Diagnostic algorithm

The Ayeni-McMaster four-pillar clinical framework is a practical way to test diagnostic concordance: compatible history, reproducible examination findings, concordant imaging, and a meaningful intra-articular injection response when an injection is needed.

Pillar	Question	Supportive pattern	Traps
1. Typical history	Does the pain story fit a hip-related problem?	Activity-related, mechanically provoked anterior/groin pain with a coherent functional limitation.	Treating a C-sign or click as pathognomonic.
2. Examination	Can you reproduce familiar pain and identify the relevant impairment?	FADIR/FABER or loading test reproduces familiar pain; ROM/strength/stability findings fit the story.	Using one positive test as a diagnosis.
3. Imaging	Does imaging show a plausible structural correlate?	Radiographs and advanced imaging explain the clinical syndrome and exclude important alternatives.	Calling morphology or a labral signal the cause without clinical concordance.
4. Injection	Does intra-articular anesthetic relief clarify an uncertain pain source?	Meaningful improvement in the familiar pain during a documented anesthetic window.	Using the response as a guarantee of postoperative success or a rigid threshold.

This framework aligns with the Warwick definition of FAI syndrome: symptoms, clinical signs, and imaging findings must coexist. Imaging is indispensable for morphology, cartilage, labrum, version, dysplasia, and exclusion of other pathology, but it is not a substitute for the patient’s story. Likewise, an injection is an adjunct: use it when it resolves an important uncertainty, especially in mixed intra-/extra-articular or spinal presentations. 1-3

Diagnostic concordance

Confirm a hip-related history and rule out red flags or a dominant non-hip source.
Perform a complete hip and regional examination; document familiar pain and competing pain generators.
Obtain appropriate radiographs and advanced imaging when indicated; assess morphology, joint preservation, and alternative diagnoses.
If the pillars agree, discuss the diagnosis and treatment options. If they conflict, pause: re-examine, review imaging, consider targeted injection, or seek the relevant non-arthroscopy opinion.

Diagnostic concordance increases as the four pillars converge. When one pillar is markedly discordant, particularly the history or injection response, an imaging finding should not carry the entire decision.

Diagnostic algorithm

References