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
a definitive diagnosis of osteoid osteoma.
Ultrasound may be used to evaluate bursitis, joint effusions and snapping hips, as
well as guiding injections.

doi: 10.1259/img.20120023
2014 The British Institute of
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

and imaging appearances of a wide spectrum of disorders of the
hip. The role of different imaging modalities is highlighted for
each condition.
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 patient (Table 1). Radiography remains a key radiological
investigation. However, ultrasound, CT and MRI have
become increasingly routine in the diagnosis of hip disorders. 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 impingement, and it may allow definitive diagnosis of osteoid
osteoma. Ultrasound is useful to evaluate soft-tissue abnormalities, 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

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used to guide needle aspiration and injection. The injection

of a local anaesthetic into the hip joint under ultrasound or
fluoroscopic guidance may allow confirmation of the hip
as the source of symptoms.1,2

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 ligamentum 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 iliofemoral, ischiofemoral and pubofemoral ligaments reinforce 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 iliopsoas tendon. Several muscles insert onto the greater trochanter, 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

decade

Occult fracture
Osteoarthritis
Trochanteric bursitis and gluteus
medius enthesopathy
Avascular necrosis
Transient bone marrow oedema
Synovial proliferative disorders
Femoroacetabular impingement
Snapping hip
Osteoid osteoma

Third to fifth
decade
Second to fourth
decade

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 excessive 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. Anterior 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 fracture becoming displaced.7
MRI is an excellent technique for identification and
characterization of radiographically occult fractures
due to acute or chronic trauma.812 In our practice, we
perform both T1 and short tau inversionrecovery (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

high-signal bone marrow oedema and also allow assessment of soft-tissue injury (Figure 2a). Radiographs may
initially appear normal and later show periosteal thickening and a sclerotic fracture line (Figure 2b). Bone scintigraphy 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 clinical 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 Scintigraphy usually allows detection of fractures 24 h following 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, myeloid cell death follows in 612 h. After 48 h, osteocyte
death occurs, and lipocytes die within 26 days.15 This is
followed by an inflammatory response increasing vascularity, leading to the formation of granulation tissue
and fibrosis. Collapse of the subchondral bone predisposes 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 1. Normal anatomy on MR arthrogram. Coronal T1 fat-

Figure 2. Stress fracture of the femoral neck. (a) Coronal short

saturated image shows intra-articular gadolinium contrast as

high signal. The superior labrum (arrow) and transverse
ligament (arrowhead) are clearly demonstrated. The ligamentum teres can be seen attaching to the fovea (open arrow).
Hyaline cartilage appears as intermediate signal.

tau inversionrecovery 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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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 involved, the prognosis is very poor despite core decompression. 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 weightbearing 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

Figure 3. Coronal short tau inversionrecovery image demonstrates an undisplaced intracapsular fracture of the
femoral neck that was not detected on radiographs. Highsignal 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 (representing fibrosis and sclerosis) on the healthy side18
(Figure 4b,c). A joint effusion and bone marrow oedema
may also be present.1820

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 radiographic evidence of subchondral collapse. The percentage of weight-bearing femoral cortex involved with
AVN on MRI is reported to be the most reliable

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 regional migratory osteoporosis (RMO).28 In these cases,
the commonest pattern is primary involvement of the hip
followed by secondary involvement of the knee or ankle.29 There may be temporal overlap such that more than
one joint is involved at a particular time. The pathophysiology 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 demonstrates 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,

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
inversionrecovery 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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Table 2. Steinberg radiologicalclinical classification
findings for the staging of avascular necrosis (AVN) of the
femoral head
Stages

Features

Abnormal MRI but normal radiographs and

scintigraphy. AVN should be suspected if it has
already been diagnosed in the contralateral
hip
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
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
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
There is segmental flattening of the femoral
head but preservation of the joint space
There is femoral head collapse and degenerative
change

II

III

IV
V

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 subchondral 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 consider. In contrast to AVN, this condition typically occurs
in elderly females who are osteoporotic and/or overweight. 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.

