unilateral hip unilateral pain were infection and avascular
pain. The common conditions presenting as necrosis.

Table- 3: Causes of Unilateral Hip Pain

Etiology No. Of Patients(N= 49) Percentage (%)
Avascular Necrosis 10 20
Infective Tubercular Arthritis 8 16
Osteomyelitis 3 6
Osteomyelitis With Septic Arthritis 2 4
Soft Tissue Infection 2 4
Osteoarthritis 2 14
Sacroilitis 5 10
Neoplasia Primary 4 8
Metastasis 2 4
Soft Tissue Tumour 1 2
Degenerative Disc Disease 2 4
Stress Fractures 1 2
Perthes Disease 2 4
Transient Osteoporosis Of Hip 1 2
Unknownetiology 5 10

A total of 36 patients presented with bilateral hip followed by osteoarthritis, sacroilitis and
pain. The common conditions presenting as degenerative lumbar disc disease.
bilateral hip pain were a vascular necrosis

Table- 4: Causes of Bilateral Hip Pain

Etiology No. Of Patients(N= 36) Percentage (%)
Avascular Necrosis 16 44
Osteoarthritis 6 17
Sacroilitis 3 08
Degenerative Disc Disease 5 14
Occult Fracture 2 05
Unknown Etiology 4 11

EVALUATION BY PLAIN RADIOGRAPHS Out of a total of 85 cases, Plain radiographs were

Plain Radiographs of the pelvis including both hip abnormal in 37 patients. A Radiological diagnosis
joints were obtained in all 85 patients prior to the could be suggested in 34 patients and non-specific
MRI evaluation. findings were present in 3 cases.

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Table-5: Diagnosis on Plain Radiographs
Diagnosis No. Of Patients(N=85)
Avascular Necrosis 10
Sacroilitis 03
Osteoarthritis 05
Degenerative Disc Disease 03
Tuberculous Arthritis 03
Primary Neoplasms 03
Metastasis 02
Perthes Disease 02
Osteomyelitis 02
Non Specific Changes 03
Normal 48

EVALUATION BY MRI
Out of a total of 85 cases evaluated by MRI a
definite diagnosis could be suggested in 76 cases.
MRI study was normal in 9 cases.

Table-6: Diagnosis on MRI

Etiology No. Of Patients Percentage
(N=85) (%)
Avascular Necrosis 26 30
Infective Tubercular Arthritis 8 9.5
Osteomyelitis 3 3.5
Osteomyelitis With Septic Arthritis 2 2.3
Soft Tissue Infection 2 2.3
Osteoarthritis 9 11
Sacroilitis 8 9.5
Neoplasia Primary 4 5
Metastasis 2 2.3
Soft Tissue Tumour 1 1.2
Degenerative Disc Disease 6 7
Stress Fractures 3 3.5
Perthes Disease 2 2.3
Transient Osteoporosis Of Hip 1 1.2
Unknown Etiology 9 11

CORRELATION OF PLAIN RADIOGRA- in 37 patients. All the 37 patients with abnormal

PHS WITH MRI plain radiographs had an abnormal MRI study.
Of the total 85 cases, MR showed abnormality in Only 9 out of 48 patients with normal plain
76 cases where as plain radiograph was abnormal radiograph had a normal MR.

TABLE –7: Correlation of Plain Radiographs With MRI.

Normal Mri Study Abnormal Mri Study
Normal Radiographs 9 39
Abnormal Radiographs 0 37

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Case 1. Adult Male with Bilateral Hip Pain Case 3- A 29 Yr Old Male with Low Grade Fever
and Left Gluteal Pain For 3 Months

