Hip Pain With a Normal X-Ray: What Else Could It Be?

Hip pain with a normal X-ray is common because X-rays mainly show bone, while many causes of hip pain involve soft tissue such as tendons or the cartilage rim of the socket. Pain can also come from the lower back, and some early bone stress injuries do not show on X-ray at first.

This guide is for adults who have had a hip X-ray reported as normal and still have pain. It explains what the X-ray can and cannot show and what to discuss next. It cannot diagnose the cause of your pain.

The NHS advises calling emergency services or going to an emergency department if you have severe pain after a fall or injury, cannot walk or put weight on the leg, or have tingling or loss of feeling in the hip or leg after an injury. Do not drive yourself.

Get urgent same-day advice if severe hip pain starts suddenly without an injury, if the hip is hot and swollen, if the skin around it changes colour, or if you feel generally unwell with a high temperature. A hot, swollen hip with fever can be a joint infection.

If pain spreads down the back of the leg, the NHS lists these as emergencies:

• Leg pain on both sides, or severe or worsening weakness or numbness in both legs.
• Numbness around the genitals or back passage.
• New difficulty passing urine, or losing control of your bladder or bowels.

A hip X-ray is good at showing bone shape, fractures that are already visible, and the joint space narrowing and bone spurs seen in established arthritis. A normal report usually means none of these were seen clearly.

It does not show tendons, muscles, the labrum or cartilage directly. OrthoInfo, the patient site of the American Academy of Orthopaedic Surgeons, notes that MRI gives better images of soft tissue than X-rays. Read the full report, check which views were taken, and ask whether anything was described as minor rather than absent.

Osteoarthritis of the hip often causes pain in the groin or thigh that can spread to the buttock or knee, with stiffness after rest. The NHS says a GP may suspect it from symptoms and examination, particularly in people aged 45 or over whose pain worsens with use and whose morning stiffness is absent or brief.

According to the NHS, X-rays are not usually needed to diagnose osteoarthritis and are mainly used to rule out other causes. So a normal X-ray does not settle the question either way. Ask how your clinician weighs your symptoms and examination against the image, and what would change their view.

The labrum is a ring of cartilage around the hip socket. OrthoInfo explains that tears can occur with femoroacetabular impingement, where the bones of the hip are shaped so that they rub together. Pain is often in the groin and can be sharp with turning, twisting or squatting, or a dull ache.

An X-ray can show the bone shape linked with impingement, but not the labrum itself. OrthoInfo describes MRI as helping identify labral and cartilage damage, sometimes with dye injected into the joint to make it clearer. Whether that scan is worthwhile depends on your examination and the likely treatment, so discuss it with your clinician.

Pain on the outside of the hip that is worse lying on that side, climbing stairs or standing on one leg may be greater trochanteric pain syndrome. Healthdirect Australia describes it as irritation of the tendons that attach the buttock muscles to the side of the hip. It is not a form of arthritis and is more common in women and people aged 40 to 60.

Healthdirect says no tests are required to diagnose it; the diagnosis comes from history and examination, and imaging is not routine. A normal X-ray is therefore expected. Exercise to strengthen the buttock muscles and changing aggravating positions are central to management, and recovery can take months.

Healthdirect suggests seeing a doctor if outer hip pain does not improve after about six weeks of self-care, or if it gets worse.

Pain in the buttock that runs down the back of the leg, with tingling, numbness or weakness, may come from an irritated nerve in the lower back, known as sciatica. A hip X-ray does not image the spine. Tell your clinician if movement, coughing or sneezing makes the pain worse.

Bone stress injuries develop when bone is repeatedly overloaded, for example after a quick increase in running or training. OrthoInfo notes that early X-rays may look normal because bone swelling cannot be seen, while MRI can show it. People with weaker bones, such as those with osteoporosis, can develop stress fractures during ordinary activity. Pain that is worsening with weight-bearing, causing a limp or aching at night needs prompt review.

Bring the full X-ray report and a note of where the pain sits, what triggers it and any recent change in activity. These questions can help.

• Which causes does a normal X-ray make less likely, and which can it not rule out?
• Does my examination point to the joint, the outer hip tendons or my back?
• Would an MRI change what we do next, or should I try a structured exercise plan first?
• Given my activity and bone health, should a stress injury be considered?
• Would a physiotherapy or musculoskeletal service assessment help?
• Which new symptoms should make me seek help sooner, and when should we review progress?

On SameCase, patients and verified doctors share de-identified cases. Reading how others with hip pain and a normal X-ray described where the pain sat, what tests followed and how assessments were reasoned can help you prepare clearer questions. Similar cases cannot diagnose your pain or tell you which scan or treatment you need; that stays with your own clinician.