What is the best initial intervention for an 80-year-old patient with severe left hip pain (10/10) and a history of similar pain 6 months ago, with a previously normal X-ray?

Management of Severe Hip Pain in an 80-Year-Old Patient

For an 80-year-old patient with severe left hip pain (10/10) and a history of similar pain 6 months ago with normal X-ray, the best initial intervention is to obtain new radiographs of the hip and pelvis, followed by MRI if radiographs are negative or equivocal.

Diagnostic Approach

Initial Imaging

• Radiographs should be the first imaging test in most, if not all, cases of hip pain 1
• The recommended views include:
  • Anteroposterior (AP) view of the pelvis
  • Lateral femoral head-neck view (such as frog-leg or cross-table lateral) 1
• These views provide important baseline information about:
  • Bone morphology
  • Joint space
  • Presence of fractures (including occult fractures common in elderly)
  • Degenerative changes

Secondary Imaging

• If radiographs are negative or equivocal but clinical suspicion remains high:
  • MRI without contrast is the next appropriate step 1
  • MRI is highly sensitive and specific for detecting many osseous and soft tissue abnormalities 1
  • MRI can detect occult fractures, avascular necrosis, bone marrow edema, and soft tissue pathologies not visible on radiographs

Pain Management During Diagnostic Workup

• Initial pain management with ibuprofen 400-800 mg every 6 hours (if not contraindicated) 2
• Consider acetaminophen as an alternative if NSAIDs are contraindicated
• Avoid opioids initially if possible, but may be necessary for severe pain (10/10) while awaiting diagnosis

Common Diagnoses to Consider in Elderly Patients

1. Occult hip fracture

   • Despite normal previous X-ray, fractures may develop or become visible over time
   • High morbidity and mortality if missed

2. Osteoarthritis

   • Common in this age group
   • May have progressed since previous imaging

3. Avascular necrosis

   • May not be apparent on initial radiographs

4. Greater trochanteric pain syndrome

   • Including gluteus medius tendinopathy or tears, bursitis 3

5. Referred pain

   • From lumbar spine or sacroiliac joints 1, 4

Diagnostic-Therapeutic Interventions

• If diagnosis remains unclear after imaging:
  • Consider image-guided diagnostic and therapeutic injection 1
  • An intra-articular injection relieving pain suggests the pain is coming from the joint itself
  • Trochanteric or iliopsoas injections may help diagnose extra-articular causes 1

Important Pitfalls to Avoid

1. Skipping radiographs and proceeding directly to advanced imaging

   • Radiographs provide essential baseline information and may reveal obvious pathology

2. Attributing pain solely to age without thorough evaluation

   • Even in elderly patients, specific diagnoses should be pursued

3. Overlooking referred pain

   • Hip pain may originate from the spine, pelvis, or knee 4

4. Delaying diagnosis

   • Particularly dangerous for occult fractures, which have high morbidity and mortality when treatment is delayed 1

5. Relying solely on previous normal X-ray

   • New pathology may have developed in the 6-month interval

By following this systematic approach with appropriate imaging and targeted interventions, you can effectively diagnose and manage severe hip pain in this elderly patient, potentially preventing serious complications and improving quality of life.