Immediate Clinical Assessment and Triage
This patient requires urgent evaluation within 24-48 hours, ideally at an orthopedic urgent care or emergency department if urgent care is unavailable, to exclude occult hip fracture or significant soft tissue injury that could lead to permanent disability if left untreated. The inability to bear weight, persistent 7/10 pain, and lack of comfortable resting position are red flags that warrant prompt imaging evaluation 1.
Key Clinical Red Flags Present
- Inability to bear weight on affected limb - This is a critical finding that necessitates exclusion of fracture, even with normal initial radiographs 1
- No pain-free position when lying down - Suggests significant structural pathology rather than simple muscle strain 2
- Pain pattern inconsistent with simple muscle strain - Deep lateral hip pain with radiation to knee, worse with hip abduction and cross-legged positioning, suggests intra-articular or deep periarticular pathology 3
- Recent statin-like supplement use (red yeast rice) - Contains monacolin K (lovastatin), which can cause myopathy, though the normal repeat potassium and lack of severe generalized muscle symptoms make rhabdomyolysis less likely 4, 5
Most Likely Differential Diagnoses
Primary Considerations:
Occult hip fracture (stress fracture or basicervical fracture) - The inability to bear weight after running activity is highly concerning. Initial radiographs can miss up to 10% of hip fractures, particularly stress fractures and basicervical fractures 1
Iliopsoas tendinitis/bursitis - Deep anterior/lateral hip pain worse with hip flexion activities, inability to sit cross-legged, and pain with lateral leg elevation are classic presentations 3
Greater trochanteric pain syndrome - Lateral hip pain worse with abduction, though typically patients can find comfortable positions at rest 2
Labral tear or femoroacetabular impingement - Deep hip pain with mechanical symptoms, though usually associated with specific provocative maneuvers 3
Recommended Diagnostic Workup Algorithm
Step 1: Urgent Imaging (Within 24-48 Hours)
Plain radiographs are mandatory as first-line imaging - Obtain AP pelvis and frog-leg lateral hip views to exclude fracture, arthritis, or structural abnormalities 3, 6. The American College of Radiology recommends this as the initial imaging for all chronic hip pain presentations 3.
Step 2: Advanced Imaging if Radiographs Negative
If plain films are negative but clinical suspicion remains high (which it should given inability to bear weight), proceed immediately to MRI without contrast 1, 3. A case series from the American Academy of Orthopaedic Surgeons demonstrates that patients with persistent hip pain and negative initial radiographs who returned 2 days later were found to have basicervical femoral neck fractures on MRI 1. This patient's presentation mirrors this scenario exactly.
MRI is superior to ultrasound in this case because it can simultaneously evaluate for:
- Occult fracture (stress fracture, basicervical fracture)
- Iliopsoas pathology (tendinitis, bursitis)
- Labral tears
- Bone marrow edema
- Soft tissue injuries 3
Step 3: Consider Ultrasound as Alternative
If MRI is not immediately available, ultrasound can evaluate iliopsoas tendon dynamically and assess for bursitis, though it cannot exclude occult fracture 3.
Appropriate Care Setting
Urgent Care is Appropriate IF:
- They can obtain plain radiographs immediately
- They have orthopedic consultation available or clear referral pathway
- They can arrange next-day MRI if radiographs are negative 1
Emergency Department is Preferred IF:
- Urgent care cannot provide immediate imaging
- Pain worsens or new symptoms develop (fever, inability to move leg at all)
- After-hours presentation when urgent care is closed 1
You should NOT wait more than 48 hours from initial presentation (which was several days ago) to obtain imaging 1. The patient has already waited too long given the severity of functional impairment.
Immediate Management Pending Evaluation
Activity Modification
- Non-weight bearing with crutches immediately - Given inability to bear weight normally, continued ambulation risks worsening occult fracture 1
- Avoid provocative positions (cross-legged sitting, lateral leg raises)
Pain Management
- NSAIDs are first-line for musculoskeletal hip pain if no contraindications 1
- Acetaminophen up to 4g daily maximum as adjunct 1
- Avoid opioids - Current evidence does not support opioid use for musculoskeletal pain due to limited benefit and high adverse event risk 1
- Ice application 15-20 minutes every 2-3 hours 7
Supplement Considerations
Discontinue red yeast rice immediately - While the normal repeat potassium makes severe rhabdomyolysis unlikely, red yeast rice contains monacolin K (lovastatin) which can cause myopathy 4, 5. The temporal relationship between supplement use and symptom onset warrants cessation until evaluation is complete.
Critical Clinical Pitfalls to Avoid
Assuming normal radiographs exclude significant pathology - Up to 10% of hip fractures are radiographically occult initially, and soft tissue pathology requires MRI or ultrasound 1, 2
Attributing symptoms to simple muscle strain - The inability to find comfortable resting position and inability to bear weight are inconsistent with uncomplicated muscle strain 2, 3
Delaying imaging in non-weight bearing patient - This is a surgical emergency if fracture is present, and delayed diagnosis can lead to avascular necrosis or nonunion 1
Missing referred pain from lumbar spine - Though less likely given the specific mechanical nature of symptoms, lumbar pathology should be considered if hip examination is inconsistent 3
Timeline for Action
Do not wait beyond 24-48 hours for evaluation - The patient has already been symptomatic for several days with progressive functional limitation. Each additional day of delay with an occult fracture increases risk of displacement and complications 1. The consistent 7/10 pain level is NOT reassuring - it indicates the underlying pathology is not resolving spontaneously and requires definitive diagnosis.