Chronic Hip Pain

Variant: 1 Chronic hip pain. Initial Imaging.

Procedure	Appropriateness Category	Relative Radiation Level
Radiography pelvis	Usually Appropriate	☢☢
Radiography hip	Usually Appropriate	☢☢☢
US hip	Usually Not Appropriate	O
Image-guided anesthetic +/- corticosteroid injection hip joint or surrounding structures	Usually Not Appropriate	Varies
MR arthrography hip	Usually Not Appropriate	O
MRI hip without and with IV contrast	Usually Not Appropriate	O
MRI hip without IV contrast	Usually Not Appropriate	O
Bone scan hip	Usually Not Appropriate	☢☢☢
CT arthrography hip	Usually Not Appropriate	☢☢☢
CT hip with IV contrast	Usually Not Appropriate	☢☢☢
CT hip without and with IV contrast	Usually Not Appropriate	☢☢☢
CT hip without IV contrast	Usually Not Appropriate	☢☢☢
Fluoride PET/CT skull base to mid-thigh	Usually Not Appropriate	☢☢☢☢

Variant: 2 Chronic hip pain. Suspect noninfectious extra-articular abnormality, such as tendonitis or bursitis. Radiographs negative or nondiagnostic. Next imaging study.

Procedure	Appropriateness Category	Relative Radiation Level
US hip	Usually Appropriate	O
MRI hip without IV contrast	Usually Appropriate	O
Image-guided anesthetic +/- corticosteroid injection hip joint or surrounding structures	May Be Appropriate	Varies
MR arthrography hip	Usually Not Appropriate	O
MRI hip without and with IV contrast	Usually Not Appropriate	O
Bone scan hip	Usually Not Appropriate	☢☢☢
CT arthrography hip	Usually Not Appropriate	☢☢☢
CT hip with IV contrast	Usually Not Appropriate	☢☢☢
CT hip without and with IV contrast	Usually Not Appropriate	☢☢☢
CT hip without IV contrast	Usually Not Appropriate	☢☢☢
Fluoride PET/CT skull base to mid-thigh	Usually Not Appropriate	☢☢☢☢

Variant: 3 Chronic hip pain. Suspect impingement or dysplasia. Radiographs negative or nondiagnostic. Next imaging study.

Procedure	Appropriateness Category	Relative Radiation Level
MR arthrography hip	Usually Appropriate	O
MRI hip without IV contrast	Usually Appropriate	O
Radiography hip additional views	May Be Appropriate	☢☢
Image-guided anesthetic +/- corticosteroid injection hip joint or surrounding structures	May Be Appropriate	Varies
CT arthrography hip	May Be Appropriate	☢☢☢
CT hip without IV contrast	May Be Appropriate	☢☢☢
US hip	Usually Not Appropriate	O
MRI hip without and with IV contrast	Usually Not Appropriate	O
Bone scan hip	Usually Not Appropriate	☢☢☢
CT hip with IV contrast	Usually Not Appropriate	☢☢☢
CT hip without and with IV contrast	Usually Not Appropriate	☢☢☢
Fluoride PET/CT skull base to mid-thigh	Usually Not Appropriate	☢☢☢☢

Variant: 4 Chronic hip pain. Suspect labral tear. Radiographs negative or nondiagnostic. Next imaging study.

Procedure	Appropriateness Category	Relative Radiation Level
MR arthrography hip	Usually Appropriate	O
MRI hip without IV contrast	Usually Appropriate	O
Image-guided anesthetic +/- corticosteroid injection hip joint or surrounding structures	May Be Appropriate	Varies
CT arthrography hip	May Be Appropriate	☢☢☢
US hip	Usually Not Appropriate	O
MRI hip without and with IV contrast	Usually Not Appropriate	O
Bone scan hip	Usually Not Appropriate	☢☢☢
CT hip with IV contrast	Usually Not Appropriate	☢☢☢
CT hip without and with IV contrast	Usually Not Appropriate	☢☢☢
CT hip without IV contrast	Usually Not Appropriate	☢☢☢
Fluoride PET/CT skull base to mid-thigh	Usually Not Appropriate	☢☢☢☢

Variant: 5 Chronic hip pain. Radiographs equivocal or positive for mild osteoarthritis. Evaluate articular cartilage integrity. Next imaging study.

