What is the best management approach for an older patient with hip pain after a fall, mild degenerative changes in both hip joints, and no acute pelvic or hip fractures?

Management of Hip Pain After Fall with Mild Degenerative Changes and No Fracture

For a patient with hip pain after a fall, normal radiographs showing only mild degenerative changes, and no acute fracture, you should provide reassurance, initiate conservative management with early mobilization as tolerated, and ensure close follow-up to monitor for occult fracture or worsening symptoms.

Immediate Assessment and Monitoring

Rule Out Occult Fracture

• Plain radiographs miss 24.1% of hip fractures, so normal X-rays do not completely exclude injury 1
• If pain persists or worsens over the next 1-2 weeks, obtain CT hip without IV contrast (94% sensitivity, 100% specificity for occult fractures) or MRI to evaluate for radiographically occult fractures, muscle tears, or hematomas 1, 2
• Do not rely on preserved range of motion or ability to bear weight to exclude fracture—patients with minimally displaced fractures can maintain function initially 1
• New inability to bear weight or worsening edema at 1-week follow-up requires urgent re-evaluation with advanced imaging 1

Pain Management

• Provide appropriate pain relief immediately using multimodal analgesia 2
• Consider acetaminophen as first-line for ongoing pain management 3
• Avoid NSAIDs if the patient has chronic kidney disease 3

Conservative Management Protocol

Mobilization and Weight-Bearing

• Allow weight-bearing as tolerated with an assistive device (crutches or walker) for the first 2-3 weeks to reduce pain while preventing deconditioning 1, 3
• Do not prescribe complete bed rest or restricted weight-bearing—immobility increases complications including pressure ulcers, pneumonia, and deconditioning 2, 1
• Early mobilization as tolerated is the standard of care and promotes healing 1, 3

Exercise and Rehabilitation

• Begin gentle range-of-motion exercises (hip flexion, abduction, adduction) after initial pain subsides, typically 3-5 days after injury 1
• Progress to resistance exercises and strengthening only after pain-free range of motion is achieved, typically 3-4 weeks 1
• For underlying mild degenerative changes, incorporate therapeutic exercise, manual therapy, and neuromuscular re-education as pain allows 4, 5
• Return to full activity only after complete pain-free function is restored, typically 6-8 weeks for severe contusions 1

Follow-Up and Secondary Prevention

Scheduled Monitoring

• Repeat clinical evaluation at 1-2 weeks to confirm clinical improvement 1
• If pain or edema worsens or fails to improve by 2 weeks, obtain MRI to evaluate for occult fracture, muscle tear, or hematoma requiring intervention 1, 6

Fall Risk Assessment and Prevention

• Perform multifactorial falls risk assessment incorporating evaluation of gait, mobility, balance, lower limb strength, medication review, cognitive capacity, footwear, and environmental factors 6
• Use standardized tests such as the Timed Up and Go test to evaluate mobility 6
• Address modifiable fall risk factors including orthostatic hypotension, medication effects, and cardiac causes 3

Bone Health Evaluation

• Each patient aged 50 years and over with a recent fracture should be evaluated systematically for risk of subsequent fractures 2
• Consider referral to a Fracture Liaison Service or Bone Health Clinic for evaluation including vitamin D, calcium, and parathyroid hormone levels, and outpatient DEXA scan 6, 3
• Recommend weight-bearing impact exercise and/or resistance training to promote bone health 6
• Ensure adequate calcium intake and vitamin D supplementation 6

Critical Pitfalls to Avoid

• Do not assume normal radiographs exclude fracture in a patient with significant trauma—proceed to CT or MRI if symptoms persist or worsen 1, 2
• Do not recommend complete immobilization—early mobilization as tolerated prevents complications and promotes healing 2, 1
• Do not ignore worsening symptoms at 1-week follow-up—this raises concern for occult fracture, particularly isolated greater trochanter fractures that can extend to the femoral neck 1
• Do not delay advanced imaging beyond 2 weeks if pain fails to improve or worsens 1