Imaging, 23 (2014), 20120023

MUSCULOSKELETAL IMAGING

Imaging the hip

A DAGHIR, MRCP, FRCR and J TEH, MRCP, FRCR

Department of Radiology, Nuffield Orthopaedic Centre, Oxford, UK

Summary
• Age is an important determinant in the aetiology of hip disorders.
• MRI is the key imaging technique in a variety of conditions involving the bone,
including occult fracture, stress fracture, avascular necrosis and transient
osteoporosis.
• Synovial diseases are well characterized on MRI, including pigmented villonodular
synovitis, synovial osteochondromatosis and inflammatory arthropathies.
• MR arthrography allows assessment of intra-articular pathology, including tears of
the acetabular labrum.
• CT provides detailed information on bone morphology and may provide doi: 10.1259/img.20120023
a definitive diagnosis of osteoid osteoma.
• Ultrasound may be used to evaluate bursitis, joint effusions and snapping hips, as © 2014 The British Institute of
well as guiding injections. Radiology

Cite this article as: Daghir A, Teh J. Imaging the hip. Imaging 2014;23:20120023.

Abstract. In this article, we review the clinical presentation used to guide needle aspiration and injection. The injection
and imaging appearances of a wide spectrum of disorders of the of a local anaesthetic into the hip joint under ultrasound or
hip. The role of different imaging modalities is highlighted for fluoroscopic guidance may allow confirmation of the hip
each condition. as the source of symptoms.1,2

In this article, we review the spectrum of pathological

conditions that involve the hip, their clinical presentation
and their radiological features. The range of pathologies
involving the hip depends greatly on the age of the pa-
tient (Table 1). Radiography remains a key radiological
investigation. However, ultrasound, CT and MRI have
become increasingly routine in the diagnosis of hip dis-
orders. MRI demonstrates bone pathology with increased
spatial resolution compared with bone scintigraphy, and
it has become the preferred modality for investigation of
occult fractures, bone marrow oedema syndromes
(BMESs) and avascular necrosis (AVN). MRI is also helpful
in the demonstration of synovial proliferative disorders
such as pigmented villonodular synovitis (PVNS). MR
arthrography (MRA) allows exquisite delineation of the
labrum and cartilage, and it has an important role in the
assessment of femoroacetabular impingement, which is
now implicated as a major cause of hip osteoarthritis (OA).
CT allows detailed assessment of bone morphology, which
is helpful in conditions like femoroacetabular impinge-
ment, and it may allow definitive diagnosis of osteoid
osteoma. Ultrasound is useful to evaluate soft-tissue ab-
normalities, including joint effusions and bursitis, and it
permits dynamic imaging in snapping hips and may be
Address correspondence to: Dr Ahmed Daghir. E-mail: ahmedda
ghir@doctors.net.uk
Anatomy
The hip is a ball and socket joint capable of transmitting
large forces. It allows a wide range of movement, while
maintaining strong stability such that dislocation occurs
much less frequently than in the shoulder. The cup-shaped
acetabulum is formed at the junction of the iliac, pubic and
ischial bones. The fibrocartilagenous labrum forms a ring
at the margin of the acetabulum, thereby increasing its
depth3,4 (Figure 1). The femoral head has a hemispherical
articular surface with a central fovea to which the liga-
mentum teres attaches. The capsule of the hip joint attaches
at the intertrochanteric line covering the anterior femoral
neck and most of the posterior femoral neck. The ilio-
femoral, ischiofemoral and pubofemoral ligaments re-
inforce the fibrous capsule. The transverse ligament and
ligamentum teres are intracapsular. The latter is a weak
ligament that transmits the foveal artery, which in adults
contributes little blood supply to the femoral head. The
femoral head receives most of its blood supply from the
medial and lateral femoral circumflex arteries, which form
a ring around the base of the femoral neck. These are at
risk when there is an intracapsular femoral neck fracture.
The lesser trochanter is the site of attachment of the ilio-
psoas tendon. Several muscles insert onto the greater tro-
chanter, including gluteus medius, gluteus minimus and
piriformis.

