What is the appropriate management for an 18-year-old female airforce IDMT with a 3-month history of bilateral hip pain, worsened by running, and diagnosed with a likely muscle strain of the rectus femoris?

Assessment of Clinical Documentation and Management Plan

Overall Note Quality

Your clinical note demonstrates solid documentation with appropriate differential diagnosis consideration, but requires critical additions to meet standard of care for this presentation. The bilateral nature of symptoms in a young female with 3 months of pain worsened by activity demands more comprehensive evaluation than documented.

Critical Gaps in Your Current Approach

Missing Diagnostic Considerations

You must rule out L3 radiculopathy before attributing bilateral hip pain solely to rectus femoris strain. 1, 2

• Dermatomal sensory testing along the medial lower leg is essential - this is pathognomonic for L3 nerve root involvement and distinguishes radiculopathy from hip pathology 1, 2
• Your note lacks documentation of lower extremity sensory examination in dermatomal distribution 1, 2
• The bilateral presentation with pain radiating to anterior/lateral thigh fits L3 distribution 1, 2
• Negative FABER helps exclude intra-articular pathology but doesn't rule out nerve root compression 2

Inadequate Imaging Workup

Plain radiographs (AP pelvis and frog-leg lateral views) should have been obtained as first-line imaging for any young adult with chronic bilateral hip pain. 3, 4

• Radiographs are mandatory to screen for underlying structural pathology including FAI syndrome, acetabular dysplasia, stress fractures, or other osseous abnormalities 3
• Imaging should never be used in isolation but combined with symptoms and clinical signs 3
• If radiographs are negative/equivocal and symptoms persist, lumbar spine MRI without contrast is indicated to evaluate for L3 nerve root compression 1, 2
• Hip MRI without contrast would be appropriate if hip-specific pathology remains suspected after negative radiographs 3

Incomplete Physical Examination Documentation

Your physical exam needs expansion:

• Document straight leg raise test bilaterally - though more sensitive for lower lumbar roots, its absence doesn't exclude L3-L4 radiculopathy 1, 2
• Asymmetric deep tendon reflexes indicate L3-L4 dysfunction - you must document patellar reflexes bilaterally 2
• Document specific provocative testing for rectus femoris (resisted hip flexion, resisted knee extension) 5
• Screen lumbar spine with range of motion and palpation given the differential 1, 2

Diagnostic Accuracy Concerns

Rectus Femoris Strain Diagnosis

Your diagnosis of bilateral rectus femoris strain is questionable without imaging confirmation and with 3-month chronicity. 5, 6, 7

• Acute muscle strains typically occur during strenuous activity with sudden onset pain 5, 8
• Bilateral simultaneous muscle strains are uncommon - this pattern should raise suspicion for alternative diagnoses 4
• Chronic pain (3 months) with worsening on return to activity suggests either incomplete healing, underlying structural pathology, or misdiagnosis 5, 7
• MRI is recommended when radiologic evaluation is necessary for diagnosis of muscle strain 5
• Incomplete intrasubstance rectus femoris tears present with chronic thigh pain and may require imaging for diagnosis 7

Alternative Hip Pathology Not Adequately Excluded

Your negative FABER test helps but doesn't definitively exclude hip-related pain conditions. 3

• Clinical examination has limited diagnostic utility for hip disease - comprehensive approach combining symptoms, signs, and imaging is essential 3
• FAI syndrome, labral tears, and other intra-articular pathology are common in young active adults and may present similarly 3
• Diagnosis should never be made on clinical examination alone 3
• The 3-month duration with activity-related worsening fits hip-related pain patterns 3

Management Plan Deficiencies

Premature Physical Therapy Referral

Referring to PT without establishing definitive diagnosis through appropriate imaging is premature and potentially harmful. 3, 1, 2

• If this is L3 radiculopathy, the treatment approach differs significantly from muscle strain 1, 2
• Conservative management for radiculopathy includes activity modification, NSAIDs, and monitoring for 6-12 weeks before considering epidural steroid injection 1, 2
• Physiotherapist-led treatment for hip-related pain should include hip and knee strengthening exercises, but only after proper diagnosis 3
• Loading an undiagnosed hip condition could worsen outcomes 3

Inadequate Follow-up Plan

• You should monitor for progressive neurologic deficit - this requires neurosurgical referral 1, 2
• 30-day profile may be insufficient if this represents structural hip pathology or radiculopathy requiring 6-12 weeks conservative management 1, 2
• No plan documented for what specific findings would trigger earlier follow-up or specialty referral 1, 2

Recommended Immediate Actions

Before Next Patient Encounter

1. Order AP pelvis and frog-leg lateral hip radiographs bilaterally 3, 4

2. Perform complete neurologic examination including:

   • Dermatomal sensory testing (especially medial lower leg for L3) 1, 2
   • Bilateral patellar reflexes 2
   • Straight leg raise bilaterally 1, 2
   • Lumbar spine examination 1, 2

3. If radiographs negative and symptoms persist, order lumbar spine MRI without contrast 1, 2

Documentation Improvements for Future Cases

Structure your HPI to address key diagnostic features:

• Exact pain location and radiation pattern (dermatomal vs myotomal) 1, 2
• Mechanism of injury if acute, or pattern of onset if insidious 5, 8
• Aggravating/relieving factors specific to diagnosis 3, 5
• Impact on function and activities of daily living 3

Physical examination should systematically document:

• Inspection (asymmetry, muscle atrophy, gait abnormalities) 7
• Palpation with specific anatomic landmarks 5
• Range of motion (active and passive) with pain provocation 3
• Strength testing (graded 0-5) for specific muscle groups 5
• Special tests with positive/negative results and interpretation 3, 2
• Neurovascular examination including dermatomal sensation and reflexes 1, 2

Clinical Reasoning Framework

For bilateral hip pain in young active adults, use this algorithm:

1. Exclude red flags (fever, weight loss, night pain, trauma) requiring urgent imaging 4
2. Obtain plain radiographs first - screens for structural pathology 3, 4
3. Perform comprehensive neurologic exam - rules out radiculopathy 1, 2
4. If radiographs normal and neuro exam abnormal → lumbar spine MRI 1, 2
5. If radiographs normal and neuro exam normal but symptoms persist → hip MRI or continue conservative management with close follow-up 3
6. Conservative management trial 6-12 weeks before advanced interventions 1, 2
7. Specialty referral if: progressive neurologic deficit, failure of conservative management, or imaging shows surgical pathology 1, 2

Specific to Military/Athletic Population

Physical activity and return to sport should be addressed but only after proper diagnosis. 3

• Goal setting should be collaborative and realistic based on actual diagnosis 3
• Return to running requires ability to tolerate high loads safely 3
• Progression should be gradual: strength → cardiovascular fitness → basic athletic movements → sport-specific tasks 3
• Symptoms during activity may not correlate with long-term joint health, but persistent pain warrants investigation 3

Your note shows good clinical reasoning in considering FAI and labral pathology, but the execution lacks the diagnostic rigor required for this presentation. The bilateral nature, chronicity, and activity pattern demand imaging and more thorough neurologic assessment before committing to a treatment plan.