What is the best course of action for a 16-year-old male with acute right hip pain that began during a high altitude hike?

Acute Hip Pain in a 16-Year-Old After High-Altitude Hiking

This 16-year-old requires immediate evaluation for high-altitude illness and musculoskeletal injury, with descent to lower altitude being the most critical initial intervention if altitude-related symptoms are present.

Immediate Assessment Priorities

The acute onset of hip pain during high-altitude exposure in an adolescent demands consideration of two distinct pathophysiological processes:

High-Altitude Illness Evaluation

• Any illness occurring at high altitude should be attributed to the altitude until proven otherwise 1
• Assess for systemic symptoms of acute mountain sickness (AMS): headache, nausea, poor sleep, lassitude, or mental status changes 1
• High-altitude exposure above 7,000 feet (approximately 2,100 meters) typically triggers symptoms, though individual variation exists 1
• Under no circumstances should a person with worsening symptoms of high-altitude illness delay descent 1

Musculoskeletal Injury Assessment

• Determine if the pain is localized to the hip/groin (suggesting intra-articular pathology) versus lateral hip (suggesting extra-articular soft tissue injury) 2
• Assess for trauma history during the hike: falls, twisting injuries, or repetitive stress from steep terrain 3
• Evaluate gait pattern and weight-bearing ability, as inability to bear weight suggests more serious pathology 3

Initial Management Algorithm

If Systemic Altitude Symptoms Present:

1. Immediate descent to lower altitude - this is the definitive treatment for any high-altitude illness 1, 4
2. Supplemental oxygen if available 1
3. Rest and avoid further ascent 5, 4
4. Acetazolamide can be considered if descent is delayed, though descent remains priority 1

If Isolated Hip Pain Without Systemic Symptoms:

1. Rest and activity modification - avoid continued hiking or weight-bearing activities that exacerbate pain 6
2. Over-the-counter analgesics (acetaminophen or ibuprofen) for pain control 7
3. Monitor for progression of symptoms over 24-48 hours 7

Diagnostic Imaging Considerations

Plain radiographs (AP pelvis and frog-leg lateral hip views) should be obtained once at lower altitude if pain persists beyond 48 hours or if there is significant functional limitation 8, 2. This will identify:

• Acute fractures (stress fracture or traumatic fracture from fall) 8
• Slipped capital femoral epiphysis (SCFE) - a critical diagnosis in adolescents with acute hip pain 2
• Avulsion fractures at muscle attachment sites 2

If radiographs are negative but pain persists, MRI without contrast is the next appropriate study to evaluate for occult fractures, bone marrow edema, or soft tissue injuries 8, 2.

Critical Pitfalls to Avoid

• Do not assume the pain is purely musculoskeletal without screening for altitude illness - the hypoxic environment at high altitude can cause systemic effects that manifest as localized pain 1
• Do not continue ascent or maintain current altitude if any symptoms worsen - progression to high-altitude cerebral edema (HACE) or high-altitude pulmonary edema (HAPE) can be life-threatening 1, 5
• Do not miss SCFE in an adolescent - this requires urgent orthopedic evaluation as it can lead to avascular necrosis if untreated 2
• Complete rest is not advised long-term, but strategic rest in the acute phase (first 48-72 hours) is appropriate while monitoring symptom evolution 6

Return to Activity Planning

If symptoms resolve with descent and rest:

• Gradual re-ascent following acclimatization protocols: no more than 600-meter net elevation gain per day above 3,000 meters, with one rest day every 1-2 ascent days 4
• If musculoskeletal injury is confirmed, exercise-based rehabilitation should be at least 3 months duration before returning to demanding hiking activities 2, 6
• Prophylactic acetazolamide may be considered for future high-altitude exposure if AMS was diagnosed 4

Specific Context for This Patient

Given the 5-hour timeframe since symptom onset, this patient is still in the acute phase. The priority is immediate descent if at significant altitude (>7,000 feet) and evaluation for both altitude illness and traumatic injury 1, 3. The combination of exertion, hypoxia, cold exposure, and rough terrain at high altitude creates multiple potential etiologies that must be systematically evaluated 3.