Fig 1 (A) - Plain Radiograph Of Pelvis Shows

Patchy Sclerosis Of Bilateral Femoral Heads.
Fig 3 (A,B)Coronal And (C) Sagittalmri Images
(B-D) - Coronal Mri Images Show Altered Signal
Show Altered Marrow Signal Around The Left
Intensity Of Both Femoral Heads With
Sacroiliac Joint With Irregularity Of Articular
Subchondral T1 Hypointensity(Geographic
Margins And Adjacent Soft Tissue
Pattern) With Marrow Edema(Right>Left) And
Hyperintensity. Final Diagnosis- Tubercular
Mild Joint Effusion On The Right.Final
Sacroilitis
Diagnosis- Avascular Necrosis Of Bilateral
Femoral Heads.
Case 4- A 12 Yr Old Boy with High Grade Fever,
Left Hip Pain and Limp for 20 Days. Theplain
Case 2 – A 33year Old Male with Left Hip Pain
Radiographs Were Unremarkable.
and Low Grade Fever for 8 Months

Fig 2 (A,B) Axial And (C,D) Coronal Mri Images

Show Altered Signal Intensity In The Head Of Fig 4 (A, B) Coronal And (C) Sagittal And (D)
Left Femur & Acetabulum With A Large Axial Mri Images Show Altered Marrow Signal
Collections In Anterior And Lateral Group Of Of Left Femoral Neck And Trochanteric Region
Muscles Of The Left Thigh. Final Diagnosis- Suggestive Of Bone Marrow Edema With
Tubercular Arthritis Of Left Hip Joint. Surrounding Soft Tissue Hyperintensity. Final
Diagnosis -Osteomyelitis Of Left Femur

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Case 5- A 58 Yr Old Male with Left Hip Pain for Case 7- A 48 Yr Old Female with Low Back
8 Months Ache and Bilateral Hip Pain For 2 Months. Plain
Radiographs Were Unremarkable.

Fig 5 (A,B,D) Coronal And (C ) Axial Mri Images

Show A Large Heterogenous Signal Intensity
Mass Lesion Involving The Left Iliac Bone And
Acetabulum With Extension To Periarticular Soft Fig 7 (A,B) Coronal And (C) Axial Mri Images
Tissues. Final Diagnosis- Chondrosarcoma Of Show Multiple T1 Hypointense, Stir Hyperintense
Left Iliac Bone Focal Lesions Involving The Pelvic Bones And
Sacrum. Final Diagnosis-Metastasis From
Case 6- A 54 Yr Old Male With Bilateral Hip Carcinoma Breast.
Pain For 10 Months. No History Of Trauma.
Case 8- A 54 Yr Old Female With Right Hip Pain
For One Month.

Fig 6 (A)-Plain Radiograph Shows Mild

Osteoarthritic Changes In Both Hip Joints.(B-D) Fig 8 (A,B) Coronal And (C,D) Axialmri Images
Coronal Mri Images Show Linear Hypointensity Show T1 Hypointense,Stir Hyperintense Expa-
(On All Sequences) Along Bilateral Femoral nsile Lesion Involving The Right Acetabulum.
Necks With Surrounding Marrow Edema. Final Final Diagnosis-Metastasis From Renal Cell
Diagnosis- Stress Fractures Of Both Femoral Carcinoma.
Necks.

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Case 9- A 12 Yrs Old Boy with Left Hip Pain and Case 11 – A 46 Yr Old Female With Right Hip
Limp For 8 Months. Pain For 1 Month.

Fig 11 (A) Mri Of Hip Joints Appears Normal.

(B,C) Sagittal Mri Images Of Lumbosacral Spine
Fig 9 (A)- Plain Radiograph Shows Smaller Left
Revealed Sacralised L5 Vertebra With Grade I
Femoral Capital Epiphysis With Irregularity Of
Spondylolisthesis Of L4 Over L5 And
Outline.(B,C) Coronal Mri Images Shows Altered
Degenerative Disc Protrusion At This Level
Marrow Signal Of Left Femoral Capital Epiphysis
Causing Neural Compression On The Right Side –
And Neck With Joint Effusion. Final Diagnosis-
The Likely Cause Of Hip Pain.
Legg Calve Perthes Disease
Case 12- A 64 Yr Old Male with Right Hip Pain
Case 10- A 31-Year-Old Male with Left Hip Pain
And Mild Swelling Of The Proximal Thigh
For 3 Months.

