What are the treatment options for persistent left hip pain?

Treatment Options for Persistent Left Hip Pain

For persistent left hip pain lasting several weeks, begin with plain radiographs (AP pelvis and frog-leg lateral hip views) immediately, followed by at least 3 months of exercise-based physical therapy as first-line treatment, combined with NSAIDs and acetaminophen for pain control. 1, 2, 3

Initial Diagnostic Workup

Obtain plain radiographs first before any other intervention or advanced imaging. 1, 3

• Get AP view of the pelvis and frog-leg lateral view of the symptomatic hip to identify bony morphology abnormalities, arthritis, fractures, and structural issues like cam morphology or acetabular dysplasia. 1
• Critical pitfall to avoid: Never proceed directly to MRI without plain radiographs first—this is a common error that can miss important pathology and waste resources. 1

If radiographs are negative or equivocal, proceed to MRI hip without IV contrast (rated 9/9 appropriateness by the American College of Radiology) to evaluate intra-articular structures like labral tears, cartilage damage, and extra-articular soft tissues. 1

• For suspected labral tears specifically, MR arthrography with intra-articular gadolinium provides superior visualization. 1
• Ultrasound can be used to examine soft tissue structures and different types of bursitis when the diagnosis remains unclear. 4

Essential clinical examination elements:

• Perform FADIR test (flexion-adduction-internal rotation)—if positive, suggests FAI syndrome or labral pathology. 1
• Screen for lumbar spine and pelvic pathology—referred pain is a common source of hip pain that is frequently missed. 1
• Assess pain location: anterior groin pain suggests intra-articular pathology, lateral hip pain suggests greater trochanteric pain syndrome, posterior/buttock pain suggests lumbar or deep gluteal syndrome. 5

First-Line Conservative Treatment

Exercise-based physical therapy is the cornerstone of treatment (moderate evidence, strong recommendation). 2, 1

• Duration must be at least 3 months for optimal benefit—shorter programs (3-7 weeks) show smaller effects. 2
• Focus on hip, trunk, and functional strengthening components with resistance exercises. 2
• Include land-based cardiovascular and resistance exercise or aquatic exercise programs. 3

Pharmacologic management:

• Continue or initiate NSAIDs (e.g., ibuprofen 800 mg three times daily with food) when not contraindicated—strong recommendation with high-quality evidence. 1, 3
• Add scheduled acetaminophen 1000 mg every 6-8 hours as first-line adjunctive therapy—can be safely combined with NSAIDs for additive analgesia. 3
• If pain persists despite NSAIDs and acetaminophen, add duloxetine 30-60 mg daily as adjunctive therapy, particularly if opioids are contraindicated. 3

What NOT to use:

• Do not prescribe opioids for hip pain—poor risk-benefit ratio per multiple guidelines. 1, 3
• Do not offer intra-articular hyaluronic acid—insufficient evidence for hip pain. 1, 3
• Do not prescribe glucosamine or chondroitin—lack of supporting evidence for hip osteoarthritis. 3

Second-Line Interventional Options

Intra-articular corticosteroid injection should be considered if oral medications provide inadequate relief (high-quality evidence, moderate strength recommendation). 1, 3

• Provides both diagnostic confirmation and therapeutic benefit lasting weeks to months. 3
• Use ultrasound or fluoroscopic guidance for improved accuracy. 3
• Rated 8/9 appropriateness by the American College of Radiology, especially when concurrent low back, pelvic, or knee pathology exists. 1

Additional Management Considerations

Patient education and shared decision-making are essential components of treatment. 2

• Discuss patient expectations openly. 2
• Recommend physical activity (which may include sport) for people with hip-related pain. 2

Monitor treatment response using patient-reported outcome measures (PROMs), measures of physical impairment, and psychosocial factors. 2

Structured self-management program including exercise and weight loss if overweight should be recommended. 3

When to Consider Advanced Imaging or Referral

Obtain MRI if:

• Initial radiographs are negative but clinical suspicion remains high (as demonstrated in the case where a patient with persistent groin pain after fall had negative initial radiographs but MRI revealed basicervical femoral neck fracture). 2
• Pain worsens over 2-3 days despite conservative management. 2
• Considering surgical intervention—MRI helps identify labral, chondral, or ligamentum teres pathology to better plan surgery. 2

Consider early orthopedic referral for conditions with good surgical outcomes: femoroacetabular impingement, labral tears, and gluteus medius tendon tears. 5

Categorization After Imaging

Once imaging is complete, hip-related pain can be categorized into three groups: 2, 1

1. FAI syndrome (cam or pincer morphology with positive FADIR test, often with labral/chondral pathology)
2. Acetabular dysplasia and/or hip instability
3. Other soft tissue conditions without specific bony morphology (labral, chondral, ligamentum teres conditions, bursitis)

Critical diagnostic principle: Never diagnose based on imaging alone—incidental findings are common in asymptomatic individuals and must be correlated with clinical examination. 2, 1