What is the next best step for a patient with a history of left hip labral tear repair, who now presents with swelling, bruising, and severe pain after a fall, and has a negative X-ray (X-ray) and is currently taking ibuprofen (ibuprofen)?

Management of Post-Fall Hip Pain After Previous Labral Repair

For a patient with a history of hip labral repair who presents with severe pain, swelling, and bruising after a fall, an MRI should be obtained immediately despite the negative X-ray, as there is high suspicion for an occult fracture or re-tear of the labrum. 1

Physical Examination Findings to Assess

• Pain with hip rotation: Increased pain with internal and external rotation of the hip strongly suggests intra-articular pathology 1
• Range of motion: Assess and document limitations in all planes
• Neurovascular status: Check distal pulses, sensation, and motor function
• Swelling and bruising: Document the extent and location
• Weight-bearing ability: Assess the patient's ability to bear weight on the affected limb
• Palpation: Check for point tenderness over the greater trochanter, ischial tuberosity, and anterior hip

Imaging Decision Algorithm

1. Initial negative X-ray with severe symptoms:

   • Proceed directly to MRI without contrast for suspected occult fracture or soft tissue injury 1, 2
   • MRI without contrast is rated 9/9 (usually appropriate) for evaluating hip pain with negative radiographs 2

2. If labral re-tear is specifically suspected:

   • MR arthrography would be the preferred imaging modality (rated 9/9 for suspected labral tears) 1
   • CT arthrography is an alternative if MRI is contraindicated (rated 7/9) 1

Rationale for Immediate MRI

The AAOS guidelines present a case remarkably similar to this patient's situation, where a patient with hip pain after a fall had negative initial radiographs but continued to have symptoms. In that case, an MRI revealed a "mildly displaced basicervical femoral neck fracture" that was not visible on plain radiographs 1. This demonstrates the critical importance of advanced imaging when clinical suspicion remains high despite negative X-rays.

The patient's history of previous labral repair puts them at higher risk for:

1. Re-tear of the labrum
2. Occult fracture at the surgical site
3. Chondral injury

Management Pending MRI Results

While waiting for the MRI:

• Weight-bearing status: Instruct the patient to use crutches and limit weight-bearing to tolerance 1
• Pain management: Continue ibuprofen at appropriate dosing (400-800mg every 6-8 hours with food, not exceeding 3200mg daily) 3
• Ice: Apply for 20 minutes every 2-3 hours to reduce swelling
• Activity modification: Avoid movements that exacerbate symptoms
• Follow-up plan: Arrange for prompt follow-up after MRI results are available

Cautions and Pitfalls

• Do not rely solely on negative X-rays: Occult fractures of the hip, especially after previous surgery, may not be visible on plain radiographs 1, 2
• Monitor for worsening symptoms: Instruct the patient to return immediately if pain increases or new symptoms develop 1
• NSAID precautions: Be aware of potential renal and gastrointestinal side effects of ibuprofen, especially with prolonged use 3
• Post-surgical considerations: Previous labral repair may alter normal anatomy and complicate interpretation of imaging 4, 5

Conclusion

The combination of severe pain (9/10), swelling, bruising, and history of previous labral repair surgery strongly suggests significant pathology despite the negative X-ray. The AAOS guidelines clearly support obtaining an MRI in this scenario, as demonstrated by their case example where an occult fracture was discovered on MRI after negative radiographs 1. Prompt diagnosis is essential to prevent complications and guide appropriate treatment.