Fig 12 (A,B) Coronal And (C,D) Axial Mri

Fig 10 (A) -Plain Radiograph of Pelvis Is Images Show A T1 Hypointense, T2 , Stir
Unremarkable. Hyperintense Lesion In The Soft Tissues Of The
(B,C) Coronal Mri Images Show Extensive Right Anterior Thigh. Final Diagnosis- Malignant
Marrow Edema In Left Femoral Head And Neck Fibrous Histiocytoma Of The Thigh
With Mild Joint Effusion.
(D-F) Follow Up Mri Images After 3 Months Of DISCUSSION
Symptomatic Treatment Appear Normal. Final This prospective study was undertaken to evaluate
Diagnosis- Transient Osteoporosis Of Left Hip patients presenting with non-traumatic hip pain
using plain radiography and MRI. Our study
included 85 patients with hip pain, out of which
64(75%) were males and 21(25%) were females.

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The patients ranged from 12 to 75 years of age of Perthes disease and one case with transient
(mean-44 years). The mean duration of hip pain in osteoporosis of the hipwere also observed in our
our study group was four and half months. study. A few cases with neoplastic lesions like
Out of 85 cases, 36(42%) patients presented with chondrosarcoma of the iliac bone, malignant
bilateral hip pain and 49(58%) patients with fibrous histiocytoma of thigh and metastatic
unilateral pain. Hip pain was also categorized lesions from carcinoma breast and renal cell
clinically as anterior or groin pain in 58(68%) carcinoma were also diagnosed.
patients, posterior or gluteal in 18(21%) and Common causes of bilateral hip pain included a
lateral or trochanteric in 9(11%) patients. vascularnecrosis followed by osteoarthritis,
After clinical assessment of possible disease plain sacroilitis and degenerative lumbar disc disease.
radiographs of the pelvis were obtained in all Etiologies presenting with unilateral hip pain
cases. Out of 85 cases, 37(44%) cases showed included inflammatory/infective and neoplastic
abnormalities on plain radiographs and the lesions. The most common cause of anterior hip
remaining were normal. Subsequently MRI was pain was avascular necrosis and infective arthritis.
performed for evaluation of both hip joints using Posterior hip pain was noted commonly in the
the hip protocol and two radiologists non-hip causes like sacroilitis and degenerative
independently reviewed the images. On MRI lumbar disc disease. Ragab Y et al[5] studied 34
76(89%) out of 85 cases showed abnormal patients with hip pain using MRI and found
findings, and the remaining 9(11%) cases were similar spectrum of disease conditions prevalent
normal. in the population.
The imaging protocol used in our study was In our study we observed that osteoarthritis of Hip
selected to combine the speed of examination with was the commonest cause of hip pain in the
imaging sequences (T1, T2 and STIR) and elderly population (5th to 7th decade) and avascular
imaging planes (Coronal, axial and sagittal). It necrosis was the commonest cause of hip pain in
was found that STIR coronal images were the 3rd and 4th decades. Inflammatory /infective
most sensitive and informative in screening out etiologies were observed in all age groups. A
normal from abnormal cases. Similar observation similar observation wasmade by Fang C and Teh
has been made by Khoury NJ et al[3] and Khurana J[6] in their study.
B et al[4] in their studies suggesting the use of The most common cause of hip pain in our study
limited MR protocol in the evaluation of limited was avascular necrosis or osteonecrosis of the
MR Hip protocol. femoral heads. Out of 85 cases with hip pain 26
Intravenous contrast administration was required patients were diagnosed as having AVN by
only in 3 of our cases with suspected infective imaging. The total number of patients with
conditions namely tubercular and septic arthritis bilateral AVN was 16 and unilateral 10 involving
and pyomyositis. a total of 42 hip joints. The most common age at
In the present study we encountered a wide presentation was 25 to 55 yrs. Out of the 26
spectrum of lesions presenting with hip pain. The patients with AVN,17 were males and 9 were
common pathologies noted were a vascular females.
necrosis of the femoral heads (26 cases), Plain radiographs were abnormal in only 10(38%)
osteoarthritis (9 cases), sacroilitis (8 cases), patients. The findings on plain radiographs
degenerative lumbar disc disease(6 cases) and a included sclerosis, flattening, subchondral
number of infective conditions like tubercular fragmentation/collapse of femoral heads in
arthritis(8 cases), septic arthritis(2 cases), oste- different stages of the disease. Secondary
omyelitis (3 cases), pyomyositis(1 case). Three osteoarthritic changes with joint space reduction
cases of occult femoral neck fractures, two cases were noted in a few patients with chronic AVN.

