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Association of hip pain with radiographic evidence of hip osteoarthritis: diagnostic test study

BMJ 2015; 351 doi: (Published 02 December 2015) Cite this as: BMJ 2015;351:h5983
  1. Chan Kim, instructor12,
  2. Michael C Nevitt, professor3,
  3. Jingbo Niu, research assistant professor1,
  4. Mary M Clancy, project manager1,
  5. Nancy E Lane, professor of medicine and rheumatology4,
  6. Thomas M Link, professor of radiology5,
  7. Steven Vlad, assistant professor of medicine and epidemiology6,
  8. Irina Tolstykh, data and statistical specialist3,
  9. Pia M. Jungmann, resident in radiology7,
  10. David T Felson, professor of medicine and epidemiology18,
  11. Ali Guermazi, professor of radiology9
  1. 1Clinical Epidemiology Research and Training Unit, Boston University School of Medicine, 650 Albany St, Room X200, Boston, MA 02116, USA
  2. 2Department of Rheumatology, Boston University School of Medicine, Boston, MA, USA
  3. 3Department of Epidemiology and Biostatistics, University of California, San Francisco, CA, USA
  4. 4Department of Rheumatology, University of California, Davis, CA, USA
  5. 5Department of Rheumatology, University of California, San Francisco, CA, USA
  6. 6Department of Rheumatology, Tufts Medical Center, Boston, MA, USA
  7. 7Department of Diagnostic and Interventional Radiology, Technische Universität München, Munich, Germany
  8. 8NIHR Manchester Biomedical Research Unit, Manchester, UK
  9. 9Department of Radiology, Boston University School of Medicine, Boston, MA, USA
  1. Correspondence to: C Kim bevochan{at}
  • Accepted 24 October 2015


Study question Is there concordance between hip pain and radiographic hip osteoarthritis?

Methods In this diagnostic test study, pelvic radiographs were assessed for hip osteoarthritis in two cohorts: the Framingham Osteoarthritis Study (community of Framingham, Massachusetts) and the Osteoarthritis Initiative (a multicenter longitudinal cohort study of osteoarthritis in the United States). Using visual representation of the hip joint, participants reported whether they had hip pain on most days and the location of the pain: anterior, groin, lateral, buttocks, or low back. In the Framingham study, participants with hip pain were also examined for hip pain with internal rotation. The authors analysed the agreement between radiographic hip osteoarthritis and hip pain, and for those with hip pain suggestive of hip osteoarthritis they calculated the sensitivity, specificity, positive predictive value, and negative predictive value of radiographs as the diagnostic test.

Study answer and limitations In the Framingham study (n=946), only 15.6% of hips in patients with frequent hip pain showed radiographic evidence of hip osteoarthritis, and 20.7% of hips with radiographic hip osteoarthritis were frequently painful. The sensitivity of radiographic hip osteoarthritis for hip pain localised to the groin was 36.7%, specificity 90.5%, positive predictive value 6.0%, and negative predictive value 98.9%. Results did not differ much for hip pain at other locations or for painful internal rotation. In the Osteoarthritis Initiative study (n=4366), only 9.1% of hips in patients with frequent pain showed radiographic hip osteoarthritis, and 23.8% of hips with radiographic hip osteoarthritis were frequently painful. The sensitivity of definite radiographic hip osteoarthritis for hip pain localised to the groin was 16.5%, specificity 94.0%, positive predictive value 7.1%, and negative predictive value 97.6%. Results also did not differ much for hip pain at other locations.

What this study adds Hip pain was not present in many hips with radiographic osteoarthritis, and many hips with pain did not show radiographic hip osteoarthritis. Most older participants with a high suspicion for clinical hip osteoarthritis (groin or anterior pain and/or painful internal rotation) did not have radiographic hip osteoarthritis, suggesting that in many cases, hip osteoarthritis might be missed if diagnosticians relied solely on hip radiographs.

Funding, competing interests, data sharing See the full paper on for funding. The authors have no competing interests. Additional data are available from bevochan{at}


  • Contributors: CK, MCN, DTF, and AG conceived and designed the study. CK, NEL, TL, PMJ, DTF, and AG acquired the data. CK, JN, SV, MMC, IT, MCN, DTF, and AG analysed and interpreted the data. CK drafted the article, and all authors were responsible for revision of critical important intellectual content. CK is the guarantor. DTF and AG contributed equally to this paper.

  • Funding: This study was Supported by the National Institutes of Health (NIH AR47785, AG18393, and AR47785), National Institute of Arthritis and Musculoskeletal and Skin Diseases (BAA-NHLBI-AR-10-06). The Osteoarthritis Initiative is a public-private partnership comprised of five contracts (N01-AR-2-2258; N01-AR-2-2259; N01-AR-2-2260; N01-AR-2-2261; N01-AR-2-2262) funded by the NIH, a branch of the Department of Health and Human Services, and conducted by the Osteoarthritis Initiative Study Investigators. Private funding partners include Merck Research Laboratories, Novartis Pharmaceuticals, GlaxoSmithKline, and Pfizer. Private sector funding for the Osteoarthritis Initiative is managed by the Foundation for the NIH. This project was also funded by the National Institute of Arthritis and Musculoskeletal and Skin Diseases, NIH, under Contract No HHSN268201000019C. This manuscript was prepared using, in part, an Osteoarthritis Initiative public use dataset and does not necessarily reflect the opinions or views of the Osteoarthritis Initiative investigators, the NIH, or the private funding partners.

  • Competing interests: All authors have completed the ICMJE uniform disclosure form at and declare: no support from any organisation for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work.

  • Ethical approval: The Framingham study was approved by the institutional review board of Boston University Medical Center. The Osteoarthritis Initiative study was approved by the institutional review board of University of California, San Francisco.

  • Data sharing: For additional data from the study, contact the corresponding author (bevochan{at} Additional data from the Osteoarthritis Initiative study are available at

  • Transparency: The manuscript’s guarantor (CK) affirms that this manuscript is an honest, accurate, and transparent account of the study being reported; that no important aspects of the study have been omitted; and that any discrepancies from the study as planned (and, if relevant, registered) have been explained.

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