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Table 1. The typical age of presentation of various hip
disorders
Age Condition
Above the fifth Occult fracture
decade Osteoarthritis
Trochanteric bursitis and gluteus
medius enthesopathy
Third to fifth Avascular necrosis
decade Transient bone marrow oedema
Synovial proliferative disorders
Second to fourth Femoroacetabular impingement
decade Snapping hip
Osteoid osteoma
Conditions affecting the bone
Stress fractures of the hip
A stress fracture occurs following repeated loading of
a bone, which cannot accommodate itself to the forces
applied to it.5 Two kinds of stress fractures are described:
fatigue fractures occur in normal bones undergoing ex-
cessive loading, and insufficiency fractures arise in
pathologically weak bone undergoing normal loading.5,6
The femoral neck is a common site of fatigue fracture
typically occurring in military recruits and athletes. An-
terior hip and groin pain is exacerbated by activity and
improves with rest. The insidious onset of symptoms
may lead to diagnostic delay and may result in the frac-
ture becoming displaced.7
MRI is an excellent technique for identification and
characterization of radiographically occult fractures
due to acute or chronic trauma.8–12 In our practice, we
perform both T1 and short tau inversion–recovery (STIR)
coronal and axial sequences.10 The T1 images are helpful
for demonstrating the low-signal fracture line, which
usually appears perpendicular to the cortex owing to the
causative compressive forces. The STIR images reveal
Figure 1. Normal anatomy on MR arthrogram. Coronal T1 fat-
saturated image shows intra-articular gadolinium contrast as
high signal. The superior labrum (arrow) and transverse
ligament (arrowhead) are clearly demonstrated. The ligamen-
tum teres can be seen attaching to the fovea (open arrow).
Hyaline cartilage appears as intermediate signal.
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A Daghir and J Teh
high-signal bone marrow oedema and also allow assess-
ment of soft-tissue injury (Figure 2a). Radiographs may
initially appear normal and later show periosteal thicken-
ing and a sclerotic fracture line (Figure 2b). Bone scintig-
raphy provides another means of diagnosis although the
sensitivity and specificity is lower than with MRI.8,13
Occult hip fractures
Radiographs are sufficient for the diagnosis of the vast
majority of hip fractures. However, when radiographs
are negative or equivocal and there remains a high clin-
ical suspicion for an occult hip fracture, a number of
imaging options are available. In our institution, MRI is
the investigation of choice employing coronal and axial
T1 and STIR sequences10,12 (Figure 3). CT is an alternative
imaging technique providing isotropic multiplanar
reformats although MRI is reported to be more sensitive
and also allows delineation of soft-tissue injury.14 Scin-
tigraphy usually allows detection of fractures 24 h fol-
lowing injury; however, in the elderly, the sensitivity is
further improved after a few days.13
Avascular necrosis
AVN, also called osteonecrosis, is common in the
femoral head and has a number of causes, the commonest
being chronic steroid use, chronic excessive alcohol use
and trauma. With interruption of the blood supply, my-
eloid cell death follows in 6–12 h. After 48 h, osteocyte
death occurs, and lipocytes die within 2–6 days.15 This is
followed by an inflammatory response increasing vas-
cularity, leading to the formation of granulation tissue
and fibrosis. Collapse of the subchondral bone predis-
poses to OA. The condition is bilateral in up to 40% of
cases, so it is important to image both hips together.
Early detection of avascular necrosis
Early detection of AVN is important because therapy
such as core decompression may be implemented sooner.
Radiographs are of limited use early on, as the typical
findings on radiographs of subchondral lucency and
collapse occur late in the disease process (Figure 4a). The
investigation of choice is MRI, which is more sensitive
Figure 2. Stress fracture of the femoral neck. (a) Coronal short
tau inversion–recovery image demonstrating high signal in the
femoral neck indicating bone marrow oedema. A low-signal
fracture line is shown perpendicular to the bone cortex
(arrow). (b) A radiograph taken on the same day shows very
subtle linear sclerosis indicating the fracture line (arrow).
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Imaging the hip
Figure 3. Coronal short tau inversion–recovery image dem-
onstrates an undisplaced intracapsular fracture of the
femoral neck that was not detected on radiographs. High-
signal bone marrow oedema surrounds a low-signal fracture
line (arrow).
and specific than scintigraphy.16,17 The protocol should
include T1 and STIR/T2 fat-saturated sequences in at least
two planes. Intravenous contrast, although not usually
necessary, demonstrates regions of reduced enhancement
in early AVN. The “double line” sign on T2 weighted
sequences is virtually pathognomonic for AVN and is
seen in up to 80% of cases. This describes a high-signal
line (representing hypervascular tissue) on the necrotic
side immediately apposed to a low-signal line (repre-
senting fibrosis and sclerosis) on the healthy side18
(Figure 4b,c). A joint effusion and bone marrow oedema
may also be present.18–20
Staging and prognosis of avascular necrosis
Staging the severity of AVN may be performed with
imaging. Several classifications exist, including the
Steinberg classification, which incorporates radiographic,
MRI and scintigraphy findings (Table 2).21
Assessing prognosis in AVN using radiographs is of
limited use, since the prognosis is poor once there is ra-
diographic evidence of subchondral collapse. The per-
centage of weight-bearing femoral cortex involved with
AVN on MRI is reported to be the most reliable
Figure 4. Avascular necrosis (AVN) of the femoral head. (a) Radiograph demonstrates subchondral collapse (arrow), a late feature
of AVN. (b, c) In a different patient: (b) coronal T1 image demonstrating a subchondral region of low signal (arrow); (c) short tau
inversion–recovery sagittal oblique image demonstrating the classical “double line” sign (arrow) of AVN. The high-signal line
represents hypervascular tissue on the necrotic side adjacent to the low-signal fibrotic/sclerotic line on the healthy side.
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parameter in determining outcome.22 The success of core
decompression may be predicted by quantifying the
percentage of involvement of the femoral head. AVN
involving ,25% of the femoral head appears to benefit
greatly from core decompression.22,23 If .50% is in-
volved, the prognosis is very poor despite core de-
compression. A good correlation exists between the
extent of weight-bearing articular surface affected and
femoral head collapse. In one study, there was a 74% rate
of femoral head collapse by 32 months if the region of
AVN involved more than two-thirds of the weight-
bearing surface area.24 Conversely, when there are small
lesions confined to the medial anterosuperior portion of
