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

Anterolateral Left Hip Pain in a Female Adult with Scoliosis and Hypercholesterolemia

Initial Diagnostic Approach

The most likely diagnosis is gluteal tendinopathy or greater trochanteric pain syndrome, which requires a structured 3-month exercise-based rehabilitation program targeting hip abductor strengthening before considering imaging. 1, 2, 3

Key Clinical Features to Assess

• Pain location: Anterolateral hip pain over the greater trochanter strongly suggests gluteal tendinopathy, hip abductor insufficiency, or greater trochanteric pain syndrome 2, 3
• Gait pattern: Assess for Trendelenburg gait (hip drop on contralateral side during single-leg stance), which indicates hip abductor weakness 2
• Aggravating factors: Pain with prolonged sitting, climbing stairs, lying on the affected side, or crossing legs suggests greater trochanteric pain syndrome 3
• Age considerations: In younger adults, consider femoroacetabular impingement or labral tears; in older adults, consider osteoarthritis 3, 4

Physical Examination Findings

• Palpation: Tenderness over the greater trochanter indicates greater trochanteric pain syndrome 3
• Provocative tests: Pain with resisted hip abduction or single-leg stance confirms hip abductor pathology 2, 3
• FABER test (Flexion, Abduction, External Rotation): Reproduces pain in intra-articular pathology like femoroacetabular impingement 5
• FADIR test (Flexion, Adduction, Internal Rotation): Reproduces pain in hip impingement 5

Primary Treatment: Exercise-Based Rehabilitation

Initiate a minimum 3-month structured exercise program targeting hip abductor strengthening with progressive loading as first-line treatment. 1, 2

Exercise Prescription Specifics

• Target muscles: Gluteus medius, gluteus minimus, hip flexors, and trunk stabilizers 2
• Loading parameters: 60-80% of 1-repetition maximum to produce strength gains 2
• Progression: Gradually increase load magnitude, sets (starting 2-3 sets), repetitions (8-12 reps), and time under tension over the 3-month period 1, 2
• Frequency: 3-4 sessions per week with adequate rest between sessions 1
• Duration: Minimum 3 months is critical for optimal outcomes 1, 2

Specific Exercise Examples

• Side-lying hip abduction with progressive resistance
• Single-leg stance exercises with progression to unstable surfaces
• Lateral band walks with increasing resistance
• Step-ups and step-downs with controlled hip mechanics
• Bridging exercises progressing to single-leg bridges

Adjunctive Treatments

• NSAIDs: Use for symptomatic relief during the rehabilitation phase (ibuprofen 400-600mg three times daily or naproxen 500mg twice daily) 2
• Avoid corticosteroid injections: These are not recommended in acute overuse scenarios and may weaken tendons 2
• Physical therapy referral: Consider if self-directed exercise fails or for supervised exercise prescription with proper form and progression 2

Management of Hypercholesterolemia

The patient's high cholesterol requires concurrent management but does not directly affect hip pain treatment. 1, 6, 7

Lipid Management Strategy

• Lifestyle modifications: Restrict saturated fats to <7% of total calories, eliminate trans fats, increase soluble fiber to >10g/day, and engage in ≥150 minutes/week of moderate-intensity aerobic activity 6
• Statin therapy: If age 40-75 years with elevated cardiovascular risk, initiate moderate-to-high intensity statin therapy (atorvastatin 10-20mg or rosuvastatin 5-10mg daily) targeting LDL-C <100 mg/dL 6
• Monitor lipids: Reassess fasting lipid panel 4-8 weeks after initiating therapy 6

Scoliosis Considerations

Adult scoliosis may contribute to asymmetric loading and hip pathology but does not change the primary treatment approach for hip pain. 8

• Assess for leg length discrepancy: Scoliosis can cause or result from pelvic obliquity due to leg length differences, which may contribute to hip pain 8
• Evaluate spinal stenosis symptoms: If present (leg pain, claudication), these require separate evaluation 8
• Monitor curve progression: Adult scoliosis can progress with asymmetric degeneration, particularly in post-menopausal women with osteoporosis 8

Imaging Strategy

Defer imaging initially and proceed with structured exercise therapy first. 2, 3

When to Order Imaging

• Plain radiographs: Order as initial imaging if red flags present (trauma, severe pain, night pain, constitutional symptoms) or if no improvement after 6-8 weeks of structured exercise 2, 3, 4
• MRI with or without gadolinium: Reserve for diagnostic uncertainty after failed conservative treatment or if surgical intervention is being considered 3, 4, 5
• Ultrasound-guided diagnostic injection: Can aid diagnosis of intra-articular vs extra-articular pain if uncertainty persists 3

Monitoring Treatment Response

• Assess progress at 4-6 week intervals using patient-reported outcomes (Hip and Groin Outcome Score or International Hip Outcome Tool) and objective measures (single-leg stance time, hip abductor strength testing) 2
• Expected timeline: Symptomatic improvement typically begins at 6-8 weeks, with maximal benefit at 3 months 1, 2
• Pain during exercise: Some discomfort is acceptable; educate that "pain does not equal damage" during appropriate loading 1, 2

Critical Pitfalls to Avoid

• Do NOT proceed directly to imaging without a trial of structured exercise therapy—this violates evidence-based guidelines and risks overtreatment of incidental findings 2
• Do NOT prescribe opioids for hip-related pain 2
• Do NOT allow unstructured "rest only"—complete rest leads to deconditioning and prolonged recovery 2
• Do NOT rush return to aggravating activities—gradual progression over 3 months is essential 2
• Do NOT ignore the scoliosis—assess for contributing factors like leg length discrepancy or pelvic obliquity 8

Referral Indications

• Orthopedic referral: Consider if no improvement after 3 months of structured exercise, or if imaging reveals femoroacetabular impingement, labral tear, or gluteus medius tendon tear (these have good surgical outcomes) 3, 5
• Physical therapy referral: For supervised exercise prescription if self-directed exercise fails 2
• Spine specialist: If scoliosis-related symptoms (spinal stenosis, progressive deformity) dominate the clinical picture 8