How Hip Pain Is Assessed: Clinical Examination, X-ray, Ultrasound, MRI and Other Tests

Short answer: Hip-pain assessment starts with the symptom pattern, medical history and physical examination—not automatically with an MRI. The clinician may compare walking, hip movement, strength, tendon loading, joint-provocation tests and neurological findings. X-ray, ultrasound, MRI, blood tests or other investigations are considered when they answer a defined question and are likely to change treatment, referral or activity advice.

The correct test depends on where the pain may originate. Deep groin pain with restricted rotation, focal outer-hip pain, buttock pain with leg tingling and sudden inability to bear weight require different assessment pathways. No single examination manoeuvre or scan finding should be interpreted in isolation.

When hip pain needs urgent assessment

Seek urgent medical assessment if:

• you cannot stand or bear weight after a fall, collision or sudden injury;
• the leg appears shortened, rotated or visibly deformed;
• pain is severe or rapidly worsening with fever, serious illness, redness, warmth or marked swelling;
• there is new loss of bladder or bowel control, saddle numbness or rapidly worsening leg weakness;
• the leg becomes cold, pale or blue, or develops substantial new one-sided swelling;
• there is progressive rest or night pain, unexplained weight loss, a mass or a history of cancer; or
• pain occurs with chest pain, breathlessness, collapse or coughing blood.

Older adults and people with osteoporosis may sustain a fracture after a relatively minor fall. Taking a few steps does not completely exclude a fracture. For a life-threatening emergency in Singapore, call SCDF 995.^[1] The Pain Relief Clinic is not an emergency service.

1. The history defines the clinical question

A useful hip-pain history may include:

• the exact location: groin, front of thigh, outer hip, buttock, sitting bone or lower back;
• whether onset followed a fall, twist, sprint, training increase or no clear event;
• which movements provoke pain: walking, pivoting, stairs, rising, sitting, lying on the side or putting on shoes;
• clicking, catching, true locking, giving way or stiffness;
• pain below the knee, tingling, numbness or weakness;
• fever, weight loss, night symptoms, urinary, abdominal or reproductive symptoms;
• osteoporosis, cancer, inflammatory disease, diabetes, steroid exposure or previous surgery;
• medication and treatment already tried; and
• the function that matters: sleep, desk work, driving, walking, sport or caregiving.

The question is not simply “What structure is abnormal?” It is “Which finding best explains this patient’s symptoms, and would identifying it change management?”

2. Walking and functional assessment

The clinician may observe walking speed, stride, limp, trunk shift and ability to load each leg. Sit-to-stand, stairs, a step-down, single-leg stance, squat or a sport-specific movement may be selected according to the patient’s symptoms and safety.

Functional tests help show what the patient can do and what provokes symptoms. They do not identify one tissue by themselves. A limp may occur with joint pain, tendon pain, weakness, fracture, nerve problems or fear of loading.

If walking is the main problem, see Why Does My Hip Hurt When Walking?

3. Hip range-of-motion examination

Active movement shows how the patient moves the leg. Passive movement allows the clinician to compare available range, stiffness and symptom reproduction when the hip is moved for the patient.

Internal and external rotation, flexion, extension, abduction and adduction may be assessed. Reduced rotation with groin pain can support a hip-joint question, but guarding, pain sensitivity and muscle tension can also restrict movement.

4. Strength and resisted-loading tests

Strength testing may include hip flexors, extensors, abductors, adductors and rotators, as well as the knee and ankle when neurological involvement is possible.

Resisted movement can help assess whether a muscle or tendon loading pattern reproduces pain. Examples include:

• resisted hip abduction for an outer-hip or gluteal-tendon question;
• resisted hip flexion for an anterior hip or iliopsoas question;
• resisted adduction for an inner-thigh or adductor question; and
• resisted knee flexion or hip extension for a proximal hamstring question.

Pain during resistance does not prove a tendon tear. Strength, location, injury mechanism and other tests must agree.

5. Palpation

Palpation may identify tenderness over the greater trochanter, gluteal tendons, hip flexors, adductors, sitting bone or other accessible tissues. Skin warmth, swelling, bruising, a lump or a pressure injury may also be detected.

Tenderness is common and is not a diagnosis by itself. Deep structures inside the hip cannot be reliably diagnosed simply by pressing the skin.

6. Hip-joint provocation tests

Selected tests move the hip into positions that may reproduce joint or surrounding-tissue symptoms. Common examples include:

• FADIR: flexion, adduction and internal rotation;
• FABER: flexion, abduction and external rotation;
• log roll: gentle rotation of the relaxed leg; and
• scour or quadrant testing: controlled loading through a moving hip.

These tests may support a hip-joint pattern when they reproduce familiar pain, but they do not independently prove impingement, a labral tear or arthritis. Imaging findings and symptoms also need correlation.

