What is the best course of treatment for a female patient with anterolateral left hip pain radiating to the back, confirmed scoliosis, and hypercholesterolemia (high cholesterol)?

Management of Anterolateral Hip Pain with Scoliosis and Hypercholesterolemia

Begin with plain radiographs of the pelvis and hip as your first diagnostic step, then initiate a 3-month exercise-based physiotherapy program while managing cholesterol with acetaminophen for pain control. 1, 2

Immediate Diagnostic Workup

Obtain both AP pelvis and lateral hip radiographs together as they provide complementary information and are rated as "usually appropriate" (9/9) for evaluating chronic hip pain. 1, 2 These films will:

• Identify hip osteoarthritis, which commonly presents with anterolateral hip pain radiating to the back 3
• Detect any hip pathology that may be contributing to or exacerbated by the scoliosis 4
• Rule out fractures or other bony abnormalities 5

If radiographs are negative or equivocal, proceed to MRI hip without IV contrast (rated 9/9), as this is the most appropriate next study for suspected extra-articular soft tissue pathology or intra-articular hip disease. 1, 2

Concurrent Conservative Treatment (Start Immediately)

Exercise-Based Physiotherapy

Initiate a structured 3-month minimum exercise program focusing on:

• Hip, trunk, and functional strengthening with progressive resistance training 1, 2
• Hip adduction, abduction, flexion, internal rotation, and external rotation strengthening (these muscle groups show consistent weakness in hip-related pain) 1, 3
• Exercise prescribed relative to symptom severity with progressive loading as tolerated 1, 2

The moderate-quality evidence supporting exercise therapy justifies starting this immediately while awaiting imaging results. 1, 2

Pain Management

Start with acetaminophen up to 4 grams daily as first-line oral analgesic, as it has the best efficacy and safety profile for long-term use. 2

If acetaminophen provides inadequate relief, add or substitute NSAIDs at the lowest effective dose. 2 Given the patient's hypercholesterolemia (which may indicate cardiovascular risk factors), use either:

• Non-selective NSAIDs plus gastroprotective agent, OR
• Selective COX-2 inhibitor 2

Reserve opioid analgesics only if NSAIDs are contraindicated, ineffective, or poorly tolerated. 2

Addressing the Scoliosis Component

The scoliosis may be:

• Type 3a (secondary adult curve) due to hip pathology creating pelvic obliquity 4
• Type 1 (primary degenerative) with asymmetric disc/facet arthritis contributing to both the curve and hip pain 4

Key consideration: The hip pain and scoliosis may be mechanically linked through asymmetric loading patterns. 4 Treating the hip pathology may reduce progression of the scoliotic curve if hip disease is creating pelvic obliquity. 4

Hypercholesterolemia Management

Continue maintenance therapy for hypercholesterolemia as prescribed, ensuring LDL-C control to reduce cardiovascular risk. 6 This is particularly important if NSAIDs become necessary for pain management, as they carry cardiovascular considerations. 2

Patient Education and Expectations

Explain to the patient that:

• Pain does not necessarily correlate with structural damage 1, 2
• Morphological abnormalities (including scoliosis) are common in asymptomatic individuals 1, 2
• Physical activity and exercise will not harm the hip joint 1, 2
• Meaningful improvement typically requires at least 3 months of consistent exercise therapy 1, 2

Monitoring and Reassessment

Track outcomes at 4-6 week intervals using:

• Patient-reported outcome measures (PROMs) 1, 2
• Physical impairment measures 1, 2
• Psychosocial factors 1, 2

Determine need for advanced interventions based on:

• Response to conservative management after 3 months 2
• Radiographic findings 1, 2
• Functional limitations despite optimal therapy 2

When to Escalate Care

Consider image-guided corticosteroid injection (rated 5/9) if rehabilitation is hindered by elevated symptom severity unresponsive to analgesics and NSAIDs. 2

Refer to orthopedic surgery if:

• Radiographic evidence of hip OA with refractory pain and disability despite 3+ months of optimal conservative management 2
• Progressive neurological symptoms develop from spinal stenosis related to scoliosis 4

Critical Pitfall to Avoid

Do not skip plain radiographs in favor of advanced imaging. 1, 2, 5 Radiographs identify most significant hip pathology, guide further workup, and may be the only imaging necessary if they reveal common disorders like osteoarthritis. 1, 2