From the Guidelines
Diagnosis and Diagnostic Tests for Acute Hip Pain Radiating to Toes
The most likely diagnosis for acute hip pain radiating down to the toes is sciatica, often caused by a herniated disc or lumbar radiculopathy 1.
Initial Diagnostic Approach
To differentiate and diagnose the cause of hip pain, the best initial approach includes:
- A thorough physical examination, including a neurological assessment.
- Imaging studies such as an X-ray or MRI of the lumbar spine. An MRI is preferred as it can better visualize soft tissue structures, including discs and nerves 1.
Further Diagnostic Tests
If the pain is severe or worsening, a lumbar spine MRI with and without contrast should be ordered urgently.
- Electromyography (EMG) and nerve conduction studies (NCS) can also be helpful in diagnosing nerve root compression or damage 1.
- Radiographs of the pelvis and hip should be the first test ordered for the evaluation of patients with chronic hip pain, as they may provide specific information for common disorders such as arthritis or less common disorders such as bone tumors 1.
- MRI hip without IV contrast or US hip is appropriate in patients with chronic hip pain when radiographs are negative, equivocal, or nondiagnostic and there is a suspicion for an extra-articular noninfectious soft tissue abnormality such as tendonitis 1.
- MR arthrography or CT arthrography is appropriate in patients with chronic hip pain when radiographs are negative, equivocal, or nondiagnostic and there is a suspicion for impingement 1.
Management
In terms of management, over-the-counter pain medications such as acetaminophen (650-1000 mg every 4-6 hours) or ibuprofen (400-800 mg every 6-8 hours) can be recommended for initial pain relief 1. If pain persists or worsens, a consultation with an orthopedic specialist or neurologist is advised for further evaluation and potential intervention, which may include physical therapy, steroid injections, or surgical options 1.
Key Points
- Always start with a thorough physical examination and consider imaging studies like X-rays or MRI for diagnosis.
- MRI is preferred for visualizing soft tissue structures.
- Consider further tests like EMG, NCS, or radiographs based on the initial findings and severity of the pain.
- Management includes over-the-counter pain medications and potentially consultation with a specialist for further intervention.
From the Research
Possible Diagnoses
- Sciatica: a set of symptoms caused by a herniated lumbar disc in the vast majority of cases, characterized by lower limb pain radiating below the knee and into the foot and toes 2
- Sacroiliac joint-related pain: can clinically mimic a radiculopathy, with patients often experiencing pain radiating to the groin and a history of a fall on the buttocks 3
- Hip pain: can be caused by various factors, including intra-articular pathology (e.g. labral tears, femoroacetabular impingement, osteoarthritis), extra-articular pathology (e.g. greater trochanteric pain syndrome, gluteus medius tendinopathy), and referred pain from lumbar spinal pathology or other sources 4, 5, 6
Diagnostic Tests
- History taking and physical examination: essential for diagnosing sciatica and hip pain, with a thorough examination of the spine, SI joints, and hips 2, 3, 4, 5
- Imaging tests:
- MRI: preferred imaging modality for sciatica, as it can visualize soft tissues better than CT and does not expose the patient to ionizing radiation 2
- Radiography: initial imaging test for hip pain, with anteroposterior view of the pelvis and frog-leg lateral view of the symptomatic hip 4, 5
- Ultrasonography: may be used to aid in the diagnosis of an intra-articular cause of pain, particularly with ultrasound-guided anesthetic injections 4
- Magnetic resonance arthrography: diagnostic test of choice for labral tears 5