the femoral head, collapse tends not to occur.
Bone marrow oedema syndromes
Transient osteoporosis of the hip (TOH), also referred
to as BMES, typically presents with acute hip pain in the
absence of previous trauma or signs of infection. TOH
was first described in females in the third trimester of
pregnancy, but it is most commonly seen in middle-aged
males.25 The pain is exacerbated by weight-bearing, and
there may be accompanying antalgic gait and muscle
wasting. The condition is self-limiting, taking an average
of 6 months for symptoms to completely resolve with
protected weight-bearing and symptomatic support.26,27
In some patients, resolution in one joint may be followed
by involvement of another, which is referred to as re-
gional migratory osteoporosis (RMO).28 In these cases,
the commonest pattern is primary involvement of the hip
followed by secondary involvement of the knee or an-
kle.29 There may be temporal overlap such that more than
one joint is involved at a particular time. The patho-
physiology of TOH and RMO remains obscure although
the role of ischaemia and trauma has been investigated.30
Radiography may demonstrate osteopenia of the femoral
head and neck, although this is a relatively late finding.
Scintigraphy exhibits increased uptake as a result of increased
bone turnover and inflammatory change, but this is not
specific. MRI is the imaging modality of choice. It demon-
strates bone marrow oedema as a diffuse intermediate/low
signal on T1 weighted sequences and high signal on T2
weighted fat-suppressed or STIR sequences several weeks
before radiographic changes are detectable26,31 (Figure 5).
Bone marrow oedema in the femoral head and neck
has a wide differential diagnosis, including AVN, TOH,
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Table 2. Steinberg radiological–clinical classification
findings for the staging of avascular necrosis (AVN) of the
femoral head
Stages Features
0 Abnormal MRI but normal radiographs and
scintigraphy. AVN should be suspected if it has
already been diagnosed in the contralateral
hip
I Abnormal MRI and scintigraphy, but normal
radiographs. Patient has mild groin pain. Stage
I represents the early resorptive stage. Late in
this stage, plain radiographs may show
minimal osteoporosis with poor definition of
the bony trabeculae. Osteoporosis only
appears when at least one-third of the mineral
content of the bone has been lost
II This stage represents the reparative stage before
flattening of the femoral head occurs. On plain
radiographs, demineralization is now evident.
It may be generalized or patchy and may
appear in the form of small cysts within the
femoral head. Patchy sclerosis may also occur,
representing apposition of new bone on dead
trabeculae
III A linear subcortical lucency, indicating
a subchondral fracture, is present, known as
the crescent sign. This may extend into the
articular cartilage at the superolateral aspect
of the femoral head. The femoral head initially
preserves its round appearance, but, later, it
demonstrates collapse
IV There is segmental flattening of the femoral
head but preservation of the joint space
V There is femoral head collapse and degenerative
change
subchondral insufficiency fracture (SIF) of the femoral
head, stress fracture of the femoral neck, arthropathy,
metastasis, osteoid osteoma and infection28,32,33 (Table 3).
There may be difficulty in distinguishing between the
MRI appearances of AVN, TOH and SIF. It is important
to differentiate between these conditions, as there are
considerable implications for prognosis and treatment.
The subchondral region of the femoral head is a critical
area to evaluate. The absence of focal subchondral
changes is predictive of a transient bone marrow oedema
lesion.32 AVN typically exhibits a smooth band of sub-
chondral low intensity on T1 weighted sequences and
a double line sign on T2 weighted sequences, which
represent repair tissue around a zone of necrotic bone.
SIF of the femoral head is another distinct entity to con-
sider. In contrast to AVN, this condition typically occurs
in elderly females who are osteoporotic and/or over-
weight. A linear low-signal band is described in the
subchondral region corresponding to the fracture line.34
Articular collapse may occur in both AVN and SIF.
Osteoid osteoma
Osteoid osteomas are benign neoplasms that usually
involve the long bones, particularly the proximal femur
and tibial shaft. The typical presentation is of localized
bone pain that is worse at night and relieved by anti-
inflammatory drugs. The tumour consists of a small ni-
dus of osteoid tissue (usually ,1 cm) that demonstrates
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A Daghir and J Teh
variable mineralization. This appears on radiographs as
a small ovoid lucent defect. The nidus is surrounded by
an osteoblastic response resulting in the appearance of
a variable degree of surrounding sclerosis. On MRI, bone
marrow oedema is present which surrounds the nidus
(which is sometimes difficult to detect) as a small in-
termediate signal focus on both T1 and T2 weighted
images.35 Intra-articular lesions may be accompanied by
synovial thickening and joint effusions with little or no
sclerosis.36 Bone scintigraphy is invariably positive but
not specific. The gold standard imaging technique is CT,
which accurately localizes the nidus, thus confirming the
diagnosis (Figure 6). CT also has an important role in
guiding radiofrequency or laser ablation of the tumour.37
Conditions affecting the soft tissues of the hip
Lesions of the acetabular labrum
Labral tears may arise as a result of developmental
dysplasia, femoroacetabular impingement, trauma or re-
petitive athletic activity. Patients with labral tears often
present with a catching type pain, sometimes associated
with clicking, snapping, locking or giving way of the
joint. Flexion and internal rotation of the hip may re-
produce pain.
MRA, requiring instillation of gadolinium contrast into
the joint, is the preferred imaging technique for evaluating
the labrum. It significantly increases the visualization of the
acetabular labrum compared with conventional MRI.38–40
The normal labrum morphology is varied. Lecouvet et al41
demonstrated that the commonest shape of the labrum is
triangular, present in 66% of asymptomatic volunteers,
whilst round labra were detected in 11% and flattened
labra in 9% of volunteers. An absent labrum was reported
in 14% of volunteers. Signal alterations within the labrum
do not correlate well with degeneration, as intermediate
or high intralabral signal intensity on T1 and proton
density-weighted images has been reported in 58% of
asymptomatic labra using conventional MRI.42 The edge
Figure 5. Transient osteoporosis of the left hip in a middle-
aged male. Coronal short tau inversion–recovery image dem-
onstrates high signal (arrow) indicating bone marrow oedema
in the femoral head and neck. The subchondral region is
involved, which is not always the case in this condition.
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Imaging the hip