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MRI detected all cases with suspected AVN in intraosseous as well as soft tissue abscess
different stages of the disease. The spectrum of suggesting tubercular etiology.
MR findings included marrow edema, crescent A Total of 5 cases with pyogenic osteomyelitis/
sign, sclerosis, articular surface irregularity, joint septic arthritis were also diagnosed in our study
space reduction and effusion.MR was found to be group. Three out of five cases in this group of
highly sensitive and specific in evaluation of AVN patients had negative plain radiographs. However,
and scores over plain radiographs, which fail to MR showed features of marrow edema,
pick up early disease. subchondral bone involvement and joint effusion
Glickestein et al [7] and Huang et al[[8] in different and together with clinical and lab investigations a
studies have described the role of MR in definite diagnosis could be reached.
evaluation of avascular necrosis and compared it Jung AH et al[10] and Sung Hwan Hong et al[11] in
with plain radiography with similar results. their studies on MR imaging features of
The next common etiological group in our study inflammatory and infective conditions of the hip
included infective pathologies in 14 patients. joint have described similar features that
These included patients of different age groups differentiate tubercular from pyogenic and
most commonly affecting the extremes of ages rheumatoid arthritis.Midiri M et al[12] in their
i.e., children and elderly patients. This age study of patients with infective conditions found
distribution is similar to that noted by Fang C and that MR findings in this group are usually non
Teh J[6]. specific but when put together with clinical and
Of these 14 cases, 8 were diagnosed as tubercular laboratory findings allows early and specific
arthritis and 5 cases had pyogenic osteomyelitis diagnosis, an observation similar to our study.
with septic arthritis in 2. Pyomyositis involving The next common etiology of hip pain in our
muscles of proximal thigh with abscess formation study was osteoarthritis (9 cases). The most
was noted in one case. common age group affected was 50 to 70 yrs.
Infective etiology was a common cause of hip Bilateral hip joint involvement was seen in 7
pain in our study where as Chevrot A et al[9] patients and unilateral hip involvement was seen
studied the causes of hip pain in adults and found in 2 patients of younger age group, both of these
that infective pathologies of hip were relatively had history of childhood trauma. Plain
rare. radiographic findings in osteoarthritis included
Plain radiographs were diagnostic for infective superior joint space loss, osteophyte formation,
arthritis only in 3 patients and osteomyelitis in 2 subchondral sclerosis and cyst formation. These
patients. Non-specific findings like osteopenia/ findings were frequently bilateral.
erosions were noted in 2 patients and no MRI in patients with osteoarthritis included
abnormality was noted in remaining seven cases features like focal loss of articular cartilage,
there by suggesting poor sensitivity and osteophytes, paralabral cysts, joint effusion and
specificity of plain radiographs in evaluation of joint space reduction. It was observed that
this subset of patients. presence of marrow edema and joint effusion
MR features were diagnostic of infective correlated well with the site and severity of
pathology in all 14 cases. The imaging features symptoms. King C Li et al [13], Horii M et al [14]
suggestive of tubercular arthritis seen in 8 patients have studied spectrum of findings in osteoarthritis
included synovial thickening, sub articular in different grades of severity of disease. The
marrow edema, bone erosions, joint effusion and findings of osteoarthritis in our study are similar
soft tissue involvement in the form of large to findings given by various authors.
abscesses. Intravenous contrast was used in one Three patients with hip pain and normal plain
patient, which showed rim enhancement of the radiographs were diagnosed as having occult

