What is the likely diagnosis and management for a 70-year-old male with a 3-month history of right hip pain, limping, and a history of arthritis in the hips and right knee, who experiences pain on the lateral and inner right thigh, worsened by exertion and improved with deep heat?

Likely Diagnosis and Management of Right Hip Pain in a 70-Year-Old Male

This patient most likely has hip osteoarthritis with possible coexisting greater trochanteric pain syndrome (GTPS), given his age, history of hip arthritis, lateral hip pain, and medial thigh pain (referred from the hip joint). 1, 2, 3

Diagnostic Reasoning

Pain Pattern Analysis

• Lateral hip pain is the hallmark of Greater Trochanteric Pain Syndrome (GTPS), which distinguishes it from pure intra-articular pathology 2
• Inner thigh/groin pain typically indicates intra-articular hip pathology such as osteoarthritis, particularly in patients over 50 years old 1, 3
• The combination of both lateral and medial pain suggests coexisting conditions, which is common—multiple hip pathologies frequently occur together 2
• The mechanism of injury (leg "giving way") suggests possible underlying hip weakness from chronic osteoarthritis with secondary gluteal tendinopathy 2, 3

Key Clinical Features Supporting Hip OA

• Age 70 years with known history of hip arthritis 1
• Pain worsened by prolonged standing and over-exertion (mechanical loading pattern) 1
• Limping gait pattern indicating antalgic compensation 1
• Pain improved with heat application (typical for osteoarthritis) 1

Immediate Diagnostic Workup

First-Line Imaging (Order Today)

Obtain AP pelvis and lateral femoral head-neck views bilaterally immediately to rapidly identify hip osteoarthritis, FAI morphology, and assess joint space narrowing 1, 2. This is the mandatory first diagnostic step before any other imaging 1.

Physical Examination Priorities

• Assess for Trendelenburg gait (hip abductor weakness suggesting gluteal tendinopathy) 2
• Perform FADIR test (flexion-adduction-internal rotation) to assess for intra-articular pathology—pain reproduction suggests hip joint involvement 4, 2
• Check for tenderness over the greater trochanter (confirms GTPS component) 2, 3
• Evaluate hip internal rotation in flexion—pain reproduction strongly suggests hip OA 1

Advanced Imaging (If Needed)

• If plain films are non-diagnostic but clinical suspicion remains high, obtain MRI of the hip without contrast to detect labral tears, early cartilage damage, bone marrow edema, and gluteal tendon pathology 1, 2
• Do not proceed to MRI without obtaining plain radiographs first—this violates consensus guidelines and may miss important bony pathology 1

Initial Management Algorithm

Immediate Pharmacologic Treatment

Initiate NSAIDs immediately (strong recommendation, high-quality evidence) for suspected hip osteoarthritis 1. This addresses both the intra-articular inflammation and periarticular soft tissue inflammation.

Physical Therapy Referral

Refer to physical therapy (moderate recommendation, high-quality evidence) targeting hip muscle strengthening, particularly hip abductors, adductors, flexors, and rotators 1. This is essential given the limping gait and likely gluteal weakness.

Additional Conservative Options

• Consider intra-articular corticosteroid injection for symptomatic relief if NSAIDs provide insufficient benefit (moderate recommendation, high-quality evidence) 1
• Ultrasound-guided anesthetic injection can serve both diagnostic and therapeutic purposes, confirming the hip joint as the pain source 3, 5

Critical Pitfalls to Avoid

Diagnostic Errors

• Do not assume primary hip joint pathology without imaging confirmation—referred pain from lumbar spine or SI joint can mimic hip pathology 1
• Do not dismiss the lateral pain component—GTPS frequently coexists with hip OA and requires specific treatment 2, 3
• Imaging alone is insufficient for diagnosis—must be combined with symptoms and clinical signs, as incidental findings are common in asymptomatic individuals 4, 2

Treatment Errors

• Avoid opioids entirely for chronic hip pain (consensus recommendation) 1
• Do not use hyaluronic acid injections for symptomatic hip OA (strong recommendation, high-quality evidence) 1
• Do not tell the patient to avoid activity due to pain—exercise improves pain and function in OA despite initial discomfort 6

Timing Considerations

• Do not delay imaging—obtaining plain radiographs promptly prevents treatment delays that can lead to inferior outcomes 7
• Early referral to orthopedics may be warranted if radiographs show advanced OA with significant functional impairment, as surgical outcomes are better when performed earlier 3, 7