What is the appropriate evaluation and management for a 72-year-old male presenting with left hip pain?

Evaluation of Left Hip Pain in 72-Year-Old Male

Plain radiographs of the hip and pelvis should be the initial imaging test for evaluating left hip pain in a 72-year-old male, followed by MRI if radiographs are negative or equivocal but clinical suspicion remains high. 1, 2

Initial Assessment

History

• Location: Determine if pain is anterior (groin), lateral (trochanteric), or posterior (buttock)
• Onset: Sudden vs gradual onset
• Aggravating/relieving factors: Weight-bearing, rest, movement
• Associated symptoms: Fever, night pain, neurological symptoms
• Previous hip problems or trauma

Physical Examination

• Gait assessment
• Range of motion testing (internal/external rotation, flexion, abduction)
• Special tests:
  • FABER (Flexion, ABduction, External Rotation) test
  • FADIR (Flexion, ADduction, Internal Rotation) test
  • Straight leg raise
  • Trendelenburg test

Diagnostic Algorithm

Step 1: Initial Imaging

• Anteroposterior (AP) pelvis and cross-table lateral radiographs of the affected hip 1, 2
  • Evaluates for fractures, osteoarthritis, avascular necrosis, and other bony abnormalities
  • Rated 9/9 (usually appropriate) by American College of Radiology 1

Step 2: If Radiographs Are Negative or Equivocal

• MRI without contrast 1, 2

  • Gold standard for detecting occult fractures, avascular necrosis, and soft tissue pathologies
  • Rated 9/9 (usually appropriate) by American College of Radiology for evaluating articular cartilage 1
  • Superior resolution of soft tissues compared to CT 1

• Alternative: CT scan if MRI is contraindicated 1

  • Less sensitive than MRI for soft tissue pathology but can detect bony abnormalities
  • Rated 6/9 (may be appropriate) by American College of Radiology when MRI is unavailable 1

Step 3: For Suspected Specific Conditions

• For suspected labral tear or femoroacetabular impingement:

  • MR arthrography (rated 9/9) 1
  • CT arthrography as alternative (rated 7/9) 1

• For suspected extra-articular soft tissue abnormality:

  • MRI without contrast (rated 9/9) 1
  • Ultrasound (rated 7/9) 1

• For suspected infection or inflammatory arthritis:

  • MRI with and without contrast (rated 8/9) 1
  • Joint aspiration if effusion present 1

Diagnostic Considerations by Location

Anterior Hip Pain (Groin)

• Osteoarthritis (most common in this age group) 3, 4
• Femoral neck stress fracture or occult fracture
• Avascular necrosis
• Labral tear
• Femoroacetabular impingement

Lateral Hip Pain

• Greater trochanteric pain syndrome (includes gluteus medius tendinopathy, bursitis) 3, 4
• Iliotibial band syndrome

Posterior Hip Pain

• Lumbar spinal pathology with referred pain 4
• Sacroiliac joint dysfunction
• Piriformis syndrome
• Ischiofemoral impingement

Diagnostic Injections

• Image-guided anesthetic injections can be valuable diagnostic tools 1, 2
  • Intra-articular injection that relieves pain suggests an intra-articular source
  • Trochanteric bursa injection can help diagnose greater trochanteric pain syndrome
  • Rated 5/9 (may be appropriate) by American College of Radiology 1

Management Considerations

Conservative Management

• For osteoarthritis or non-specific hip pain:
  • Acetaminophen as first-line treatment 2
  • NSAIDs with gastroprotection if no contraindications 2
  • Physical therapy focusing on strengthening and range of motion 2

Interventional Options

• Corticosteroid injections for inflammatory conditions 5
  • Intra-articular: 20-80 mg methylprednisolone for large joints like the hip 5
  • Should not be repeated more frequently than every 1-5 weeks 5

Surgical Referral

• Consider orthopedic referral for:
  • Displaced fractures
  • Advanced osteoarthritis unresponsive to conservative management
  • Labral tears or femoroacetabular impingement in active patients 3

Common Pitfalls to Avoid

• Failing to obtain proper radiographic views (both AP pelvis and lateral hip)
• Missing referred pain from lumbar spine or abdominal/pelvic sources
• Overlooking occult hip fractures in elderly patients with normal radiographs
• Attributing all hip pain to osteoarthritis without considering other diagnoses
• Delaying surgical referral for conditions with good surgical outcomes (e.g., labral tears)

By following this structured approach to evaluating left hip pain in a 72-year-old male, clinicians can efficiently reach an accurate diagnosis and initiate appropriate treatment to improve patient outcomes.