Table 3. Differential diagnosis of femoral head/neck

oedema
Avascular necrosis
Transient osteoporosis/bone marrow oedema syndrome
Subchondral insufficiency fracture
Stress fracture of the femoral neck
Inflammatory arthropathy
Infection
Osteoid osteoma
Metastasis

of the labrum may normally overlap the margin of the

articular cartilage, giving an appearance of cartilage un-
dercutting labrum. A sulcus may be present at the ante-
rosuperior acetabular–labral junction and is considered
by some to be a normal variant.4
Tears are diagnosed on MRA when intrasubstance
Figure 7. Labral tear. MR arthrogram axial T1 fat-saturated
contrast material is demonstrated. T1 fat-saturated
image demonstrates linear high signal (intra-articular con-
sequences are therefore of particular importance when trast) penetrating the acetabular labrum (arrow).
evaluating the labrum (Figure 7). Contrast that separates
the labrum and acetabulum is typical of labral de-
tachment. Peri-labral cysts are associated with underlying cartilage disease is important because, in cases of ad-
labral tears.43,44 These cysts are usually extra-articular vanced damage, joint-sparing arthroscopic treatment is
and may erode into the adjacent bone. unlikely to be helpful.

Femoroacetabular impingement
Femoroacetabular impingement is a recently described
cause of hip pain resulting from morphological abnor-
malities of the hip. Two types are described, cam and
pincer, although most patients have a combination of
both types.45 Cam- and pincer-type deformities are not
thought to be painful by themselves. Rather, they pre-
dispose to damage to the acetabular labrum and cartilage,
which is painful. Identifying these morphological abnor-
malities has important implications as surgical correction
may prevent the onset of OA.46,47 Arthroscopic manage-
ment involving recontouring of the cam and/or pincer
deformity has been reported to have favourable early
outcomes in most patients although the long-term benefit
is not known.48 Accurate assessment of the extent of
Cam impingement
Cam-type deformity, typically occurring in athletic
males, describes loss of the normal sphericity of the fem-
oral head owing to the presence of an osseous bump at the
head/neck junction, which is usually found antero-
laterally49 (Figure 8). It is so-called because of the re-
semblance to a camshaft in motor engines. Although a cam
deformity is often idiopathic, similar morphology may
arise secondarily as a result of conditions including
trauma, chronic slipped upper femoral epiphysis, previous
osteotomy and Perthes’ disease. Repeated contact between
the osseous bump and the labrum causes labral tearing
and detachment. This process leads to cartilage damage
and OA. A triad of findings on MRA has been described
consisting of a femoral head/neck osseous bump, antero-
superior cartilage abnormality and anterosuperior labral
abnormality50 (Figure 9). The degree of loss of sphericity
may be quantified using the a angle (Figure 10). This angle
can be measured on an axial oblique MR image or on
a cross-table lateral radiograph of the hip. An a angle .50°
may be considered abnormal.51

Figure 6. Osteoid osteoma. Axial CT demonstrates the lucent Figure 8. Cam deformity. Radiograph in a 46-year-old male
nidus (arrow) in a typical location in the femoral neck. Note shows bilateral cam deformities (osseous bumps) of the
the surrounding osteoblastic response resulting in sclerosis. anterolateral femoral head/neck junctions (arrows).