7. Tests for outer-hip and gluteal-tendon pain

Assessment may include tenderness over the greater trochanter, resisted hip abduction, single-leg stance and selected positions that compress or load the gluteal tendons. The patient’s response to walking, stairs and side-lying also matters.

A single positive test cannot reliably separate tendon change, bursal involvement and referred pain. The clinician should also assess the hip joint and lower back where appropriate.

8. Lumbar and neurological examination

Buttock, groin or thigh pain can be referred from the lumbar spine. When symptoms include burning pain, tingling, numbness, weakness or pain below the knee, examination may include:

• lumbar movement;
• leg strength in relevant nerve distributions;
• sensation and reflexes;
• straight-leg-raise testing; and
• slump or other neural-tension testing where appropriate.

A positive straight-leg raise does not automatically prove a slipped disc. It is interpreted with the symptom distribution and neurological findings. Similarly, a normal hip scan does not exclude a spinal or nerve contributor.

9. Examination beyond the hip

Groin and hip-region pain may sometimes arise from a hernia, abdomen, pelvis, urinary or reproductive system. Vascular and skin problems can also mimic musculoskeletal pain. Associated symptoms determine whether an appropriate examination or referral outside the hip is needed.

When is an X-ray considered?

X-rays show bones, joint-space changes, alignment, fracture, some forms of arthritis and certain hip shapes. They may be considered:

• after trauma or when fracture is suspected;
• for chronic hip pain when a bone or joint cause is being assessed;
• when osteoarthritis, dysplasia or impingement-related shape is relevant; or
• before some procedures or referrals.

The American College of Radiology rates pelvis and hip radiography as usually appropriate initial imaging for chronic hip pain.^[2] X-rays use ionising radiation, but the dose and benefit are considered for the individual clinical question.

A normal X-ray does not exclude early bone stress injury, a labral problem, tendon disorder or referred spinal pain. Conversely, arthritis or hip-shape findings on X-ray may not be the cause of symptoms.

When is ultrasound considered?

Ultrasound can assess superficial soft tissues in real time and may be used for:

• gluteal or proximal hamstring tendon questions;
• bursal fluid or superficial swelling;
• dynamic assessment of selected snapping tendons;
• a suspected hernia in an appropriate pathway; or
• guidance for selected injections or aspirations.

Ultrasound is operator-dependent and does not provide the same overview of bone marrow, cartilage, labrum and deep joint as MRI. A scan can show tendon changes that are not necessarily painful.

When is MRI considered?

MRI uses a magnetic field and radiofrequency signals rather than ionising radiation. It can assess bone marrow, cartilage, labrum, tendons, muscles and other soft tissues.

Hip or pelvis MRI may be considered when:

• a suspected occult fracture or bone stress injury is not explained by X-ray;
• osteonecrosis is a concern;
• a significant tendon tear or muscle injury may change management;
• persistent symptoms suggest a labral, cartilage or other intra-articular problem;
• pain remains unexplained after assessment and initial imaging; or
• results are needed for a defined procedural or referral decision.

MRI is not automatically the first or most useful test for every hip symptom. The scanned region matters: lumbar MRI may be more appropriate when neurological and spinal findings dominate.

Standard MRI versus MR arthrography

A standard MRI may answer many hip questions. MR arthrography involves contrast placed into the joint before imaging and may be considered for selected detailed labral or cartilage questions. It is more invasive and is not required for every suspected labral problem.

The choice depends on the suspected condition, scanner and protocol, prior imaging, patient suitability and whether the result will change management.

When is CT considered?

CT uses ionising radiation and provides detailed bone imaging. It may be considered for complex fracture assessment, detailed bony anatomy, surgical planning or another specific question that X-ray and MRI do not answer adequately.

When are blood tests useful?

Blood tests are not routine for every mechanical hip pain presentation. They may be considered when infection, inflammatory arthritis, metabolic bone disease or another systemic condition is suspected. Results are interpreted with symptoms and examination; a single inflammatory marker does not establish a diagnosis.

What about diagnostic injections?

A carefully targeted local anaesthetic injection may sometimes help assess whether pain arises from inside the hip joint or another specific structure. The response is interpreted alongside the history, examination and imaging.

Diagnostic injections are not perfect. Relief may be incomplete, temporary or affected by spread of medication. A response does not automatically prove that surgery or repeated injection is required.

Why scan findings may not equal the pain source

Imaging commonly detects age-related or incidental changes. A labral abnormality, tendon change, hip-shape variation or arthritis may be present without causing the patient’s current pain.

A useful report should therefore be matched against:

• the exact symptom location and trigger;
• examination findings;
• the severity of functional limitation;
• other possible pain sources; and
• the decision the scan was intended to guide.

Patient-specific testing scenarios

If you have deep groin pain and stiffness

Hip-joint examination and an X-ray may be the appropriate starting point. MRI may be considered if symptoms, examination and initial imaging leave a labral, cartilage, bone-marrow or other management-changing question.

