Getting the diagnosis right in young patients presenting with hip pain

I was on the faculty of a hip preservation meeting recently in Switzerland, where as part of the teaching programme there were a number of case discussions. This proved to be particularly interesting, as what is clear is that even among ‘experts’ there is quite some difference in interpretation of investigations and therefore of the diagnosis and approach to treatment.

It is often difficult to give an opinion based on pictures alone as talking to and examining the patient is such a critical part of making a diagnosis particularly in relation to the different variations of hip morphology that can lead to symptoms of pain around the hip. There is definitely room for improvement in terms of how investigations are standardised and interpreted and also the definitions that we use to determine whether something is normal or abnormal.

One of the critical issues leading to differences in interpretation is the way individuals tilt their pelvis. A structurally normal hip can behave in a very abnormal way leading to pain if the pelvis is functionally tilted. Determining if the hip is abnormal or not can depend on how the pelvis is tilted at the time of an X-ray, and this will look very different if the X-ray is taken with the patient standing or lying down.

The challenge is to agree on distinct parameters that are abnormal and to develop imaging techniques that can take into account the variations in pelvic tilt during different activities. These are certainly in the process of being developed. Our focus has been on using CT scans with dynamic motion of the hip which provides a lot of additional information and further simulation techniques will undoubtedly shed more light on why some hips become unstable, damaged or painful.