Procedure	Appropriateness Category	Relative Radiation Level
MR arthrography hip	Usually Appropriate	O
MRI hip without IV contrast	Usually Appropriate	O
CT arthrography hip	May Be Appropriate	☢☢☢
US hip	Usually Not Appropriate	O
Image-guided anesthetic +/- corticosteroid injection hip joint or surrounding structures	Usually Not Appropriate	Varies
MRI hip without and with IV contrast	Usually Not Appropriate	O
Bone scan hip	Usually Not Appropriate	☢☢☢
CT hip with IV contrast	Usually Not Appropriate	☢☢☢
CT hip without and with IV contrast	Usually Not Appropriate	☢☢☢
CT hip without IV contrast	Usually Not Appropriate	☢☢☢
Fluoride PET/CT skull base to mid-thigh	Usually Not Appropriate	☢☢☢☢

Variant: 6 Chronic hip pain. Radiographs suspicious for intra-articular synovial hyperplasia or neoplasia, including nodular synovitis, diffuse tenosynovial giant cell tumor, osteochondromatosis, other synovial neoplasm. Next imaging study.

Procedure	Appropriateness Category	Relative Radiation Level
MRI hip without and with IV contrast	Usually Appropriate	O
MRI hip without IV contrast	Usually Appropriate	O
CT arthrography hip	May Be Appropriate	☢☢☢
US hip	Usually Not Appropriate	O
Image-guided anesthetic +/- corticosteroid injection hip joint or surrounding structures	Usually Not Appropriate	Varies
Image-guided aspiration hip	Usually Not Appropriate	Varies
MR arthrography hip	Usually Not Appropriate	O
Bone scan hip	Usually Not Appropriate	☢☢☢
CT hip with IV contrast	Usually Not Appropriate	☢☢☢
CT hip without and with IV contrast	Usually Not Appropriate	☢☢☢
CT hip without IV contrast	Usually Not Appropriate	☢☢☢
Fluoride PET/CT skull base to mid-thigh	Usually Not Appropriate	☢☢☢☢

Variant: 7 Chronic hip pain with low back or knee pathology or pain. Radiographs demonstrate hip osteoarthritis. Want to quantify amount of pain related to the hip. Next imaging study.

Procedure	Appropriateness Category	Relative Radiation Level
Image-guided anesthetic +/- corticosteroid injection hip joint or surrounding structures	Usually Appropriate	Varies
US hip	Usually Not Appropriate	O
MR arthrography hip	Usually Not Appropriate	O
MRI hip without and with IV contrast	Usually Not Appropriate	O
MRI hip without IV contrast	Usually Not Appropriate	O
Bone scan hip	Usually Not Appropriate	☢☢☢
CT arthrography hip	Usually Not Appropriate	☢☢☢
CT hip with IV contrast	Usually Not Appropriate	☢☢☢
CT hip without and with IV contrast	Usually Not Appropriate	☢☢☢
CT hip without IV contrast	Usually Not Appropriate	☢☢☢
Fluoride PET/CT skull base to mid-thigh	Usually Not Appropriate	☢☢☢☢

Panel Members

Shari T. Jawetz, MD^a; Michael G. Fox, MD, MBA^b; Donna G. Blankenbaker, MD^c; Jamie T. Caracciolo, MD^d; Matthew A. Frick, MD^e; Nicholas C. Nacey, MD^f; Nicholas Said, MD, MBA^g; Akash Sharma, MD, MBA^h; Susanna Spence, MDⁱ; J. Derek Stensby, MD^j; Naveen Subhas, MD, MPH^k; Creighton C. Tubb, MD^l; Eric A. Walker, MD, MHA^m; Florence Yu, MD, MPHⁿ; Francesca D. Beaman, MD^o.