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fractures of femoral necks on MRI. Fractures were correlate to TOH. Similar observation was made
bilateral in 2 cases and unilateral in one. Two of in our study.
these patients were young athletes. Seven out of 85 cases with hip pain were
The diagnostic findings for stress fractures for diagnosed as having neoplastic lesions including
MRI included linear hypointensity in femoral benign and malignant tumors of the bones/ soft
neck (on all sequences) with surrounding marrow tissues. These included chondrosarcoma of the
edema. The present study correlated with iliac bone, malignant fibrous histiocytoma of the
observations made by Sankey RA et al [15], thigh. MRI detected two cases with metastatic
Mengiardi et al [16],Fang C and Teh J [6]in their bone lesions involving the iliac bone and
studies. Newberg AH and Newman JS [17] in their acetabulum. MR features of these benign and
study advocate MR as initial imaging modality malignant bone and soft tissue lesions were
after initial radiography for detecting occult suggestive but non-specific and the final diagnosis
fractures. was established by cytology/histopathology.
Perthes disease was diagnosed in 2 cases. Both Sacroilitis was diagnosed in 8 patients out of
were young patients presenting with unilateral hip whom 5 were bilateral. All 5 cases with bilateral
pain. Plain radiographs were abnormal in both sacroilitis were diagnosed to have seronegative
cases and showed asymmetry in size of femoral spondyloarthropathy. The three cases with
epiphysis, articular surface irregularity and unilateral sacroilitis were diagnosed as tubercular
widening of medial joint space.MR findings in in etiology based on imaging, lab findings and
Perthes disease included presence of T1 response to treatment.
hypointensity, T2, STIR hyperintensity suggestive Degenerative lumbar disc disease was diagnosed
of marrow edema in the femoral epiphysis with as the cause of hip pain in 6 patients. All six
irregularity of outline, widening of the medial patients were above 40 years of age. Four of these
joint space. The contralateral epiphysis was presented with bilateral hip pain whereas two of
normal on MRI. them presented with unilateral hip pain. Hip joint
Bos CF et al[18]studied 16 hips with Perthes was normal on MRI in all 6 patients. Degenerative
disease over a mean period of two years. The disc disease was identified on sagittal MR images
imaging findings in their study correlated with our and the study was extended to include the lumbar
present study, spine.
Transient osteoporosis of hip was diagnosed in Mengiardi B et al[16] in their study described
one of our cases, a 31-year-old male with various conditions causing hip arising from the
unilateral hip pain of three months duration. His hip and from surrounding structures. According to
plain radiographs were normal with no clinical/ the author hip pain may arise from the pelvis,
lab abnormality. MRI images revealed diffuse sacroiliac joint, lumbar spine and periarticular
marrow edema in the femoral head and neck with structures. Our study similarly showed sacroilitis,
sparing of the subchondral bone. The patient was degenerative disc disease and periarticular
managed conservatively with symptomatic infective and neoplastic conditions as a cause of
treatment. A follow-up MRI after 3 months was hip pain.
normal thereby confirming the diagnosis. Thus the imaging spectrum of a number of
Grimm J et al[19] in their study on TOH described conditions resulting hip pain were evaluated by
typical stages of TOH with normalization of MR plain radiography and MR and we found that
findings within 6 to 10 months. Malizos KN et combined with clinical diagnosis and lab tests
al[20] described that absence of subchondral imaging can provide specific diagnosis in a large
lesions and sparing of subchondral zone from number of conditions. MR is particularly useful in
marrow edema were MR findings that highly early detection of avascular necrosis, stress

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