Peer Reviewed

What's Your Diagnosis?

What Is the Cause of an Older Patient’s Persistent Hip Pain?

Stacy H. Leung, MD, MBA,
Matthew P. LeBlanc, MD,
Namita Bhardwaj, MD, MS, MPH,
John C. Hagedorn, II, MD
Volume 65 - Issue 11 - November 2025

  • Correct Answer: C. Acetabular labral tear 

    Acetabular labral tears are commonly recognized as a contributing cause of hip pain and, if present for several years, may lead to the progression of osteoarthritis (OA)1,2. The sharp pain is in the groin and may have an associated click or catching sensation.3 Although plain radiographs may not reveal the diagnosis, MRA generally provides a definitive one.3 In this case, the AP and lateral radiographs showed bilateral femoral heads, which are not concentrically round with spurring at the cranial lateral acetabulum. The radiograph did not show any fractures and only minimal-to-no arthritic changes in the bilateral hips. No fractures were found in the lateral radiograph of the left hip and only minimal-to-no arthritic changes. The coronal T2 MRI with arthrogram showed no edema in the femoral neck. Finally, the axial T2 MRI of the hip with arthrogram showed posterior cystic changes of the acetabulum and posterior labral tear. 

    A patient with a femoral neck stress fracture will present with anterior groin pain at onset that is severe and specifically localized. Severity, as seen on MRI, ranges from edema to cortical fracture.3-5 The patient’s history includes chronic pain that was felt in the hip and down the thigh with less suggestive evidence of pinpoint tenderness localized to one specific area such as the anterior groin.

    Generally, OA presents as anterior hip pain with activity, reduced range of motion, and grinding like sensation known as crepitus.6 Plain radiographs are often sufficient for diagnosis and findings include joint space narrowing and subchondral sclerosis with or without osteophyte formation.6-8 Although the patient’s age suggests a possibility of OA, plain imaging failed to reveal overt findings of OA to be a cause of the pain.

    Femoracetabular impingement presents with pain in the hip or anterior groin accompanied by a click or catching sensation.9-11 X-ray imaging reveals a prominent acetabular dome resembling a pincer deformity.9-11 A cam lesion can also be identified, which exemplifies an asymmetric femoral head.9-11 Diagnosis is usually delayed due to the overlapping nature of symptoms until advanced imaging is completed. In this case, considering the patient’s overlapping symptoms, chronology of symptoms, and physical examination findings, advanced imaging points towards a more specific diagnosis.

    Treatment and Management. The patient was offered surgical intervention, specifically either a hip arthroscopy or a surgical hip dislocation. Due to advancement in technology and the risk of complications with surgical hip dislocation, hip arthroscopy is the standard of care. However, the patient elected to proceed with an image-guided intra-articular steroid injection. One week later, the patient reported complete resolution of his left hip pain and associated symptoms. 

    Outcome and follow-up. Seven months from initial presentation, the symptoms returned, and the patient opted for hip arthroscopy. Following outpatient surgery, the patient was advised to return to activities as tolerated and return to clinic as needed based on his surgeon’s specific physical therapy protocol. This visit often occurs 6 months post-operation. 

    Discussion. Acetabular labral tears occur in patients of both sexes, throughout all ages, including athletes who perform repetitive pivoting motions on a load-bearing femur.2,12,13 Its prevalence ranges from 22% of athletes with groin pain to 55% of patients with mechanical hip pain.12 

    Acetabular labral tears are difficult to diagnose.3,14 Inconsistent physical examination findings, due to variations in location of the tears, creates overlap in symptoms, which contributes to the complexity of diagnosis.15 Studies have shown that an accurate diagnosis occurs after 3.3 healthcare provider visits spanning a period of 2 years.7,15 The best practice for diagnosis of a hip labral tear is obtaining a thorough patient history and providing a physical examination with x-rays of the hip (AP pelvis and lateral x-ray of the hip of concern). If the patient history and/or physical examination is positive for pain on internal rotation and no arthritis is seen on x-ray, then MRI of the hip with or without arthrogram is indicated. An arthrogram can help diagnose labral tears by indicating where contrast fluid “escapes” on MRI.

    In addition to high clinical suspicion, appropriate management requires proper diagnosis.3 Magnetic resonance arthrography provides a sensitivity and accuracy of 90% and 91%, respectively, in the absence of articular cartilage abnormalities, whereas arthroscopy has a sensitivity and specificity of 100%.15 Initial treatment begins with at least a 6-week trial of non-surgical management involving rest, anti-inflammatory and pain medications, along with physical therapy.15 In our case, due to the duration of the patient’s pain, he was offered surgical options sooner. For patients with persistent hip pain that does not resolve, a clinician should maintain a high level of clinical suspicion for acetabular labral tears.   