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 intermediate 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 repetitive 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 reproduce 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.3840
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

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 antiinflammatory drugs. The tumour consists of a small nidus of osteoid tissue (usually ,1 cm) that demonstrates
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Figure 5. Transient osteoporosis of the left hip in a middleaged male. Coronal short tau inversionrecovery image demonstrates 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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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 undercutting labrum. A sulcus may be present at the anterosuperior acetabularlabral junction and is considered
by some to be a normal variant.4
Tears are diagnosed on MRA when intrasubstance
contrast material is demonstrated. T1 fat-saturated
sequences are therefore of particular importance when
evaluating the labrum (Figure 7). Contrast that separates
the labrum and acetabulum is typical of labral detachment. Peri-labral cysts are associated with underlying
labral tears.43,44 These cysts are usually extra-articular
and may erode into the adjacent bone.

Femoroacetabular impingement
Femoroacetabular impingement is a recently described
cause of hip pain resulting from morphological abnormalities 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 predispose to damage to the acetabular labrum and cartilage,
which is painful. Identifying these morphological abnormalities has important implications as surgical correction
may prevent the onset of OA.46,47 Arthroscopic management 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

Figure 7. Labral tear. MR arthrogram axial T1 fat-saturated

image demonstrates linear high signal (intra-articular contrast) penetrating the acetabular labrum (arrow).

cartilage disease is important because, in cases of advanced damage, joint-sparing arthroscopic treatment is
unlikely to be helpful.

Cam impingement
Cam-type deformity, typically occurring in athletic
males, describes loss of the normal sphericity of the femoral head owing to the presence of an osseous bump at the
head/neck junction, which is usually found anterolaterally49 (Figure 8). It is so-called because of the resemblance 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, anterosuperior 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

the surrounding osteoblastic response resulting in sclerosis.

shows bilateral cam deformities (osseous bumps) of the

anterolateral femoral head/neck junctions (arrows).

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Figure 11. (a) Pincer deformity due to idiopathic protrusio

Figure 9. Cam impingement. MR arthrogram coronal T1 fatsaturated 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 middleaged 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) radiographs 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

acetabuli in an 82-year-old female. Radiograph shows overlap of the femoral head (black arrow) with the ilioischial line
(white arrowheads). (b) In the same patient: the centreedge
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
centreedge angle on an AP radiograph (Figure 11b). A
value .40 has been used to define a pincer abnormality.52 A value ,25 in adults indicates abnormal undercoverage often due to developmental hip dysplasia.53 The
centreedge angle can also be measured on coronal MRI
images.54 With progressive disease, the labrum may become 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 condition, 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 between the ischial tuberosity and lesser trochanter is typically much narrower in patients with this condition than in

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 12. Ischiofemoral impingement. Axial short tau

inversionrecovery image demonstrates bursa-like formation
(arrow) in the ischiofemoral space, which is narrow (arrowheads). There are less severe changes on the contralateral side.

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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 osteochondroma. 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 bursalike formation58 (Figure 12). However, the imaging abnormalities 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 measurement of the ischiofemoral space.

Inflammatory arthropathy
Inflammatory arthropathies such as rheumatoid arthritis 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 inversionrecovery image demonstrates high
signal synovial hypertrophy (arrows) and faint low signal
bodies indicating mineralization (arrowhead).

hip joint. On plain radiographs, joint space loss is predominantly in the axial region, unlike the superior joint
space loss that is typical of OA. Longstanding inflammatory arthropathy leads to widespread cartilage
damage, resulting in circumferential loss of hip joint
space. Erosions are not a common finding. With ultrasound, an effusion and synovial hypertrophy are detected early in the course of disease (Figure 13). There are
non-specific findings on MRI, including effusion, synovial 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 iliopsoas 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 inversionrecovery (b) images show low-signal
synovial proliferation (arrows).

arthritis may be very difficult to distinguish from a noninfective inflammatory arthropathy. However, there are
findings that are more specific for infection, including
soft-tissue collections, sinus tract formation and osteomyelitis. 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 radiographs 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 effusions, subchondral bone marrow oedema, labral abnormalities and cystic subchondral lesions.62,63 There may be
associated features of femoroacetabular impingement
(see section Femoroacetabular impingement).

Figure 19. Iliopsoas bursitis in a patient with rheumatoid

arthritis. Coronal short tau inversionrecovery 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. Differentiating primary from secondary SOC may be difficult clinically 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

Synovial osteochondromatosis
Primary synovial osteochondromatosis (SOC) is a benign 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
inversionrecovery (b) images demonstrate low-signal synovial thickening (arrows) and erosions (arrowhead).