Summary of Literature Review

Introduction/Background

Initial Imaging Definition

Discussion of Procedures by Variant

Variant 1: Chronic hip pain. Initial Imaging.

Variant 1: Chronic hip pain. Initial Imaging.
A. Bone scan hip

Variant 1: Chronic hip pain. Initial Imaging.
B. CT arthrography hip

Variant 1: Chronic hip pain. Initial Imaging.
C. CT hip with IV contrast

Variant 1: Chronic hip pain. Initial Imaging.
D. CT hip without and with IV contrast

Variant 1: Chronic hip pain. Initial Imaging.
E. CT hip without IV contrast

Variant 1: Chronic hip pain. Initial Imaging.
F. Fluoride PET/CT skull base to mid-thigh

Variant 1: Chronic hip pain. Initial Imaging.
G. Image-guided anesthetic +/- corticosteroid injection hip joint or surrounding structures

Variant 1: Chronic hip pain. Initial Imaging.
H. MR arthrography hip

Variant 1: Chronic hip pain. Initial Imaging.
I. MRI hip without and with IV contrast

Variant 1: Chronic hip pain. Initial Imaging.
J. MRI hip without IV contrast

Variant 1: Chronic hip pain. Initial Imaging.
K. Radiography hip

Variant 1: Chronic hip pain. Initial Imaging.
L. Radiography pelvis

Variant 1: Chronic hip pain. Initial Imaging.
M. US hip

Variant 2: Chronic hip pain. Suspect noninfectious extra-articular abnormality, such as tendonitis or bursitis. Radiographs negative or nondiagnostic. Next imaging study.

Variant 2: Chronic hip pain. Suspect noninfectious extra-articular abnormality, such as tendonitis or bursitis. Radiographs negative or nondiagnostic. Next imaging study.
A. Bone scan hip

Variant 2: Chronic hip pain. Suspect noninfectious extra-articular abnormality, such as tendonitis or bursitis. Radiographs negative or nondiagnostic. Next imaging study.
B. CT arthrography hip

Variant 2: Chronic hip pain. Suspect noninfectious extra-articular abnormality, such as tendonitis or bursitis. Radiographs negative or nondiagnostic. Next imaging study.
K. US hip

Variant 3: Chronic hip pain. Suspect impingement or dysplasia. Radiographs negative or nondiagnostic. Next imaging study.

Variant 3: Chronic hip pain. Suspect impingement or dysplasia. Radiographs negative or nondiagnostic. Next imaging study.
A. Bone scan hip

Variant 3: Chronic hip pain. Suspect impingement or dysplasia. Radiographs negative or nondiagnostic. Next imaging study.
B. CT arthrography hip

Variant 3: Chronic hip pain. Suspect impingement or dysplasia. Radiographs negative or nondiagnostic. Next imaging study.
C. CT hip with IV contrast

Variant 3: Chronic hip pain. Suspect impingement or dysplasia. Radiographs negative or nondiagnostic. Next imaging study.
D. CT hip without and with IV contrast

Variant 3: Chronic hip pain. Suspect impingement or dysplasia. Radiographs negative or nondiagnostic. Next imaging study.
E. CT hip without IV contrast

Variant 3: Chronic hip pain. Suspect impingement or dysplasia. Radiographs negative or nondiagnostic. Next imaging study.
F. Fluoride PET/CT skull base to mid-thigh

Variant 3: Chronic hip pain. Suspect impingement or dysplasia. Radiographs negative or nondiagnostic. Next imaging study.
G. Image-guided anesthetic +/- corticosteroid injection hip joint or surrounding structures

Variant 3: Chronic hip pain. Suspect impingement or dysplasia. Radiographs negative or nondiagnostic. Next imaging study.
H. MR arthrography hip

