What are the treatment options for right hip pain that worsens with side stepping?

Right Hip Pain with Side Stepping: Diagnostic and Treatment Approach

Start with plain radiographs (AP pelvis and lateral hip views) immediately, followed by MRI without contrast if radiographs are negative or equivocal, while simultaneously initiating hip abductor strengthening exercises and NSAIDs. 1, 2

Initial Diagnostic Workup

Plain radiographs are mandatory as the first imaging study and should include both AP pelvis and lateral views to evaluate for femoroacetabular impingement, labral pathology, osteoarthritis, or bony abnormalities that commonly cause pain with lateral movements like side stepping. 1, 2 The ACR guidelines emphasize that radiographs provide essential screening information and guide selection of subsequent imaging—skipping this step violates evidence-based protocols and may miss critical bony pathology. 1, 2

Key Clinical Features to Assess

• Pain location and pattern: Side stepping pain suggests hip abductor tendinopathy (gluteus medius/minimus), greater trochanteric pain syndrome, or intra-articular pathology with lateral instability. 3, 4
• Provocative maneuvers: Test hip internal/external rotation, FABER test, and single-leg stance (Trendelenburg sign) to differentiate intra-articular from extra-articular causes. 1, 3
• Gait abnormalities: Trendelenburg gait indicates hip abductor weakness, pointing toward gluteal tendinopathy rather than intra-articular disease. 5, 3

Advanced Imaging When Radiographs Are Non-Diagnostic

If radiographs are negative or equivocal, proceed directly to MRI of the hip (appropriateness rating 9/9 from ACR). 1, 2 Standard MRI without contrast is sufficient for detecting soft tissue pathology including gluteal tendon tears, trochanteric bursitis, and early labral tears. 1, 6

MR arthrography with intra-articular gadolinium is the gold standard for suspected labral tears if clinical suspicion remains high after standard MRI, particularly in younger patients with mechanical symptoms. 1, 2 However, for lateral hip pain with side stepping, standard MRI usually provides adequate diagnostic information for extra-articular pathology. 1

Primary Treatment Strategy

First-Line Conservative Management

Initiate hip-targeted exercise therapy immediately while awaiting imaging results, focusing on hip abductor strengthening (gluteus medius and minimus) with progressive loading over a minimum 3-month period. 1, 5 This approach has high-quality evidence regardless of whether the pain source is intra-articular or extra-articular. 1, 5

• Exercise parameters: Target 60-80% of 1-repetition maximum with progressive increases in load, sets, and repetitions over 12 weeks. 5
• Duration commitment: The 3-month minimum is critical—shorter durations produce suboptimal outcomes. 5

Oral NSAIDs should be used when not contraindicated (strong recommendation, high-quality evidence from AAOS) for symptomatic relief during the rehabilitation phase. 1, 5 Acetaminophen may be considered as an alternative if NSAIDs are contraindicated. 1

Adjunctive Interventions

Consider ultrasound-guided corticosteroid injection into the trochanteric bursa or peritendinous area if symptoms are severe enough to impair rehabilitation participation (moderate recommendation, high-quality evidence). 1 The ACR guidelines note that injections are both diagnostic and therapeutic for extra-articular hip pain. 1

Physical therapy referral is appropriate for supervised exercise prescription if self-directed exercise fails or if proper form and progression are uncertain. 1, 5

Diagnostic Injection for Unclear Cases

If the pain generator remains uncertain after imaging, image-guided diagnostic injection (either intra-articular hip or peritrochanteric) definitively determines the source. 1, 2, 6 A positive response to intra-articular injection confirms intra-articular pathology, while lack of response suggests extra-articular causes like gluteal tendinopathy or iliotibial band syndrome. 1, 3

Monitoring and Reassessment

Reassess at 4-6 week intervals using patient-reported outcome measures (Hip and Groin Outcome Score or International Hip Outcome Tool) and objective findings like single-leg stance ability and pain provocation tests. 5 If no improvement occurs after 6-8 weeks of structured conservative management, reconsider the diagnosis or refer to orthopedics. 6, 5

Critical Pitfalls to Avoid

• Never skip plain radiographs and proceed directly to MRI—this violates ACR guidelines and may miss important bony pathology like stress fractures or cam/pincer morphology. 1, 2, 6
• Do not allow unstructured rest without exercise therapy—passive rest alone produces inferior outcomes compared to progressive loading programs. 5
• Avoid opioids entirely—consensus guidelines strongly oppose opioid use for hip-related pain. 1, 6, 5
• Do not diagnose based on imaging alone—incidental findings are common in asymptomatic individuals, so clinical correlation is essential. 1, 6
• Screen for referred pain from lumbar spine and sacroiliac joints systematically, as these commonly masquerade as hip pain. 1, 6, 3