What is the next step in managing a patient with left gluteal pain that worsens with walking and going up stairs?

Management of Left Gluteal Pain Worsening with Walking and Stair Climbing

The next step in managing a patient with left gluteal pain that worsens with walking and going up stairs should be a magnetic resonance imaging (MRI) scan of the hip to rule out occult fracture or gluteal tendinopathy.

Diagnostic Approach

When evaluating gluteal pain that worsens with activity, particularly walking and stair climbing, several important considerations must guide your approach:

1. Initial Imaging:

   • Plain radiographs (X-rays) of the hip and pelvis should be obtained first to rule out obvious fractures or arthritis
   • If radiographs are negative but symptoms persist or worsen, MRI is indicated 1

2. Key Clinical Features to Assess:

   • Pain location (lateral, posterior, or deep gluteal)
   • Pain triggers (weight-bearing activities, particularly stairs)
   • Duration of symptoms (acute vs chronic)
   • History of trauma or falls (even minor ones)

Evidence-Based Management Algorithm

Step 1: Rule Out Occult Fracture

The case study in the AAOS hip fracture guideline highlights a critical scenario: a patient with hip pain after a fall had initial negative radiographs but worsening symptoms, and MRI later revealed a "mildly displaced basicervical femoral neck fracture" 1. This demonstrates the importance of advanced imaging when symptoms persist despite negative initial radiographs.

Step 2: If No Fracture, Consider Gluteal Tendinopathy

Gluteal tendinopathy presents with:

• Pain worsening with walking and stairs
• Lateral hip pain
• Increased discomfort with weight-bearing activities 2

Research shows individuals with gluteal tendinopathy demonstrate:

• Greater hip adduction moments during walking 3
• Altered trunk and pelvic kinematics 4
• Particular difficulty with stair ascent 4

Step 3: Treatment Based on Diagnosis

If gluteal tendinopathy is confirmed:

• Initial management should be conservative 2:
  • Physical therapy focusing on gluteal strengthening
  • Anti-inflammatory measures
  • Activity modification
  • Possible corticosteroid injection for short-term relief

If fracture is identified:

• Urgent orthopedic referral for surgical management 1

Rehabilitation Considerations

For gluteal tendinopathy, a multimodal approach is recommended:

• Strengthening of gluteal and quadriceps muscles 5
• Education about activity modification 1
• Addressing biomechanical factors that may contribute to pain 4

Research demonstrates that individuals with gluteal pain show:

• Reduced gluteus medius activity during functional tasks 6
• Altered movement patterns that increase stress on the affected structures 3

Common Pitfalls to Avoid

1. Misdiagnosis: Relying solely on plain radiographs when symptoms persist can miss occult fractures or soft tissue pathology 1

2. Delayed Treatment: The AAOS guideline demonstrates that delayed diagnosis of hip fractures can lead to displacement and more complex surgical management 1

3. Inadequate Pain Management: According to EULAR recommendations, pain management should be personalized and may require a stepped approach 1

4. Overlooking Biomechanical Factors: Research shows altered biomechanics during walking and stair climbing in those with gluteal pain, which must be addressed in treatment 3, 4

By following this evidence-based approach with appropriate imaging as the next step, you can ensure accurate diagnosis and appropriate management of gluteal pain that worsens with activity, potentially preventing further deterioration and improving outcomes for your patient.