What is the best management approach for a 25-year-old active female with no significant past medical history, presenting with left hip/groin pain, likely due to muscle strain or greater trochanter pain syndrome, which started after completing a physical training (PT) test and recurred after walking on a treadmill?

Assessment of Your Clinical Note

Your clinical documentation and management plan are appropriate and align with current evidence-based guidelines for greater trochanteric pain syndrome (GTPS) in a young active patient, though obtaining plain radiographs would strengthen your diagnostic approach.

Strengths of Your Clinical Assessment

History and Physical Examination

• You correctly identified the key diagnostic feature: tenderness to palpation over the greater trochanter is the hallmark physical finding for GTPS 1, 2
• Your negative special tests appropriately ruled out intra-articular pathology: negative Patrick's test, piriformis test, and Ober's test help exclude FAI syndrome and other hip joint disorders 3
• The clinical presentation fits GTPS perfectly: lateral hip pain triggered by activity (PT test, treadmill walking) with point tenderness over the greater trochanter is classic 1, 2
• You appropriately documented the absence of red flags: no trauma, fever, or systemic symptoms helps exclude serious pathology like infection, fracture, or tumor 3

Differential Diagnosis Considerations

• GTPS is more likely than muscle strain given the specific tenderness over the greater trochanter and the activity-related pattern 1, 2
• The location of pain is critical: GTPS presents with lateral hip pain, while FAI syndrome and labral tears typically present with groin pain as the primary symptom 3, 4
• Your examination effectively excluded intra-articular pathology: 5/5 hip strength and negative provocative tests make FAI syndrome, labral tears, or significant hip joint pathology unlikely 3, 4

Areas for Improvement

Imaging Recommendation

• Plain radiographs should be obtained as first-line imaging: the American College of Radiology recommends AP pelvis and lateral hip radiographs for all patients with hip pain to exclude fractures, arthritis, tumors, and bone abnormalities 3, 5, 6
• Radiographs are essential even when GTPS is suspected clinically: lumbar spine pathology and hip joint osteoarthritis can present with nearly identical lateral hip pain, making imaging critical for accurate diagnosis 1, 2
• This is particularly important in military populations: stress fractures and other osseous pathology must be excluded in active duty personnel with activity-related hip pain 5

Conservative Management Protocol

• Your NSAID recommendation is evidence-based and appropriate: NSAIDs are first-line pharmacologic treatment for GTPS 7, 2
• Activity modification and stretching are correct initial interventions: most GTPS cases resolve with conservative measures including rest from aggravating activities, physical therapy, and weight management 1, 7, 2
• Consider adding specific physical therapy referral: targeted hip abductor strengthening (gluteus medius and minimus) and iliotibial band stretching have demonstrated benefit in GTPS 8, 2

Follow-up Timeline

• Your 3-week follow-up recommendation is reasonable: most GTPS cases improve within 4 months to 1 year with conservative management 8, 7
• If symptoms persist beyond 3-6 months of conservative treatment, consider corticosteroid injection: lateral hip injections with corticosteroid and local anesthetic provide short-term pain relief (first few months) for refractory GTPS 7, 2
• Ultrasound-guided injection is preferred over blind injection: ultrasound allows precise targeting of the trochanteric bursa and can confirm the diagnosis 1

Critical Diagnostic Pitfalls to Avoid

Lumbar Spine Pathology

• Always consider referred pain from the lumbar spine: radicular pain from L2-L4 nerve roots can mimic lateral hip pain and must be excluded 4, 1, 2
• Document any history of low back pain: GTPS has higher prevalence in patients with coexisting low back pain 2

Hip Joint Pathology

• Hip osteoarthritis can present with lateral hip pain: though groin pain is more typical, OA can cause lateral hip symptoms and coexist with GTPS 6, 1
• The absence of groin pain helps exclude FAI syndrome and labral tears: not having groin pain significantly reduces the likelihood of intra-articular hip pathology 3, 4

Recommended Documentation Enhancement

Add to your assessment: "Plain radiographs (AP pelvis and lateral hip) recommended to exclude stress fracture, hip joint arthritis, and osseous pathology prior to initiating conservative management for presumed GTPS" 3, 5, 1

Specify physical therapy interventions: "Home exercise program should include hip abductor strengthening, iliotibial band stretching, and activity modification to avoid repetitive hip flexion and external rotation" 8, 2

Clarify escalation plan: "If symptoms persist beyond 6-8 weeks of conservative management, consider ultrasound-guided corticosteroid injection to trochanteric bursa" 7, 2