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Figure 20. Gluteus medius bursitis. Coronal short tau

inversionrecovery image shows distension of the bursa deep
to the gluteus medius tendon (arrow).
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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 calcification. 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 intermediate signal on T1 weighted sequences. Intraarticular 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
2045 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 proliferations exhibiting a reddish colour due to haemosiderin
deposition. Fibrosis, chronic inflammation and hyalinization are found in established disease.69,71,72 Immunophenotypic 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 margins 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 extend into the iliopsoas bursa. Bone erosions exhibit variable 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 inflammation, or bursitis, may arise as a result of friction
from repetitive activity, trauma, infection or the involvement 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 ischiogluteal 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 Trochanteric 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 (arrowheads) 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

A Daghir and J Teh

bursitis occurs deep to the tendon of gluteus medius

(Figure 20). Interrogation using Doppler may reveal increased 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 ultrasound. 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 impingement 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 suspected extra-articular snapping, as it provides real-time
anatomical visualization of the involved structures, as the
patient reproduces the painful movement. Dynamic sonography 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). Iliopsoas tendinosis and bursitis may also be found in this
condition. External snapping hip results from abnormal
jerky movements of the iliotibial band or gluteus maximus over the greater trochanter86 (Figure 22).
MRA is often required for the evaluation of intraarticular causes of snapping hip.

REFERENCES
1. Crawford RW, Gie GA, Ling RS, Murray DW. Diagnostic
value of intra-articular anaesthetic in primary osteoarthritis
of the hip. J Bone Joint Surg Br 1998; 80: 27981.
2. Odoom JE, Allen GM, Wilson DJ. Response to local anaesthetic injection as a predictor of successful hip surgery. Clin
Radiol 1999; 54: 4303.
3. Ghebontni L, Roger B, El-khoury J, Brasseur JL, Grenier PA.
MR arthrography of the hip: normal intra-articular structures and common disorders. Eur Radiol 2000; 10: 838.
4. Petersilge CA. From the RSNA Refresher Courses. Radiological Society of North America. Chronic adult hip
pain: MR arthrography of the hip. Radiographics 2000; 20
Spec No: S4352. doi: 10.1148/radiographics.20.suppl_1.
g00oc12s43
5. Daffner RH, Pavlov H. Stress fractures: current concepts.
AJR Am J Roentgenol 1992; 159: 24552. doi: 10.2214/
ajr.159.2.1632335