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Figure 9. Cam impingement. MR arthrogram coronal T1 fat-
saturated image shows a cam deformity (arrowhead). There
is an associated labral tear (arrow) and thinning of the
articular cartilage.
Pincer impingement
Pincer-type impingement, more common in middle-
aged females, describes focal or diffuse enlargement of
the acetabulum resulting in overcoverage of the femoral
head.51 Cranial acetabular retroversion, coxa profunda
and protrusio acetabuli are types of morphology leading
to pincer impingement. On anteroposterior (AP) radio-
graphs of the pelvis, cranial acetabular retroversion is
present when the cranial part of the anterior acetabular
wall is identified lateral to the posterior acetabular wall.
Coxa profunda describes the overlap of the acetabular
fossa with the ilioischial line, whereas protrusio acetabuli
describes the overlap of the femoral head with the
Figure 10. The a angle in cam impingement: MR arthrogram
axial oblique T1 fat-saturated image. The a angle helps to
identify a cam deformity by measuring the loss of sphericity
of the femoral head. First, a best-fit circle is drawn outlining
the femoral head. A line is then drawn along the femoral
neck axis. A second line is drawn from the centre of the circle
to the point at which the femoral neck contour protrudes
from the circle owing to the cam deformity (arrow). The
angle between these lines is the a angle.
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Figure 11. (a) Pincer deformity due to idiopathic protrusio
acetabuli in an 82-year-old female. Radiograph shows over-
lap of the femoral head (black arrow) with the ilioischial line
(white arrowheads). (b) In the same patient: the centre–edge
angle in pincer deformity. A line is drawn connecting both
femoral head centres. The a angle (*) is then measured
between a perpendicular line through the femoral head
centre and a line from the femoral head centre to the lateral
edge of the acetabulum.
ilioischial line, which is more severe (Figure 11a). The
degree of pincer deformity may be measured using the
centre–edge angle on an AP radiograph (Figure 11b). A
value .40° has been used to define a pincer abnormal-
ity.52 A value ,25° in adults indicates abnormal under-
coverage often due to developmental hip dysplasia.53 The
centre–edge angle can also be measured on coronal MRI
images.54 With progressive disease, the labrum may be-
come ossified and detach to form an os acetabulum.
There is a high prevalence of synovial herniation pits at
the anterosuperior femoral neck in patients with both
types of femoroacetabular impingement, although their
aetiology and clinical relevance are yet to be established.55,56
The radiographic findings are of a small rounded lucent
lesion with a thin sclerotic margin. The main diagnostic
pitfall is to mistake a herniation pit for an osteoid osteoma.57
Ischiofemoral impingement
Ischiofemoral impingement is a newly recognized con-
dition, which remains the subject of debate. The condition
is found predominantly in females of middle age.58
Patients typically present with posterior hip pain that
may radiate towards the lower extremity.59 The space be-
tween the ischial tuberosity and lesser trochanter is typi-
cally much narrower in patients with this condition than in
Figure 12. Ischiofemoral impingement. Axial short tau
inversion–recovery image demonstrates bursa-like formation
(arrow) in the ischiofemoral space, which is narrow (arrow-
heads). There are less severe changes on the contralateral side.
Imaging 2014, 23, 20120023
Imaging the hip
Figure 13. Sagittal ultrasound image shows a moderate hip
joint effusion. Note anechoic fluid (arrow) and convexity of
the overlying capsule and iliopsoas tendon.
controls (normally measuring approximately 2 cm).59
Narrowing of the space may be congenital or related to
previous trauma, surgery, joint degeneration or osteo-
chondroma. A combination of narrowing of this space and
abnormalities of the quadratus femoris muscle (which lies
in this space) has been described.60 MRI may demonstrate
oedema, focal fatty infiltration and partial tears in the
quadratus femoris; additionally, there may be involvement
of the adjacent hamstring and iliopsoas tendons and bursa-
like formation58 (Figure 12). However, the imaging ab-
normalities may sometimes be incidental; for example,
there may be bilateral MRI findings in patients presenting
with unilateral pain. Also, positioning of the hip in internal
or external rotation during the scan may alter the mea-
surement of the ischiofemoral space.
Inflammatory arthropathy
Inflammatory arthropathies such as rheumatoid ar-
thritis or ankylosing spondylitis commonly involve the
Figure 14. Established synovial osteochondromatosis. A
radiograph of the hip demonstrates multiple small, ossified
bodies in the hip joint.
