What are the treatment options for a female with left hip pain radiating to the feet?

Treatment Options for Left Hip Pain Radiating to the Feet

Start with plain radiographs (AP pelvis and lateral hip views) as your first diagnostic step, then proceed to MRI hip without IV contrast if radiographs are negative or equivocal, and consider image-guided corticosteroid injection for both diagnosis and treatment. 1, 2

Initial Diagnostic Workup

First-Line Imaging

• Obtain plain radiographs immediately - both AP pelvis and lateral hip views are complementary and rated 9/9 (usually appropriate) by the American College of Radiology as the first imaging test 1, 2
• Radiographs screen for common disorders including arthritis, fractures, and bone tumors 1
• Critical pitfall: Pain radiating to the feet suggests possible referred pain from lumbar spine pathology - you must evaluate both hip and spine as potential sources 1, 2

If Radiographs Are Negative or Equivocal

• MRI hip without IV contrast is rated 9/9 (usually appropriate) as the next step 1, 2
• Consider MRI lumbar spine if clinical suspicion exists for nerve compression or radicular pain causing the foot radiation 2
• Ultrasound hip is rated 7/9 (usually appropriate) as an alternative for suspected soft tissue abnormalities like tendonitis 1

Treatment Algorithm Based on Findings

Conservative Management

• NSAIDs: Ibuprofen 400 mg every 4-6 hours (maximum 3200 mg daily) for pain relief 3
• Use the lowest effective dose for the shortest duration 3
• Administer with meals or milk if gastrointestinal complaints occur 3

Image-Guided Interventions

• Anesthetic and corticosteroid injection into the hip joint or surrounding structures is rated 5/9 (may be appropriate) for suspected extra-articular soft tissue abnormalities 1
• Diagnostic injection is rated 8/9 (usually appropriate) when you need to determine if pain originates from the hip versus concurrent low back, pelvic, or knee pathology 2
• These injections provide both diagnostic information and therapeutic benefit 2

Advanced Imaging for Specific Pathology

• MR arthrography if you suspect labral tear or femoroacetabular impingement after initial workup 2
• CT arthrography is an acceptable alternative to MR arthrography 2

Clinical Decision Points

When to Suspect Intra-articular vs. Extra-articular Pathology

• Intra-articular causes (labral tears, femoroacetabular impingement, osteoarthritis) typically present with anterior hip pain and respond well to intra-articular injection 4, 5
• Extra-articular causes (greater trochanteric pain syndrome, tendonitis) present laterally and may respond to periarticular injection 1, 4
• Referred pain from lumbar spine presents posteriorly and radiates down the leg - this is your most likely scenario given radiation to feet 4, 2

Surgical Referral Considerations

• Femoroacetabular impingement, labral tears, and gluteus medius tendon tears have good surgical outcomes - consider early referral if diagnosed 4
• Arthroscopy may be needed for hip impingement to prevent progression to osteoarthritis 5

Critical Pitfalls to Avoid

• Do not skip plain radiographs - proceeding directly to advanced imaging without radiographs is not recommended 1, 2
• Do not ignore the spine - pain radiating to the feet strongly suggests lumbar pathology as a concurrent or primary source 1, 2
• Do not use peripheral nerve blocks for diagnosis - they are experimental/investigational with insufficient evidence 2
• Do not obtain both pelvis and hip views may miss important pathology 2

Specific Algorithm for This Patient

1. Obtain AP pelvis and lateral left hip radiographs immediately 1, 2
2. If radiographs show arthritis or other pathology: Treat accordingly with NSAIDs and consider injection 1, 3
3. If radiographs are negative/equivocal: Order MRI hip without IV contrast AND consider MRI lumbar spine given radiation to feet 1, 2
4. If diagnosis remains unclear after MRI: Perform image-guided diagnostic injection to confirm hip as pain source 2
5. If injection relieves pain: Hip is the source - proceed with appropriate hip-specific treatment 2
6. If injection does not relieve pain: Focus on lumbar spine or other referred pain sources 2