10 of 12

6. Dorne HL, Lander PH. Spontaneous stress fractures of the

femoral neck. AJR Am J Roentgenol 1985; 144: 3437. doi:
10.2214/ajr.144.2.343
7. Johansson C, Ekenman I, Tornkvist H, Eriksson E. Stress
fractures of the femoral neck in athletes. The consequence of
a delay in diagnosis. Am J Sports Med 1990; 18: 5248.
8. Rizzo PF, Gould ES, Lyden JP, Asnis SE. Diagnosis of occult
fractures about the hip. Magnetic resonance imaging compared with bone-scanning. J Bone Joint Surg Am 1993; 75:
395401.
9. Haramati N, Staron RB, Barax C, Feldman F. Magnetic
resonance imaging of occult fractures of the proximal femur.
Skeletal Radiol 1994; 23: 1922.
10. Pandey R, McNally E, Ali A, Bulstrode C. The role of MRI in
the diagnosis of occult hip fractures. Injury 1998; 29: 613.
11. Deutsch AL, Mink JH, Waxman AD. Occult fractures of the
proximal femur: MR imaging. Radiology 1989; 170: 11316.
doi: 10.1148/radiology.170.1.2909083
12. Alam A, Willett K, Ostlere S. The MRI diagnosis and
management of incomplete intertrochanteric fractures of the
femur. J Bone Joint Surg Br 2005; 87: 12535. doi: 10.1302/
0301-620X.87B9.16558
13. Holder LE, Schwarz C, Wernicke PG, Michael RH. Radionuclide bone imaging in the early detection of fractures of
the proximal femur (hip): multifactorial analysis. Radiology
1990; 174: 50915. doi: 10.1148/radiology.174.2.2404320
14. Lubovsky O, Liebergall M, Mattan Y, Weil Y, Mosheiff R.
Early diagnosis of occult hip fractures: MRI versus CT scan.
Injury 2005; 36: 78892. doi: 10.1016/j.injury.2005.01.024
15. Vogler JB 3rd, Murphy WA. Bone marrow imaging. Radiology 1988; 168: 67993. doi: 10.1148/radiology.168.3.
3043546
16. Mitchell MD, Kundel HL, Steinberg ME, Kressel HY, Alavi
A, Axel L. Avascular necrosis of the hip: comparison of MR,
CT, and scintigraphy. AJR Am J Roentgenol 1986; 147: 6771.
doi: 10.2214/ajr.147.1.67
17. Beltran J, Herman LJ, Burk JM, Zuelzer WA, Clark RN,
Lucas JG, et al. Femoral head avascular necrosis: MR imaging with clinical-pathologic and radionuclide correlation.
Radiology 1988; 166: 21520. doi: 10.1148/radiology.166.1.
3336682
18. Mitchell DG, Rao VM, Dalinka MK, Spritzer CE, Alavi A,
Steinberg ME, et al. Femoral head avascular necrosis: correlation of MR imaging, radiographic staging, radionuclide
imaging, and clinical findings. Radiology 1987; 162: 70915.
doi: 10.1148/radiology.162.3.3809484
19. Wu Z, Yan X, Liu Z, Pan S, Cao X. Avascular necrosis of the
femoral head: MR imaging with radiological and histological correlation. Chin Med J (Engl) 1998; 111: 599602.
20. Vande Berg BE, Malghem JJ, Labaisse MA, Noel HM,
Maldague BE. MR imaging of avascular necrosis and transient marrow edema of the femoral head. Radiographics 1993;
13: 50120. doi: 10.1148/radiographics.13.3.8316660
21. Steinberg ME, Hayken GD, Steinberg DR. A quantitative
system for staging avascular necrosis. J Bone Joint Surg Br
1995; 77: 3441.
22. Lafforgue P, Dahan E, Chagnaud C, Schiano A, Kasbarian M,
Acquaviva PC. Early-stage avascular necrosis of the femoral
head: MR imaging for prognosis in 31 cases with at least 2
years of follow-up. Radiology 1993; 187: 199204. doi: 10.1148/
radiology.187.1.8451413
23. Beltran J, Knight CT, Zuelzer WA, Morgan JP, Shwendeman
LJ, Chandnani VP, et al. Core decompression for avascular
necrosis of the femoral head: correlation between long-term
results and preoperative MR staging. Radiology 1990; 175:
5336. doi: 10.1148/radiology.175.2.2326478
24. Shimizu K, Moriya H, Akita T, Sakamoto M, Suguro T.
Prediction of collapse with magnetic resonance imaging of
avascular necrosis of the femoral head. J Bone Joint Surg Am
1994; 76: 21523.

