What is the likely diagnosis and treatment for a 56-year-old female patient with a 6-7 week history of deep-seated left hip pain, morning stiffness, and a history of a fall 1.5 months prior, with previous knee issues and perceived strength loss?

Diagnostic Assessment and Management

Most Likely Diagnosis

Your patient most likely has greater trochanteric pain syndrome (GTPS), specifically gluteus medius tendinopathy, rather than intra-articular hip pathology or post-traumatic arthritis. The lateral bony hip location, deep-seated pain that improves with pressure application, morning stiffness that resolves with ambulation, and absence of a specific tender point are classic features of GTPS rather than intra-articular disease 1, 2.

Why This is Not Intra-Articular Hip Disease

• Intra-articular hip pathology (osteoarthritis, labral tears, femoroacetabular impingement) typically presents with anterior hip and groin pain, not lateral hip pain 1, 2
• The lateral bony location of her pain strongly suggests extra-articular pathology, specifically GTPS, which is the most common cause of lateral hip pain in adults 1
• Imaging should never be used in isolation but must be combined with symptoms and clinical signs when making treatment decisions 3
• The delayed onset (one month post-fall) and lack of immediate hip symptoms after the fall make acute traumatic injury or post-traumatic arthritis less likely 1

Why the Fall is Likely Coincidental

• The temporal disconnect between the fall (1.5 months ago) and symptom onset (6-7 weeks ago, approximately 1 month post-fall) suggests the fall may be unrelated to the current hip pain 1
• She had no immediate hip symptoms after the fall, only knee abrasions and shoulder discomfort 1
• GTPS commonly develops from repetitive use or degenerative changes in middle-aged women, independent of trauma 1

Critical Diagnostic Workup Beyond X-ray

Your hip X-ray order is appropriate as the initial imaging study, but you must obtain AP pelvis and lateral femoral head-neck radiographs (not just hip views) to properly evaluate hip morphology 3. However, based on her presentation:

• If radiographs are negative or equivocal and lateral hip pain persists, MRI without contrast is the next appropriate imaging study to evaluate soft tissue structures including gluteus medius tendon, trochanteric bursa, and iliotibial band 3, 1
• Plain radiographs have limited sensitivity for soft tissue pathology like tendinopathy or bursitis 3, 1
• Ultrasound can effectively evaluate GTPS and allows for real-time dynamic assessment, though MRI provides more comprehensive soft tissue visualization 3

Ruling Out Lumbar Radiculopathy

You must actively exclude L3 radiculopathy, which can mimic lateral hip pain but presents with dermatomal sensory loss along the medial aspect of the lower leg 4:

• Specifically examine for sensory changes in the L3 dermatome (medial lower leg) 4
• The absence of dermatomal sensory loss effectively distinguishes hip pathology from L3 radiculopathy 4
• Her pain distribution (lateral bony hip without leg radiation or sensory changes) makes radiculopathy unlikely 4

Treatment Algorithm

Conservative Management (First-Line, 6-12 weeks)

• Activity modification to avoid aggravating movements 4
• NSAIDs for pain control (if no contraindications) 4, 5
• Physical therapy focusing on hip abductor strengthening and stretching 4, 5
• Weight loss if BMI elevated 5
• Monitor for progressive neurologic deficit or red flags 4

If Conservative Management Fails

• Consider ultrasound-guided corticosteroid injection into the trochanteric bursa or peritendinous area for both diagnostic confirmation and therapeutic benefit 3
• Diagnostic injections can definitively confirm the pain source 3

Surgical Referral Indications

• Progressive neurologic deficit 4
• Failure of conservative management after 6-12 weeks 4
• Gluteus medius tendon tears identified on MRI typically have good surgical outcomes and warrant early orthopedic referral 1

Common Pitfalls to Avoid

• Do not assume the fall caused the hip pain without immediate post-traumatic symptoms 1
• Do not diagnose hip arthritis based on imaging alone without correlating with clinical presentation 3
• Do not overlook that incidental imaging findings are common in asymptomatic individuals and must be interpreted with clinical context 3
• Avoid opiates for osteoarthritis pain management 5
• Remember that her ability to walk does not exclude serious pathology, though her presentation is most consistent with GTPS rather than fracture 6

Reassessing Your Initial Impression

Your impression of "arthritis from repetitive use or delayed sequelae from a fall" should be reconsidered because:

• The lateral location argues against intra-articular arthritis 1, 2
• Morning stiffness that improves with activity is seen in both arthritis and GTPS, but the lateral location is key 1, 5
• The deep bone-like pain with relief from pressure application is more characteristic of GTPS than arthritis 1