A woman who is two weeks postpartum after a cesarean delivery presents with hip pain; what is the appropriate evaluation and management?

Hip Pain at 2 Weeks Post-Cesarean Section

Begin with scheduled acetaminophen 975 mg every 8 hours plus ibuprofen 600 mg every 6 hours for presumed musculoskeletal pain, but immediately evaluate for life-threatening causes including venous thromboembolism and deep tissue infection before attributing symptoms to routine post-surgical discomfort. 1, 2

Immediate Life-Threatening Differential

The incidence of venous thromboembolism (VTE) is 2.6 per 1000 cesarean births, increasing to 4.3 per 1000 with longer postpartum follow-up, making pulmonary embolism with diaphragmatic irritation a critical consideration at 2 weeks postpartum. 2 Never dismiss persistent hip or shoulder pain as "normal" post-cesarean discomfort without excluding serious pathology, as VTE incidence peaks in the first 2-4 weeks postpartum. 2

Critical Red Flags Requiring Urgent Workup

• Fever, tachycardia, dyspnea, chest pain, or leg swelling mandate immediate evaluation for VTE or infection. 2
• Unilateral leg swelling, warmth, or tenderness suggests DVT. 2
• Tachycardia, tachypnea, fever, or hypotension require urgent workup. 2
• Deep tissue infection (such as subphrenic abscess or iliopsoas fasciitis) can present without systemic signs initially, requiring palpation for focal tenderness, induration, or fluctuance. 2, 3

Mandatory Diagnostic Evaluation

• Obtain CT chest/abdomen with contrast to evaluate for pulmonary embolism, subphrenic abscess, or intra-abdominal collection if any red flags are present. 2
• Perform lower extremity Doppler ultrasound if DVT is suspected. 2
• Complete blood count and inflammatory markers (CRP, ESR) should be obtained if infection is suspected. 2

Musculoskeletal and Obstetric-Specific Causes

Once life-threatening causes are excluded, consider pregnancy-related and post-surgical etiologies:

Acetabular Labral Tear

• Acetabular labral tears should be considered in the differential diagnosis for hip pain in postpartum women, particularly if pain began during pregnancy or delivery. 4
• Freeing the distal lower extremity to externally rotate during labor may prevent acute labral tears. 4
• When nonoperative management fails after 4-6 weeks, arthroscopic repair leads to significant improvement (average modified Harris hip score improved from 53.1 preoperatively to 84.3 postoperatively). 4

Piriformis Syndrome

• Prolonged sitting and weight bearing in the upright position after cesarean delivery can cause sciatic nerve compression at the sacroiliac joint with concomitant irritation, inflammation, and spasm of the piriformis muscle. 5
• Presents with sudden onset pain in the buttock and hip radiating to the posterior knee. 5
• Piriformis syndrome is frequently underdiagnosed in the obstetric population because back pain with radiation after spinal anesthesia is often attributed to the procedure itself. 5

Transient Osteoporosis of Pregnancy

• Rare but can present with severe hip pain preventing weight-bearing, typically developing in the third trimester but persisting postpartum. 6
• Radiographs reveal gross osteopenia of the femoral heads. 6
• Can involve bilateral hips and rarely the knee. 6

Iliopsoas Fasciitis

• Presents with extreme pain in the pelvic wall, sacroiliac joint region, or thigh—symptoms uncommon in uncomplicated endometritis. 3
• Can be complicated by sepsis but typically improves with protracted antibiotic treatment. 3
• Consider when patients complain of extreme flank pain and tenderness in the pelvic wall. 3

Evidence-Based Pain Management Protocol

First-Line Multimodal Analgesia

Prescribe paracetamol (acetaminophen) and NSAIDs as foundational therapy, which should already be part of post-cesarean pain management. 1

• Acetaminophen 975 mg every 8 hours OR 650 mg every 6 hours. 1, 7
• Ibuprofen 600 mg every 6 hours (maximum 3200 mg daily). 1, 8
• Both medications are safe during breastfeeding. 7

Adjunctive Non-Pharmacological Measures

• Transcutaneous electrical nerve stimulation (TENS) can be used as an adjunctive measure. 1, 2
• Ice packs or heating pads may provide additional relief. 1, 7

Opioid Use: Reserve for Severe Breakthrough Pain Only

Minimize opioid utilization and develop individualized post-discharge opioid prescribing practices to reduce unnecessary consumption. 1

• A short course of low-dose opioids (e.g., 5-10 tablets of hydrocodone 5 mg) can be considered for severe pain not adequately treated by non-opioid options. 1, 7
• Approximately 1 in 300 women exposed to opioids after cesarean delivery develop chronic opioid use. 1, 7
• Most women use only half of prescribed opioids post-cesarean, and 95% do not dispose of unused medication. 1, 7

Clinical Pitfalls to Avoid

• Do not attribute all hip pain to musculoskeletal causes in the postpartum period; the differential is broader and includes life-threatening conditions. 2
• Recognize that deep tissue infection can present without fever or leukocytosis initially, requiring high clinical suspicion. 2
• Persistent severe pain at 2 weeks post-cesarean is NOT normal and requires thorough evaluation. 9
• Pain after cesarean section is often under-treated due to unfounded fears that analgesic drugs might induce maternal and neonatal side-effects. 1
• Inadequate postoperative pain relief may lead to hyperalgesia, persistent postoperative pain, delayed recovery, impaired mother-child bonding, and complicated breastfeeding. 1, 10

Follow-Up and Escalation

If pain persists beyond 4-6 weeks despite optimal medical management, consider:

• MRI of the hip to evaluate for labral tear, transient osteoporosis, or other structural pathology. 4, 6
• Referral to orthopedics for consideration of arthroscopic evaluation if labral tear is suspected. 4
• Physical therapy and gait training once acute pain is controlled. 6