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Figure 15. Proliferative synovial osteochondromatosis. An
axial short tau inversion–recovery image demonstrates high
signal synovial hypertrophy (arrows) and faint low signal
bodies indicating mineralization (arrowhead).
hip joint. On plain radiographs, joint space loss is pre-
dominantly in the axial region, unlike the superior joint
space loss that is typical of OA. Longstanding in-
flammatory arthropathy leads to widespread cartilage
damage, resulting in circumferential loss of hip joint
space. Erosions are not a common finding. With ultra-
sound, an effusion and synovial hypertrophy are detec-
ted early in the course of disease (Figure 13). There are
non-specific findings on MRI, including effusion, syno-
vial thickening and peri-articular bone marrow oedema.
Septic arthritis
Septic arthritis of the hip, although rare, is important to
exclude owing to the risk of long-term joint damage if left
untreated. Infection may result from haematogenous
spread, direct inoculation or by spreading along the iliop-
soas muscle from the spine.61 Using imaging alone, septic
Figure 16. Pigmented villonodular synovitis of the hip joint
in a 29-year-old male. Note the presence of multiple erosions
of the femoral head, neck and acetabulum (arrows), which
are well circumscribed with sclerotic margins.
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Figure 17. Pigmented villonodular synovitis of the hip joint
(the same patient as Figure 16). Coronal T1 weighted (a) and
short tau inversion–recovery (b) images show low-signal
synovial proliferation (arrows).
arthritis may be very difficult to distinguish from a non-
infective inflammatory arthropathy. However, there are
findings that are more specific for infection, including
soft-tissue collections, sinus tract formation and osteo-
myelitis. Ultrasound may guide aspiration of an effusion
for laboratory testing.
Osteoarthritis
OA is certainly the commonest cause of hip pain and
stiffness in the elderly. The classical findings on radio-
graphs of superior joint space loss, osteophyte formation,
femoral neck buttressing, subchondral sclerosis and cyst
formation are well described. In addition to superior joint
space loss, medial joint space loss is more common in
females than males. In early OA, radiographs may appear
relatively normal and, in these situations, MRI may be
useful to determine if there is significant hip pathology.
On MRI, the key features of hip OA include joint effu-
sions, subchondral bone marrow oedema, labral abnor-
malities and cystic subchondral lesions.62,63 There may be
associated features of femoroacetabular impingement
(see section Femoroacetabular impingement).
Synovial osteochondromatosis
Primary synovial osteochondromatosis (SOC) is a be-
nign monoarticular condition of uncertain aetiology. It
presents with pain, swelling and movement restriction
Figure 18. Amyloid arthropathy secondary to long-term
haemodialysis. Coronal T1 weighted (a) and short tau
inversion–recovery (b) images demonstrate low-signal syno-
vial thickening (arrows) and erosions (arrowhead).
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A Daghir and J Teh
Figure 19. Iliopsoas bursitis in a patient with rheumatoid
arthritis. Coronal short tau inversion–recovery image shows
fluid distension of the iliopsoas bursa (arrow).
often with a long insidious onset. The condition affects
more males than females. The hip is the third most
commonly involved joint after the knee and elbow. In
addition to joints, bursae and tendon sheaths may rarely
be affected. SOC is characterized by synovial metaplasia
containing multiple nodules of hyaline cartilage. These
nodules detach and form loose bodies within the joint.64
There is variable calcification and ossification of the
loose bodies. Initially, there is a stage of active synovial
proliferation eventually leading to inactive synovial
disease and multiple loose bodies.65 SOC commonly
gives rise to premature OA. Malignant transformation is
exceedingly rare.66
Secondary SOC may occur as a result of trauma, OA,
osteonecrosis and neuropathic arthropathy. Differentiat-
ing primary from secondary SOC may be difficult clini-
cally and radiologically. However, the intra-articular
bodies in secondary SOC tend to be larger, fewer and
non-uniform in size compared with primary disease.64
Figure 20. Gluteus medius bursitis. Coronal short tau
inversion–recovery image shows distension of the bursa deep
to the gluteus medius tendon (arrow).
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Imaging the hip
Figure 21. Internal snapping hip syndrome. (a) A dynamic
ultrasound image showing a transverse section of the
iliopsoas muscle (narrow arrowheads) and iliopsoas tendon
(arrow). Before the snap occurs, the tendon is separated
from the superior pubic ramus (wide arrowhead) by part of
