What causes severe pain in the right hip and upper leg that prevents walking?

Severe Right Hip and Upper Leg Pain with Inability to Walk

This presentation most likely represents a hip fracture, particularly in older adults, and requires immediate emergency department evaluation with plain radiographs as the first diagnostic step. 1

Immediate Assessment and Action

Obtain AP pelvis and lateral hip radiographs immediately - these are the essential first imaging studies and will identify the majority of hip fractures including femoral neck fractures, intertrochanteric fractures, and other acute bony pathology. 1

Key Clinical Features Suggesting Hip Fracture:

• Shortened and externally rotated lower extremity on examination strongly indicates displaced femoral neck fracture 1
• Inability to bear weight or ambulate is a cardinal sign of hip fracture 1
• Severe pain localized to the hip and upper thigh that prevents walking 1

Critical Initial Management:

• Provide multimodal analgesia immediately including peripheral nerve block (iliofascial block) for pain control - do not delay pain management for diagnostic workup 1, 2
• Check neurovascular status including dorsalis pedis pulse and lower extremity sensation 1
• Obtain basic metabolic panel and hemoglobin 1
• Arrange urgent orthopedic consultation if fracture is identified 1

If Initial Radiographs Are Negative

Order MRI of the hip if radiographs are negative but clinical suspicion remains high - occult hip fractures (particularly nondisplaced femoral neck fractures) may not be visible on plain films initially. 1, 3

Alternative Diagnoses to Consider:

Intra-articular pathology:

• Labral tear with femoroacetabular impingement - more common in younger adults, causes anterior hip pain with mechanical symptoms 1, 3, 4
• Severe osteoarthritis - gradual onset, worse with weight-bearing, responds to NSAIDs 1, 3
• Avascular necrosis of femoral head - requires MRI as plain films can be normal early 2, 3

Extra-articular causes:

• Greater trochanteric pain syndrome (gluteus medius tendinopathy/bursitis) - causes lateral hip pain, point tenderness over greater trochanter 3, 4, 5
• Iliopsoas tendinitis or bursitis - causes anterior hip pain, pain with hip flexion 3, 4
• Proximal hamstring tendinopathy - causes posterior hip/buttock pain 3, 5

Referred pain sources:

• Lumbar spine pathology (nerve root compression, spinal stenosis) - radiating pain down leg, worse with sitting or standing, may improve with position change 1, 3, 5
• Sacroiliac joint dysfunction - posterior hip/buttock pain 4, 5

Diagnostic Algorithm

1. Start with AP pelvis and lateral hip radiographs - identifies most fractures and osteoarthritis 1

2. If radiographs show fracture: Proceed to urgent orthopedic surgery within 24-48 hours for optimal outcomes 1

3. If radiographs are negative but patient cannot walk:

   • Order MRI immediately to rule out occult fracture, avascular necrosis, or soft tissue pathology 1, 2, 3
   • Consider stress fracture, labral tear, or severe soft tissue injury 1, 3

4. If MRI shows intra-articular pathology: Consider diagnostic/therapeutic intra-articular injection under fluoroscopy or ultrasound guidance 1, 3

5. If all imaging is negative: Evaluate spine with lumbar radiographs or MRI for referred pain 1, 3, 5

Common Pitfalls to Avoid

• Never assume normal radiographs exclude fracture in a patient who cannot walk - occult hip fractures require MRI for detection 1, 2
• Do not delay pain management waiting for imaging or diagnosis - multimodal analgesia should begin immediately 1, 2
• Check both hips on imaging - contralateral hip may have occult pathology 1
• Consider age-appropriate differential - younger patients more likely to have labral tears or impingement; older patients more likely to have fractures or osteoarthritis 1, 3