Variant 3: Chronic hip pain. Suspect impingement or dysplasia. Radiographs negative or nondiagnostic. Next imaging study.
I. MRI hip without and with IV contrast

Variant 3: Chronic hip pain. Suspect impingement or dysplasia. Radiographs negative or nondiagnostic. Next imaging study.
J. MRI hip without IV contrast

Variant 3: Chronic hip pain. Suspect impingement or dysplasia. Radiographs negative or nondiagnostic. Next imaging study.
K. Radiography hip additional views

Variant 3: Chronic hip pain. Suspect impingement or dysplasia. Radiographs negative or nondiagnostic. Next imaging study.
L. US hip

Variant 4: Chronic hip pain. Suspect labral tear. Radiographs negative or nondiagnostic. Next imaging study.

Variant 4: Chronic hip pain. Suspect labral tear. Radiographs negative or nondiagnostic. Next imaging study.
A. Bone scan hip

Variant 4: Chronic hip pain. Suspect labral tear. Radiographs negative or nondiagnostic. Next imaging study.
B. CT arthrography hip

Variant 4: Chronic hip pain. Suspect labral tear. Radiographs negative or nondiagnostic. Next imaging study.
C. CT hip with IV contrast

Variant 4: Chronic hip pain. Suspect labral tear. Radiographs negative or nondiagnostic. Next imaging study.
D. CT hip without and with IV contrast

Variant 4: Chronic hip pain. Suspect labral tear. Radiographs negative or nondiagnostic. Next imaging study.
E. CT hip without IV contrast

Variant 4: Chronic hip pain. Suspect labral tear. Radiographs negative or nondiagnostic. Next imaging study.
F. Fluoride PET/CT skull base to mid-thigh

Variant 4: Chronic hip pain. Suspect labral tear. Radiographs negative or nondiagnostic. Next imaging study.
G. Image-guided anesthetic +/- corticosteroid injection hip joint or surrounding structures

Variant 4: Chronic hip pain. Suspect labral tear. Radiographs negative or nondiagnostic. Next imaging study.
H. MR arthrography hip

Variant 4: Chronic hip pain. Suspect labral tear. Radiographs negative or nondiagnostic. Next imaging study.
I. MRI hip without and with IV contrast

Variant 4: Chronic hip pain. Suspect labral tear. Radiographs negative or nondiagnostic. Next imaging study.
J. MRI hip without IV contrast

Variant 4: Chronic hip pain. Suspect labral tear. Radiographs negative or nondiagnostic. Next imaging study.
K. US hip

Variant 5: Chronic hip pain. Radiographs equivocal or positive for mild osteoarthritis. Evaluate articular cartilage integrity. Next imaging study.

Variant 5: Chronic hip pain. Radiographs equivocal or positive for mild osteoarthritis. Evaluate articular cartilage integrity. Next imaging study.
A. Bone scan hip

Variant 5: Chronic hip pain. Radiographs equivocal or positive for mild osteoarthritis. Evaluate articular cartilage integrity. Next imaging study.
B. CT arthrography hip

Variant 5: Chronic hip pain. Radiographs equivocal or positive for mild osteoarthritis. Evaluate articular cartilage integrity. Next imaging study.
C. CT hip with IV contrast

Variant 5: Chronic hip pain. Radiographs equivocal or positive for mild osteoarthritis. Evaluate articular cartilage integrity. Next imaging study.
D. CT hip without and with IV contrast

Variant 5: Chronic hip pain. Radiographs equivocal or positive for mild osteoarthritis. Evaluate articular cartilage integrity. Next imaging study.
E. CT hip without IV contrast

Variant 5: Chronic hip pain. Radiographs equivocal or positive for mild osteoarthritis. Evaluate articular cartilage integrity. Next imaging study.
F. Fluoride PET/CT skull base to mid-thigh