the muscle. (b) When the patient performs a specific hip
movement, the tendon abruptly strikes the superior pubic
ramus accompanied by an audible snap.
The classical radiographic appearance of multiple
small calcified bodies around a joint occurs late on in the
disease (Figure 14). In the early stages, there may be
a normal appearance or soft-tissue swelling without cal-
cification. Joint space widening, erosions and features of
OA may also be present. An apple core appearance of the
femoral neck may be seen with chronic erosions.67
MRI is a useful modality for evaluating SOC. The key
finding is of synovial hypertrophy, which exhibits a high
signal on T2 weighted/STIR sequences and an in-
termediate signal on T1 weighted sequences. Intra-
articular septations may be detected. The appearance of
multiple intra-articular bodies depends on the degree of
mineralization, and these may be purely cartilaginous
demonstrating intermediate signal on T2 weighted
sequences, calcified exhibiting intermediate/low signal
on all sequences or ossified when fatty marrow signal is
present68 (Figure 15).
Pigmented villonodular synovitis
PVNS is a benign proliferative synovial condition,
which is characterized by recurrent bloody effusions and
joint erosions. The cause is uncertain with some evidence
pointing to an inflammatory reaction of the synovium or
a benign neoplastic process.69,70 Most patients are aged
20–45 years, with an equal incidence between the sexes.71
The condition is typically monoarticular, most commonly
involving the knee followed by the hip.71,72 Histologically,
PVNS consists of villous or frond-like synovial pro-
liferations exhibiting a reddish colour due to haemosiderin
deposition. Fibrosis, chronic inflammation and hyaliniza-
tion are found in established disease.69,71,72 Immunophe-
notypic differences help distinguish PVNS from other
causes of haemosiderotic synovitis (i.e. synovitis due to
recurrent haemarthrosis), for example haemophilia.73
Radiographs in the early stages may be normal. Dense
(haemosiderin-laden) soft-tissue joint swelling may later
be detected with recurrent haemarthroses. The joint
space is initially preserved until the later stages when
there is cartilage damage. Erosions with sclerotic mar-
gins may arise as a result of the tight capsule of the
birpublications.org
hip67,74 (Figure 16). These may be better appreciated on CT
than on radiographs.
MRI reveals diffuse or nodular thickening of the
synovium with characteristic low to intermediate signal
on T1 and T2 weighted sequences owing to the presence of
haemosiderin.75 In addition, gradient echo sequences
reveal abundant magnetic susceptibility effect, which
returns very low signal. Synovial proliferation may ex-
tend into the iliopsoas bursa. Bone erosions exhibit vari-
able signal intensity depending on the presence of fluid,
synovium or haemosiderin (Figure 17). The differential
diagnosis for large low/intermediate signal erosions of
the hip includes amyloid arthropathy due to long-term
haemodialysis (Figure 18).
Bursitis
Bursae are synovial-lined structures found between
tendons and muscles over bony prominences. Bursal in-
flammation, or bursitis, may arise as a result of friction
from repetitive activity, trauma, infection or the in-
volvement by systemic inflammatory conditions such as
rheumatoid arthritis. Gait disturbances and previous hip
arthroplasty may contribute to bursitis around the hip.
The commonly encountered types of bursitis around
the hip involve the trochanteric, iliopsoas and ischioglu-
teal bursae. Around the greater trochanter, bursae are
present deep to each of the three gluteal muscles.76 The
iliopsoas bursa is the largest bursa in the body and
communicates with the hip joint in approximately 15% of
individuals. Patients with bursitis typically present with
point tenderness. Iliopsoas bursitis may also give rise to
pain in the anterior knee and thigh owing to irritation of
the femoral nerve (Figure 19).
Radiographs are usually unhelpful in demonstrating
bursitis, although, occasionally, calcific deposits may be
present.77 Nevertheless, radiographs are usually obtained
to exclude other causes of hip pain such as OA.
Ultrasound plays an important role in the diagnosis of
bursitis as it identifies fluid in the bursa and allows the
sonographer to relate findings to symptoms.78 Trochan-
teric bursitis appears as a compressible rim-like sac of low
echogenicity over the greater trochanter. Gluteus medius
Figure 22. External snapping hip syndrome. (a) Dynamic
ultrasound image shows the gluteus maximus muscle (arrow-
heads) in transverse section lying over the greater trochanter
(arrow). (b) When the patient performs a specific hip
movement, the gluteus maximus muscle abruptly jerks away
bringing the iliotibial band into contact with the greater
trochanter accompanied by an audible snap.
9 of 12

