What is the likely diagnosis and management for a 30-year-old male with acute onset of deep anterior unilateral hip pain, limited range of motion, and tingling in the toes, following heavy lifting, with no history of similar conditions?

Acute Anterior Hip Pain in a Young Adult Following Heavy Lifting

Most Likely Diagnosis

This presentation is most consistent with L3 radiculopathy rather than primary hip pathology, given the acute onset following heavy lifting, deep anterior hip pain, and toe tingling without true radicular symptoms. 1

Critical Diagnostic Approach

Immediate Red Flag Exclusion

First, you must exclude serious pathology that requires urgent intervention:

• Femoral neck stress fracture - Can present with deep anterior hip pain after activity and progress to complete fracture if weight-bearing continues 2, 3
• Septic arthritis - Though less likely given the mechanism, acute severe pain warrants consideration; joint aspiration is definitive 4
• Slipped capital femoral epiphysis (SCFE) - Less likely at age 30 but should be considered in the differential 4, 5

Key Distinguishing Clinical Features

Perform these specific examination maneuvers to differentiate nerve root from hip pathology:

• Dermatomal sensory testing along the medial lower leg - Sensory loss here is the defining feature of L3 radiculopathy and distinguishes it from hip pathology 1
• FABER (Flexion-Abduction-External Rotation) and FADIR (Flexion-Adduction-Internal Rotation) tests - Negative tests effectively exclude intra-articular hip pathology 1
• Straight leg raise - Note that this is more sensitive for lower lumbar nerve roots (L4-S1), so a negative test does NOT exclude L3 radiculopathy 1

The toe tingling is a critical clue - Hip arthritis causes lateral hip/thigh aching WITHOUT dermatomal sensory changes, whereas L3 radiculopathy follows a specific dermatomal pattern (buttock, lateral hip, anterior-lateral thigh, medial lower leg) 1

Imaging Algorithm

Initial Imaging (Order Both)

1. AP pelvis radiograph with 15 degrees internal hip rotation 4, 5
2. Lateral view of the affected hip (cross-table or frog-leg) 4, 5

Rationale: Radiographs are mandatory first-line imaging to exclude fracture, which cannot be reliably diagnosed or excluded by physical examination alone 4. The pelvis view allows comparison with the contralateral side 5.

If Radiographs Are Negative

Lumbar spine MRI without contrast is the definitive next step if clinical suspicion for L3 radiculopathy remains high based on dermatomal sensory findings 1. This provides superior visualization of disc herniation, foraminal stenosis, or other compressive pathology at the L3 nerve root level 1.

Hip MRI without contrast should be considered if hip-specific tests are positive or if there is concern for occult femoral neck stress fracture, which can be missed on plain radiographs 4, 2. MRI is valuable for detecting occult traumatic fractures and stress fractures 2.

Management Algorithm

Conservative Management (First 6-12 Weeks)

Initiate immediately unless red flags are present:

• Activity modification - Avoid heavy lifting and provocative movements 1, 6
• NSAIDs for pain control 1, 6
• Physical therapy - Directed at core stabilization and proper lifting mechanics 1
• Ice and elevation for acute pain management 6

Monitor closely for progressive neurologic deficit - This would mandate urgent surgical referral 1

If Conservative Management Fails (6-12 Weeks)

Epidural steroid injection under fluoroscopic or CT guidance at the L3 level provides both diagnostic confirmation and therapeutic benefit 1

Surgical Referral Indications

Refer to neurosurgery or spine surgery if:

• Progressive neurologic deficit develops at any time 1
• Failure of conservative management after 6-12 weeks 1
• Imaging reveals significant nerve root compression requiring decompression 1

Critical Pitfalls to Avoid

Do not assume this is simple hip pathology - The combination of acute onset after heavy lifting, deep pain, and toe tingling strongly suggests nerve root involvement rather than intra-articular hip disease 1. Missing L3 radiculopathy can lead to prolonged disability.

Do not delay imaging - Femoral neck stress fractures can progress to complete fractures with continued weight-bearing, resulting in significantly worse outcomes 2, 3. Delays in diagnosis of hip fractures are associated with increased mortality, complication rates, and hospital length of stay 4.

Do not rely solely on straight leg raise - This test is insensitive for upper lumbar radiculopathy (L3), so a negative test does not exclude the diagnosis 1.

Do not skip the pelvis radiograph - Hip-only views may miss contralateral pathology and lack the comparison view needed for accurate diagnosis 4, 5.