If the outer hip hurts when lying on your side

Clinical assessment of gluteal tendons, strength, single-leg loading and compression may be sufficient to begin treatment. Ultrasound or MRI may help when a substantial tear is suspected or symptoms persist despite an appropriate plan.

If buttock pain travels down the leg

Lumbar and neurological examination becomes important. Straight-leg-raise or slump testing may be relevant. The correct scan, if needed, may be lumbar rather than hip MRI.

If pain began after a fall and you cannot bear weight

Urgent fracture assessment is required. X-ray is commonly used first, but further imaging may be needed if clinical concern remains despite negative X-rays.

If you want an MRI for reassurance

Discuss what result would change the plan. An examination or X-ray may answer the main question more efficiently, while unnecessary imaging can reveal incidental findings that create confusion. MRI is valuable when appropriately targeted.

If physiotherapy has not helped

Reassess the diagnosis, exercise dose and progression before selecting a scan. Imaging may be appropriate when symptoms have not responded as expected and a defined result could alter treatment or referral.

If you need to return to work quickly

The assessment should define required walking, sitting, lifting and stair demands. Testing may clarify safety or diagnosis, but obtaining a scan does not itself restore function or guarantee recovery within a fixed period.

Integrated doctor and physiotherapy assessment

The Pain Relief Clinic has in-house physiotherapists for integrated management with the licensed medical doctor. Where physiotherapy is clinically appropriate, this can align medical screening, hip and lumbar examination, movement assessment, imaging decisions, rehabilitation and referral planning.

Integrated care may be useful when symptoms overlap across the hip, tendons, lower back and nerves or when previous physiotherapy has not helped. Physiotherapists practising in Singapore are regulated by the Allied Health Professions Council and require registration and a valid Practising Certificate.^[3]

Insurance referrals and supporting paperwork

The clinic may assist with clinically appropriate referrals and supporting paperwork for insurance claims. Coverage, required documents, pre-authorisation and reimbursement depend on the patient’s policy and insurer. A referral, form or medical report does not guarantee approval or payment.

Before X-ray, ultrasound, MRI, physiotherapy, an injection or specialist consultation, patients may wish to ask whether their insurer requires a doctor’s referral, panel provider, pre-authorisation, itemised invoice, imaging report or medical report.

Frequently asked questions

Can a clinical examination diagnose hip pain without a scan?

Often it can establish a reasonable working diagnosis and safe initial plan. Imaging is added when it is needed to answer a specific question or change management.

Is MRI always better than X-ray?

No. X-ray is useful for fractures, arthritis, alignment and hip shape. MRI is better for many bone-marrow and soft-tissue questions. The useful test is the one matched to the suspected condition.

Does a positive FADIR test mean I have hip impingement?

No. It may reproduce a hip-joint pattern but is not specific enough to prove impingement or a labral tear on its own.

Is straight-leg raise a hip test?

It is mainly used to assess neural sensitivity in a lumbar or sciatic-type presentation. It may reproduce hip-region symptoms, but the result must be interpreted with neurological and spinal findings.

Can ultrasound diagnose a labral tear?

Ultrasound is useful for several superficial and dynamic soft-tissue questions but is not generally the main test for detailed assessment of the deep hip labrum.

What if my X-ray is normal but the hip still hurts?

A normal X-ray does not exclude tendon, labral, early bone stress, nerve or referred-pain problems. The next step depends on the history and examination rather than ordering every possible scan.

Key points

• Hip-pain assessment starts with the history, functional needs and examination.
• No single clinical test or scan finding proves the pain source by itself.
• X-ray, ultrasound, MRI and CT answer different questions.
• The correct scan region depends on whether the suspected source is hip, pelvis or lumbar spine.
• Testing is most useful when the result may change treatment, referral or safety advice.

Arrange a hip-pain assessment in Singapore

If hip pain persists, limits walking, sleep or work, or has not improved with an initial plan, a structured assessment can help determine whether rehabilitation, an X-ray, ultrasound, MRI, medical treatment or referral may be appropriate.

The Pain Relief Clinic
350 Orchard Road, #10-00 Shaw House
Singapore 238868
Call or WhatsApp: +65 9068 9605

Not every investigation or treatment discussed on this page is required, offered or recommended by the clinic. Availability and permissible use of tests, medicines, devices, injections, procedures and emerging treatments in Singapore may change with evolving Ministry of Health, Health Sciences Authority and Singapore Medical Council requirements. Individual decisions require clinical assessment and should follow current Singapore regulations and professional guidance.

References

1. Singapore Civil Defence Force. Emergency Medical Services.
2. American College of Radiology. ACR Appropriateness Criteria: Chronic Hip Pain.
3. Allied Health Professions Council Singapore. Registers of Allied Health Professionals.

Disclaimer: This information is provided for general reference only and should be used in consultation with your licensed medical doctor. It is not a diagnosis or a substitute for personalised medical advice. Seek urgent care for severe, rapidly worsening or warning-feature symptoms.

Reviewed by Dr Terence Tan — 13 September 2026