What are the initial management recommendations for acute on chronic hip pain?

Management of Acute on Chronic Hip Pain

Begin with plain radiographs (AP pelvis with cross-table lateral of the affected hip) as your initial diagnostic step, followed by a structured approach to pain control and functional rehabilitation based on the underlying pathology identified. 1, 2

Initial Diagnostic Approach

First-Line Imaging

• Obtain standard radiographs immediately: anteroposterior (AP) view of the pelvis with 15 degrees of internal hip rotation and a cross-table lateral view of the symptomatic hip 1
• The pelvis view is essential because it allows comparison with the contralateral side and detects concomitant pelvic fractures (sacrum, pubic rami) that occur frequently with hip pathology 2, 3
• Radiographs can be performed portably and rapidly, reducing morbidity by avoiding unnecessary patient movement 1

When Radiographs Are Negative But Suspicion Remains High

• Proceed directly to MRI without IV contrast if clinical suspicion for occult fracture persists after negative radiographs, as MRI has nearly 100% sensitivity for proximal femoral fractures 2, 3
• CT without IV contrast is an acceptable alternative when MRI is unavailable or contraindicated, though patients with negative/equivocal CT may still require MRI 1
• Approximately 10% of proximal femoral fractures are not identified on initial radiographs, making advanced imaging critical when clinical suspicion remains 2, 3

Critical Pitfall to Avoid

• Never rely on ultrasound as initial imaging for hip fracture detection—it has only 65% specificity even with experienced sonographers and cannot comprehensively evaluate bones and soft tissues 2

Immediate Pain Management Priorities

Life-Threatening Concerns to Rule Out First

• Assess for vascular compromise immediately: blue, purple, or pale extremity requires emergency activation 4
• Evaluate for severe bleeding, as long bone fractures can cause life-threatening blood loss 4
• Check for open fractures requiring urgent attention due to high infection risk 4

Multimodal Analgesia Approach

• Implement immobilization in the position found to reduce pain and prevent further injury 4
• Apply ice packs to decrease pain and swelling in the acute period 4
• Use a multimodal analgesic regimen including regular intravenous acetaminophen, NSAIDs, and opioids as needed 4
• Reassess pain levels regularly using the Numeric Rating Scale (NRS) for communicative patients 4

Special Considerations for Elderly Patients

• Up to 42% of patients over 70 years old don't receive adequate analgesia for fractures 4
• Inadequate pain control can lead to agitation, aggression, and delirium, especially in elderly patients 4
• Early multimodal pain management prevents delirium and other complications in this population 4

Management Based on Underlying Pathology

If Fracture Confirmed on Imaging

• Surgical delay beyond 12 hours significantly increases 30-day mortality risk in patients over 50 years with hip fractures 1
• Obtain noncontrast CT when further characterization of fracture alignment is needed for surgical decision-making 1
• After hip dislocation reduction, obtain repeat radiographs to confirm successful relocation 1

If Soft Tissue Injury Suspected (Negative Fracture Workup)

• Order MRI hip without contrast to evaluate for tendon, muscle, or ligament injury as the source of acute pain 1
• MRI detects 100% of proximal hamstring avulsions versus only 58.3% with ultrasound 1
• MRI is particularly useful for gluteus tendon tears, iliofemoral ligament injury, and ligamentum teres pathology 1

If Chronic Osteoarthritis with Acute Exacerbation

• Physical therapy and exercise are important components of multimodal treatment 5
• Consider intra-articular injections, regenerative therapies, or radiofrequency ablation for persistent pain before total hip arthroplasty 5
• Fluoroscopic-guided radiofrequency of periarticular hip branches can provide pain relief up to 36 months 6

Conservative Management for Non-Arthritic Hip Pain

Rehabilitation Protocol

• Address biomechanical deficiencies with neuromuscular training of the hip and lumbopelvic regions 7
• Implement patient education, activity modification, and limitation of aggravating factors 7
• Prescribe individualized physical therapy focusing on functional movement control 8
• Patients who improve functional movement control (single leg squat test, step-down test) report significantly less pain and greater functional ability 8

Warning Signs Requiring Urgent Re-evaluation

• Increasing pain despite appropriate analgesia may indicate fracture displacement or instability requiring surgical intervention 4
• Neurological symptoms, signs of compartment syndrome, or signs of infection require immediate attention 4
• These complications are associated with increased costs, complication rates, hospital length-of-stay, and mortality 1, 3