What is the best course of action for a patient with left hip pain, without a clear traumatic cause, fracture, dislocation, or subluxation, and who can be referred to an orthopedic (ortho) specialist?

Management of Left Hip Pain Without Fracture, Dislocation, or Subluxation

For a patient with left hip pain and negative radiographs showing no fracture, dislocation, or subluxation, you should obtain advanced imaging (MRI or CT) to exclude occult fracture before referring to orthopedics, allow weight-bearing as tolerated with an assistive device, and provide close follow-up at 1-2 weeks to reassess clinical trajectory. 1

Immediate Diagnostic Considerations

Rule Out Occult Fracture First

• Plain radiographs miss 24.1% of hip fractures, and even patients with basicervical or minimally displaced fractures can maintain range of motion and weight-bearing ability initially 1
• If clinical suspicion remains high despite negative radiographs (persistent pain with internal/external rotation, groin pain, inability to ambulate comfortably), obtain CT hip without IV contrast immediately as the next imaging study 2, 1
• CT has 94% sensitivity and 100% specificity for detecting radiographically occult hip fractures and changes management in 20% of cases 1
• MRI hip without IV contrast is equally appropriate as the next imaging study if CT is unavailable, as it can detect occult fractures, bone marrow edema, and soft tissue pathology 2, 3
• The American College of Radiology rates both CT and MRI as "usually appropriate" (rating 9) for suspected fracture with negative radiographs 2

Critical Pitfall to Avoid

• Do not assume normal radiographs exclude fracture in a patient with significant trauma mechanism, persistent groin pain, or pain with hip rotation 1
• Delays in diagnosing occult hip fractures increase mortality risk—surgical delay >12 hours significantly increases 30-day mortality in patients >50 years 2

Initial Management While Awaiting Advanced Imaging

Weight-Bearing and Mobility

• Allow weight-bearing as tolerated with assistive device (crutches or walker) for the first 2-3 weeks 1
• Do not prescribe complete bed rest, as immobility increases complications and prevents early mobilization 1
• This approach reduces pain while preventing deconditioning 1

Pain Management

• Provide appropriate analgesia (NSAIDs if not contraindicated, acetaminophen) while diagnostic workup proceeds 4

Follow-Up Protocol

Timing and Red Flags

• Schedule re-evaluation at 1-2 weeks to confirm clinical improvement 1
• If pain or edema worsens or fails to improve by 2 weeks, obtain MRI to evaluate for occult fracture, muscle tear, or hematoma requiring intervention 1
• New inability to bear weight requires urgent re-evaluation 1

Differential Diagnosis Based on Pain Location

Once occult fracture is excluded, consider these diagnoses based on anatomic location:

Anterior Hip/Groin Pain (Intra-articular Pathology)

• Labral tear with femoroacetabular impingement in younger adults 4, 5
• Osteoarthritis in older adults 4, 5
• If radiographs are negative and you suspect labral pathology, MR arthrography hip is the diagnostic test of choice (ACR rating 9) 2
• Standard MRI without contrast is also highly appropriate (ACR rating 9) for evaluating articular cartilage 2

Lateral Hip Pain (Extra-articular Pathology)

• Greater trochanteric pain syndrome (gluteus medius tendinopathy, bursitis, iliotibial band friction) is the most common cause 4, 5
• If radiographs are negative and you suspect soft tissue abnormality, MRI hip without IV contrast (ACR rating 9) or ultrasound (ACR rating 7) are appropriate 2
• The American College of Radiology recommends MRI or ultrasound to evaluate extra-articular soft tissue abnormalities when diagnosis remains unclear 6

Posterior Hip Pain

• Consider lumbar radiculopathy, piriformis syndrome/deep gluteal syndrome, sacroiliac joint dysfunction, ischiofemoral impingement, or hamstring tendinopathy 4, 5

When to Refer to Orthopedics

Immediate Referral Indications

• Any occult fracture detected on CT or MRI requires urgent orthopedic consultation 3, 1
• Suspected hip dislocation or subluxation (though you've excluded this) 2

Early Referral for Good Surgical Outcomes

• Femoroacetabular impingement with labral tears have good surgical outcomes with early intervention 4
• Gluteus medius tendon tears have good surgical outcomes 4
• Consider early referral if advanced imaging confirms these diagnoses rather than prolonging conservative management 4

Routine Referral After Conservative Trial

• Persistent symptoms despite 6-8 weeks of conservative management (physical therapy, activity modification, NSAIDs) 4
• Progressive functional limitation despite appropriate treatment 4

Conservative Management for Non-Fracture Diagnoses

If advanced imaging excludes fracture and confirms soft tissue or degenerative pathology:

• Begin gentle range-of-motion exercises (hip flexion, abduction, adduction) after initial pain subsides, typically 3-5 days 1
• Progress to resistance exercises only after pain-free range of motion is achieved, typically 3-4 weeks 1
• Physical therapy focused on hip strengthening and core stability 4
• Image-guided anesthetic/corticosteroid injection can be both diagnostic and therapeutic for intra-articular or bursal pathology (ACR rating 5 for diagnostic purposes) 2

Key Clinical Pearls

• Pain location guides diagnosis: anterior/groin suggests intra-articular pathology, lateral suggests greater trochanteric pain syndrome, posterior suggests referred pain from spine or deep gluteal syndrome 4, 5
• Age matters: younger adults more likely to have labral tears/FAI, older adults more likely to have osteoarthritis 4, 5
• Preserved range of motion does not exclude fracture—patients with minimally displaced fractures can maintain function initially 1
• If trochanteric bursa injection fails to relieve pain, reconsider the diagnosis rather than attributing symptoms to arthritis 6