Imaging 2014, 23, 20120023

Imaging the hip

25. Potter H, Moran M, Schneider R, Bansal M, Sherman C,
Markisz J. Magnetic resonance imaging in diagnosis of
transient osteoporosis of the hip. Clin Orthop 1992; 280:
2239.
26. Grimm J, Higer HP, Benning R, Meairs S. MRI of transient
osteoporosis of the hip. Arch Orthop Trauma Surg 1991; 110:
98102.
27. Guerra JJ, Steinberg ME. Distinguishing transient osteoporosis from avascular necrosis of the hip. J Bone Joint Surg Am
1995; 77: 61624.
28. Wilson AJ, Murphy WA, Hardy DC, Totty WG. Transient
osteoporosis: transient bone marrow edema? Radiology 1988;
167: 75760. doi: 10.1148/radiology.167.3.3363136
29. Cahir JG, Toms AP. Regional migratory osteoporosis. Eur J
Radiol 2008; 67: 210. doi: 10.1016/j.ejrad.2008.01.051
30. Vande Berg BC, Lecouvet FE, Koutaissoff S, Simoni P,
Malghem J. Bone marrow edema of the femoral head and
transient osteoporosis of the hip. Eur J Radiol 2008; 67: 6877.
doi: 10.1016/j.ejrad.2008.01.061
31. Bloem JL. Transient osteoporosis of the hip: MR imaging.
Radiology 1988; 167: 7535. doi: 10.1148/radiology.167.3.
3363135
32. Vande Berg BC, Malghem JJ, Lecouvet FE, Jamart J,
Maldague BE. Idiopathic bone marrow edema lesions of the
femoral head: predictive value of MR imaging findings.
Radiology 1999; 212: 52735. doi: 10.1148/radiology.212.2.
r99au03527
33. Hayes CW, Conway WF, Daniel WW. MR imaging of bone
marrow edema pattern: transient osteoporosis, transient
bone marrow edema syndrome, or osteonecrosis. Radiographics 1993; 13: 100111; discussion 1012. doi: 10.1148/
radiographics.13.5.8210586
34. Yamamoto T, Schneider R, Bullough PG. Subchondral insufficiency fracture of the femoral head: histopathologic
correlation with MRI. Skeletal Radiol 2001; 30: 24754.
35. Assoun J, Richardi G, Railhac JJ, Baunin C, Fajadet P, Giron J,
et al. Osteoid osteoma: MR imaging versus CT. Radiology
1994; 191: 21723. doi: 10.1148/radiology.191.1.8134575
36. Allen SD, Saifuddin A. Imaging of intra-articular osteoid
osteoma. Clin Radiol 2003; 58: 84552.
37. Lindner NJ, Ozaki T, Roedl R, Gosheger G, Winkelmann W,
Wortler K. Percutaneous radiofrequency ablation in osteoid
osteoma. J Bone Joint Surg Br 2001; 83: 3916.
38. Czerny C, Hofmann S, Neuhold A, Tschauner C, Engel A,
Recht MP, et al. Lesions of the acetabular labrum: accuracy
of MR imaging and MR arthrography in detection and
staging. Radiology 1996; 200: 22530.
39. Hodler J, Yu JS, Goodwin D, Haghighi P, Trudell D, Resnick D.
MR arthrography of the hip: improved imaging of the
acetabular labrum with histologic correlation in cadavers. AJR
Am J Roentgenol 1995; 165: 88791. doi: 10.2214/ajr.165.4.
7676987
40. Petersilge CA, Haque MA, Petersilge WJ, Lewin JS,
Lieberman JM, Buly R. Acetabular labral tears: evaluation
with MR arthrography. Radiology 1996; 200: 2315. doi:
10.1148/radiology.200.1.8657917
41. Lecouvet FE, Vande Berg BC, Malghem J, Lebon CJ, Moysan P,
Jamart J, et al. MR imaging of the acetabular labrum: variations
in 200 asymptomatic hips. AJR Am J Roentgenol 1996; 167:
10258. doi: 10.2214/ajr.167.4.8819406
42. Cotten A, Boutry N, Demondion X, Paret C, Dewatre F,
Liesse A, et al. Acetabular labrum: MRI in asymptomatic
volunteers. J Comput Assist Tomogr 1998; 22: 17.
43. Hase T, Ueo T. Acetabular labral tear: arthroscopic diagnosis
and treatment. Arthroscopy 1999; 15: 13841. doi: 10.1053/
ar.1999.v15.0150131
44. Schnarkowski P, Steinbach LS, Tirman PF, Peterfy CG,
Genant HK. Magnetic resonance imaging of labral cysts of
the hip. Skeletal Radiol 1996; 25: 7337.