Variant 5: Chronic hip pain. Radiographs equivocal or positive for mild osteoarthritis. Evaluate articular cartilage integrity. Next imaging study.
G. Image-guided anesthetic +/- corticosteroid injection hip joint or surrounding structures

Variant 5: Chronic hip pain. Radiographs equivocal or positive for mild osteoarthritis. Evaluate articular cartilage integrity. Next imaging study.
H. MR arthrography hip

Variant 5: Chronic hip pain. Radiographs equivocal or positive for mild osteoarthritis. Evaluate articular cartilage integrity. Next imaging study.
I. MRI hip without and with IV contrast

Variant 5: Chronic hip pain. Radiographs equivocal or positive for mild osteoarthritis. Evaluate articular cartilage integrity. Next imaging study.
J. MRI hip without IV contrast

Variant 5: Chronic hip pain. Radiographs equivocal or positive for mild osteoarthritis. Evaluate articular cartilage integrity. Next imaging study.
K. US hip

Variant 6: Chronic hip pain. Radiographs suspicious for intra-articular synovial hyperplasia or neoplasia, including nodular synovitis, diffuse tenosynovial giant cell tumor, osteochondromatosis, other synovial neoplasm. Next imaging study.

Variant 7: Chronic hip pain with low back or knee pathology or pain. Radiographs demonstrate hip osteoarthritis. Want to quantify amount of pain related to the hip. Next imaging study.

Variant 7: Chronic hip pain with low back or knee pathology or pain. Radiographs demonstrate hip osteoarthritis. Want to quantify amount of pain related to the hip. Next imaging study.
A. Bone scan hip

Summary of Highlights

Supporting Documents

The evidence table, literature search, and appendix for this topic are available at https://acsearch.acr.org/list. The appendix includes the strength of evidence assessment and the final rating round tabulations for each recommendation.

For additional information on the Appropriateness Criteria methodology and other supporting documents, please go to the ACR website at https://www.acr.org/Clinical-Resources/Clinical-Tools-and-Reference/Appropriateness-Criteria.

Safety Considerations in Pregnant Patients

Appropriateness Category Names and Definitions

Appropriateness Category Name	Appropriateness Rating	Appropriateness Category Definition
Usually Appropriate	7, 8, or 9	The imaging procedure or treatment is indicated in the specified clinical scenarios at a favorable risk-benefit ratio for patients.
May Be Appropriate	4, 5, or 6	The imaging procedure or treatment may be indicated in the specified clinical scenarios as an alternative to imaging procedures or treatments with a more favorable risk-benefit ratio, or the risk-benefit ratio for patients is equivocal.
May Be Appropriate (Disagreement)	5	The individual ratings are too dispersed from the panel median. The different label provides transparency regarding the panel’s recommendation. “May be appropriate” is the rating category and a rating of 5 is assigned.
Usually Not Appropriate	1, 2, or 3	The imaging procedure or treatment is unlikely to be indicated in the specified clinical scenarios, or the risk-benefit ratio for patients is likely to be unfavorable.

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Disclaimer

The ACR Committee on Appropriateness Criteria and its expert panels have developed criteria for determining appropriate imaging examinations for diagnosis and treatment of specified medical condition(s). These criteria are intended to guide radiologists, radiation oncologists and referring physicians in making decisions regarding radiologic imaging and treatment. Generally, the complexity and severity of a patient’s clinical condition should dictate the selection of appropriate imaging procedures or treatments. Only those examinations generally used for evaluation of the patient’s condition are ranked. Other imaging studies necessary to evaluate other co-existent diseases or other medical consequences of this condition are not considered in this document. The availability of equipment or personnel may influence the selection of appropriate imaging procedures or treatments. Imaging techniques classified as investigational by the FDA have not been considered in developing these criteria; however, study of new equipment and applications should be encouraged. The ultimate decision regarding the appropriateness of any specific radiologic examination or treatment must be made by the referring physician and radiologist in light of all the circumstances presented in an individual examination.