What is the appropriate initial management for a 39-year-old female presenting with hip pain?

Initial Management of Hip Pain in a 39-Year-Old Female

Begin with anteroposterior pelvis and lateral femoral head-neck radiographs immediately, as plain films are the mandatory first-line imaging to identify hip osteoarthritis, femoroacetabular impingement (FAI) syndrome, labral pathology, or other structural abnormalities that commonly cause hip pain in this age group. 1, 2, 3

Immediate Diagnostic Workup

Clinical Assessment

Perform a focused physical examination targeting:

• Pain location: Groin pain suggests intra-articular pathology (FAI, labral tear, early OA), while lateral pain indicates greater trochanteric pain syndrome and posterior pain suggests referred lumbar spine pathology, deep gluteal syndrome, or ischiofemoral impingement 2, 4
• Internal rotation test: Pain with passive internal rotation in flexion strongly suggests intra-articular hip pathology including FAI syndrome or labral tears 1, 2
• FADIR test (Flexion-Adduction-Internal Rotation): Positive test indicates labral or chondral pathology 1
• Range of motion assessment: Document flexion, internal/external rotation, and any limitations 1, 5
• Muscle strength testing: Assess hip abductors, adductors, flexors, and rotators, as weakness is consistently present in hip-related pain 1, 2

Initial Imaging Protocol

• Obtain AP pelvis and lateral femoral head-neck radiographs bilaterally as the first diagnostic step 1, 2, 3
• These rapidly identify fractures, advanced arthritis, FAI morphology (cam/pincer lesions), acetabular dysplasia, and bony abnormalities 1, 3
• Critical pitfall: Never diagnose hip pathology based on imaging alone—diagnosis requires correlation with clinical signs and symptoms 1

Advanced Imaging (When Indicated)

If radiographs are non-diagnostic but clinical suspicion remains high:

• Order MRI or MRA of the hip to assess labral tears, early cartilage damage, ligamentum teres pathology, and soft tissue abnormalities not visible on plain films 1, 2, 3
• MRI is particularly indicated if non-surgical treatment fails and surgery is being considered 1

Immediate Symptomatic Management

First-Line Pharmacological Treatment

• Start NSAIDs at the lowest effective dose as primary analgesia (strong recommendation, high-quality evidence) 2, 6, 3
• NSAIDs have superior efficacy compared to acetaminophen for moderate-to-severe hip pain 6
• Add proton pump inhibitor if gastrointestinal risk factors exist, or consider selective COX-2 inhibitor 6
• Acetaminophen up to 4 grams daily may be added for breakthrough pain, though it has limited efficacy as monotherapy 2, 6

Non-Pharmacological Interventions

• Refer immediately to physical therapy (moderate recommendation, high-quality evidence) focusing on: 2, 6, 3
  • Hip muscle strengthening, particularly abductors, adductors, flexors, and rotators 1, 2
  • Range of motion exercises 6
  • Gait training and functional performance tasks including single-leg balance 1, 6

Diagnostic Categories After Initial Workup

Based on imaging and clinical findings, categorize into: 1

1. FAI syndrome: Cam or pincer morphology on radiographs with positive FADIR test and groin pain
2. Acetabular dysplasia/hip instability: Decreased center-edge angle on AP pelvis radiograph
3. Other conditions: Labral tears, chondral lesions, or soft-tissue pathology without specific bony morphology

Next Steps if Conservative Management Fails

After 4-6 Weeks of NSAIDs and Physical Therapy

• Consider ultrasound or fluoroscopy-guided intra-articular corticosteroid injection if pain remains uncontrolled (moderate recommendation, high-quality evidence) 2, 6, 3
• This provides both diagnostic confirmation of intra-articular pathology and therapeutic benefit 2

Surgical Referral Indications

• Persistent symptoms despite 3-6 months of conservative management 1
• Confirmed structural pathology (FAI, labral tear, gluteus medius tear) amenable to surgical correction 4
• Progressive functional limitation affecting quality of life 2

Critical Pitfalls to Avoid

• Never assume primary hip joint pathology without imaging confirmation, as lumbar spine or sacroiliac joint pathology can mimic hip pain 1, 3
• Do not proceed to MRI without obtaining plain radiographs first, as this violates consensus guidelines and may miss important bony pathology 3
• Avoid opioids entirely for hip pain management due to poor risk-benefit ratio (strong recommendation) 6, 3
• Do not use hyaluronic acid injections for symptomatic hip conditions (strong recommendation, high-quality evidence) 3
• Never diagnose based on imaging alone—incidental findings are common in asymptomatic individuals and require clinical correlation 1

Screening for Red Flags

Evaluate for serious pathology requiring urgent referral: 7

• Severe gait disturbance with Trendelenburg sign
• Night pain disrupting sleep
• Empty end-feel with passive range of motion
• Constitutional symptoms (fever, weight loss, night sweats)
• History of malignancy