birpublications.org

45. Beck M, Kalhor M, Leunig M, Ganz R. Hip morphology

influences the pattern of damage to the acetabular cartilage:
femoroacetabular impingement as a cause of early osteoarthritis of the hip. J Bone Joint Surg Br 2005; 87: 101218. doi:
10.1302/0301-620X.87B7.15203
46. Murphy S, Tannast M, Kim YJ, Buly R, Millis MB. Debridement of the adult hip for femoroacetabular impingement: indications and preliminary clinical results. Clin
Orthop Relat Res 2004; 429: 17881.
47. Guanche CA, Bare AA. Arthroscopic treatment of femoroacetabular impingement. Arthroscopy 2006; 22: 95106. doi:
10.1016/j.arthro.2005.10.018
48. Byrd JW, Jones KS. Arthroscopic management of femoroacetabular impingement in athletes. Am J Sports Med 2011;
39(Suppl.) 7S13S. doi: 10.1177/0363546511404144
49. Ito K, Minka MA 2nd, Leunig M, Werlen S, Ganz R.
Femoroacetabular impingement and the cam-effect. A MRIbased quantitative anatomical study of the femoral headneck offset. J Bone Joint Surg Br 2001; 83: 1716.
50. Kassarjian A. Hip MR arthrography and femoroacetabular
impingement. Semin Musculoskelet Radiol 2006; 10: 20819.
doi: 10.1055/s-2006-957174
51. Tannast M, Siebenrock KA, Anderson SE. Femoroacetabular
impingement: radiographic diagnosiswhat the radiologist
should know. AJR Am J Roentgenol 2007; 188: 154052. doi:
10.2214/AJR.06.0921
52. Kutty S, Schneider P, Faris P, Kiefer G, Frizzell B, Park R,
et al. Reliability and predictability of the centre-edge angle
in the assessment of pincer femoroacetabular impingement.
Int Orthop 2012; 36: 50510. doi: 10.1007/s00264-011-1302-y
53. Fredensborg N. The CE angle of normal hips. Acta Orthop
Scand 1976; 47: 4035.
54. Chen L, Boonthathip M, Cardoso F, Clopton P, Resnick D.
Acetabulum protrusio and center edge angle: new MRimaging measurement criteriaa correlative study with
measurement derived from conventional radiography.
Skeletal Radiol 2009; 38: 1239.
55. Leunig M, Beck M, Kalhor M, Kim YJ, Werlen S, Ganz R.
Fibrocystic changes at anterosuperior femoral neck: prevalence in hips with femoroacetabular impingement. Radiology
2005; 236: 23746. doi: 10.1148/radiol.2361040140
56. Gunther KP, Hartmann A, Aikele P, Aust D, Ziegler J. Large
femoral-neck cysts in association with femoroacetabular
impingement. A report of three cases. J Bone Joint Surg Am
2007; 89: 86370. doi: 10.2106/JBJS.F.00885
57. Shin AY, Morin WD, Gorman JD, Jones SB, Lapinsky AS.
The superiority of magnetic resonance imaging in differentiating the cause of hip pain in endurance athletes. Am J
Sports Med 1996; 24: 16876.
58. Torriani M, Souto SC, Thomas BJ, Ouellette H, Bredella MA.
Ischiofemoral impingement syndrome: an entity with hip pain
and abnormalities of the quadratus femoris muscle. AJR Am J
Roentgenol 2009; 193: 18690. doi: 10.2214/AJR.08.2090
59. Tosun O, Algin O, Yalcin N, Cay N, Ocakoglu G,
Karaoglanoglu M. Ischiofemoral impingement: evaluation
with new MRI parameters and assessment of their reliability.
Skeletal Radiol 2012; 41: 57587. doi: 10.1007/s00256-011-1257-5
60. Patti JW, Ouellette H, Bredella MA, Torriani M. Impingement of lesser trochanter on ischium as a potential cause for
hip pain. Skeletal Radiol 2008; 37: 93941. doi: 10.1007/
s00256-008-0551-3
61. Teh J, Wilson DJ. Imaging of the irritable hip and hip infection. In: Baert AL, Davies AMJ, Johnson K, Whitehouse
RW, eds. Imaging of the hip and bony pelvis. Dordrecht,
Netherlands: Springer; 2005. pp. 14158.
62. Boutry N, Paul C, Leroy X, Fredoux D, Migaud H, Cotten A.
Rapidly destructive osteoarthritis of the hip: MR imaging
findings. AJR Am J Roentgenol 2002; 179: 65763. doi:
10.2214/ajr.179.3.1790657