bursitis occurs deep to the tendon of gluteus medius
(Figure 20). Interrogation using Doppler may reveal in-
creased flow in the wall of the bursal sac. If there is no
evidence of bursitis, the gluteus medius tendon should be
carefully evaluated, as enthesitis is a common cause of
trochanteric point tenderness. Ultrasound may also be
used to guide therapeutic injections.79
On T2 weighted or STIR images, bursitis demonstrates
fluid signal intensity.80,81 The adjacent tendon may also
demonstrate enthesopathic changes. An advantage of
MRI is in being able to demonstrate tendon and bone
marrow changes, which cannot be detected on ultra-
sound. MRI abnormalities in the trochanteric regions are,
however, common incidental findings in patients without
trochanteric symptoms.
Snapping hip syndrome
Snapping hip syndrome describes an audible snap or
click, which is reproduced with specific movements of the
hip accompanied by discomfort. The syndrome is common
amongst athletes and dancers.82,83 Snapping hip syndrome
may be due to external, internal or intra-articular causes.
External snapping hip is usually caused by slipping of the
iliotibial band or gluteus maximus muscle over the greater
trochanter.78,82 Internal snapping hip is caused by im-
pingement of the iliopsoas tendon over the iliopectineal
eminence.84 Intra-articular snapping hip is usually caused
by a labral tear or intra-articular loose bodies.82
Ultrasound is the preferred imaging modality for sus-
pected extra-articular snapping, as it provides real-time
anatomical visualization of the involved structures, as the
patient reproduces the painful movement. Dynamic so-
nography of internal snapping shows abnormal trapping
of part of the iliac muscle between the iliopsoas tendon
and superior pubic ramus when moving into the frog-leg
position; on moving back to the neutral position, the
tendon abruptly jerks back, thereby striking the superior
pubic ramus with an audible snap85 (Figure 21). Iliop-
soas tendinosis and bursitis may also be found in this
condition. External snapping hip results from abnormal
jerky movements of the iliotibial band or gluteus max-
imus over the greater trochanter86 (Figure 22).
MRA is often required for the evaluation of intra-
articular causes of snapping hip.
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