    AUTHORS:
    Stacy H. Leung, MD, MBA1 • Matthew P. LeBlanc, MD1 • Namita Bhardwaj, MD, MS, MPH1,2 • John C. Hagedorn, II, MD2

    AFFILIATIONS:
    1Department of Family Medicine, The University of Texas Medical Branch, 301 University Blvd, Galveston, TX 77555-1123
    2Department of Orthopaedic Surgery and Rehabilitation, The University of Texas Medical Branch, 301 University Blvd, Galveston, TX 77555-0165

    CITATION:
    Leung SH, LeBlanc MP, Bhardwaj N, Hagedorn JC. What Is the Cause of an Older Patient’s Persistent Hip Pain? Consultant. Published online August 28, 2025. doi: 10.25270/con.2025.08.000003
    Received November 27, 2024. Accepted April 8, 2025

    DISCLOSURES:
    The authors report no relevant financial relationships.

    CORRESPONDENCE:
    Namita Bhardwaj, MD, MS, MPH, Department of Orthopaedic Surgery and Rehabilitation, The University of Texas Medical Branch, 301 University Blvd, Galveston, TX 77555-0165 (email: nabhardw@utmb.edu)

    References                                                                                                   

    1. Farjo LA, Glick JM, Sampson TG. Hip arthroscopy for acetabular labral tears. Arthroscopy. Mar 1999; 15(2): 232-7. doi:10.1053/ar.1999.v15.015013
    2. McCarthy J, Noble P, Aluisio FV, Schuck M, Wright J, Lee JA. Anatomy, pathologic features, and treatment of acetabular labral tears. Clin Orthop Relat Res. Jan 2003;(406):38-47.
    3. Narvani AA, Tsiridis E, Tai CC, Thomas P. Acetabular labrum and its tears. Br J Sports Med. Jun 2003;37(3):207-11. doi:10.1136/bjsm.37.3.207
    4. Sundkvist J, Möller M, Rogmark C, Wolf O, Mukka S. Stress fractures of the femoral neck in adults: an observational study on epidemiology, treatment, and reoperations from the Swedish Fracture Register. Acta Orthop. Apr 8 2022;93:413-416. doi:10.2340/17453674.2022.2460
    5. Robertson GA, Wood AM. Femoral neck stress fractures in sport: a current concepts review. Sports Med Int Open. Feb 2017;1(2):E58-e68. doi:10.1055/s-0043-103946
    6. Katz JN, Arant KR, Loeser RF. Diagnosis and treatment of hip and knee osteoarthritis: a review. JAMA. Feb 9 2021;325(6):568-578. doi:10.1001/jama.2020.22171
    7. Allen KD, Thoma LM, Golightly YM. Epidemiology of osteoarthritis. Osteoarthritis Cartilage. Feb 2022;30(2):184-195. doi:10.1016/j.joca.2021.04.020
    8. Fransen M, McConnell S, Hernandez-Molina G, Reichenbach S. Exercise for osteoarthritis of the hip. Cochrane Database Syst Rev. Apr 22 2014;2014(4):Cd007912. doi:10.1002/14651858.CD007912.pub2
    9. Lee WY, Kang C, Hwang DS, Jeon JH, Zheng L. Descriptive epidemiology of symptomatic femoroacetabular impingement in young athlete: single center study. Hip Pelvis. Mar 2016;28(1):29-34. doi:10.5371/hp.2016.28.1.29
    10. Nepple JJ, Byrd JW, Siebenrock KA, Prather H, Clohisy JC. Overview of treatment options, clinical results, and controversies in the management of femoroacetabular impingement. J Am Acad Orthop Surg. 2013;21 Suppl 1:S53-8. doi:10.5435/jaaos-21-07-s53
    11. Fortier LM, Popovsky D, Durci MM, Norwood H, Sherman WF, Kaye AD. An updated review of femoroacetabular impingement syndrome. Orthop Rev (Pavia). 2022;14(3):37513. doi:10.52965/001c.37513
    12. Groh MM, Herrera J. A comprehensive review of hip labral tears. Curr Rev Musculoskelet Med. Jun 2009;2(2):105-17. doi:10.1007/s12178-009-9052-9
    13. Mason JB. Acetabular labral tears in the athlete. Clin Sports Med. Oct 2001;20(4):779-90. doi:10.1016/s0278-5919(05)70284-2
    14. Hase T, Ueo T. Acetabular labral tear: arthroscopic diagnosis and treatment. Arthroscopy. Mar 1999;15(2):138-41. doi:10.1053/ar.1999.v15.0150131
    15. Beaulé PE, O'Neill M, Rakhra K. Acetabular labral tears. J Bone Joint Surg Am. Mar 1 2009;91(3):701-10. doi:10.2106/jbjs.H.00802

    ©2025 HMP Global. All Rights Reserved.
    Any views and opinions expressed are those of the author(s) and/or participants and do not necessarily reflect the views, policy, or position of Consultant360 or HMP Global, their employees, and affiliates.