11 of 12

A Daghir and J Teh

63. Horii M, Kubo T, Hirasawa Y. Radial MRI of the hip with
moderate osteoarthritis. J Bone Joint Surg Br 2000; 82: 3648.
64. Villacin AB, Brigham LN, Bullough PG. Primary and secondary synovial chondrometaplasia: histopathologic and
clinicoradiologic differences. Hum Pathol 1979; 10: 43951.
65. Milgram JW. Synovial osteochondromatosis: a histopathological study of thirty cases. J Bone Joint Surg Am 1977; 59:
792801.
66. Davis RI, Hamilton A, Biggart JD. Primary synovial chondromatosis: a clinicopathologic review and assessment of
malignant potential. Hum Pathol 1998; 29: 6838.
67. Goldberg RP, Weissman BN, Naimark A, Braunstein E.
Femoral neck erosions: sign of hip joint synovial disease.
AJR Am J Roentgenol 1983; 141: 10711. doi: 10.2214/
ajr.141.1.107
68. Kim SH, Hong SJ, Park JS, Cho JM, Kim EY, Ahn JM, et al.
Idiopathic synovial osteochondromatosis of the hip: radiographic and MR appearances in 15 patients. Korean J Radiol
2002; 3: 2549.
69. Granowitz SP, DAntonio J, Mankin HL. The pathogenesis
and long-term end results of pigmented villonodular synovitis. Clin Orthop 1976; 114: 33551.
70. Rao AS, Vigorita VJ. Pigmented villonodular synovitis (giantcell tumor of the tendon sheath and synovial membrane). A
review of eighty-one cases. J Bone Joint Surg Am 1984; 66: 7694.
71. Dorwart RH, Genant HK, Johnston WH, Morris JM. Pigmented villonodular synovitis of synovial joints: clinical,
pathologic, and radiologic features. AJR Am J Roentgenol
1984; 143: 87785. doi: 10.2214/ajr.143.4.877
72. Bravo SM, Winalski CS, Weissman BN. Pigmented villonodular synovitis. Radiol Clin North Am 1996; 34: 31126, xxi.
73. Mahendra G, Kliskey K, Athanasou NA. Immunophenotypic distinction between pigmented villonodular synovitis
and haemosiderotic synovitis. J Clin Pathol 2010; 63: 758.
doi: 10.1136/jcp.2009.070342
74. Cotten A, Flipo RM, Chastanet P, Desvigne-Noulet MC,
Duquesnoy B, Delcambre B. Pigmented villonodular

12 of 12

75.

76.

77.

78.

79.
80.

81.
82.
83.
84.

85.

86.

synovitis of the hip: review of radiographic features in 58

patients. Skeletal Radiol 1995; 24: 16.
Hughes TH, Sartoris DJ, Schweitzer ME, Resnick DL. Pigmented villonodular synovitis: MRI characteristics. Skeletal
Radiol 1995; 24: 712.
Woodley SJ, Mercer SR, Nicholson HD. Morphology of the
bursae associated with the greater trochanter of the femur.
J Bone Joint Surg Am 2008; 90: 28494. doi: 10.2106/JBJS.
G.00257
Lagier R, Vasey H. Calcium pyrophosphate dihydrate
(CPPD) crystal deposition in the trochanteric bursa of a patient with hip osteoarthritis. J Rheumatol 1986; 13: 4734.
Pelsser V, Cardinal E, Hobden R, Aubin B, Lafortune M.
Extraarticular snapping hip: sonographic findings. AJR Am J
Roentgenol 2001; 176: 6773. doi: 10.2214/ajr.176.1.1760067
Cho KH, Park BH, Yeon KM. Ultrasound of the adult hip.
Semin Ultrasound CT MR 2000; 21: 21430.
Wunderbaldinger P, Bremer C, Schellenberger E, Cejna M,
Turetschek K, Kainberger F. Imaging features of iliopsoas
bursitis. Eur Radiol 2002; 12: 40915. doi: 10.1007/
s003300101041
Kozlov DB, Sonin AH. Iliopsoas bursitis: diagnosis by MRI.
J Comput Assist Tomogr 1998; 22: 6258.
Allen WC, Cope R. Coxa saltans: the snapping hip revisited.
J Am Acad Orthop Surg 1995; 3: 3038.
Schaberg JE, Harper MC, Allen WC. The snapping hip
syndrome. Am J Sports Med 1984; 12: 3615.
Cardinal E, Buckwalter KA, Capello WN, Duval N. US of
the snapping iliopsoas tendon. Radiology 1996; 198: 5212.
doi: 10.1148/radiology.198.2.8596860
Deslandes M, Guillin R, Cardinal E, Hobden R, Bureau NJ.
The snapping iliopsoas tendon: new mechanisms using
dynamic sonography. AJR Am J Roentgenol 2008; 190:
57681. doi: 10.2214/AJR.07.2375
Choi YS, Lee SM, Song BY, Paik SH, Yoon YK. Dynamic
sonography of external snapping hip syndrome. J Ultrasound
Med 2002; 21: 7538.

Imaging 2014, 23, 20120023