Bone Of Contention: Construction Worker With Acute Hip Pain

HISTORY: A 55-year-old male construction worker presented to the sports medicine clinic with a 3-month history of persistent right hip pain. The pain was localized to the right lateral distal thigh and radiated proximally towards his groin. The onset was sudden and not associated with any specific injury or trauma. His symptoms persisted despite conservative management with rest and job modification. After an initial x-ray of his hip was obtained at urgent care, he presented to his PCP 3 weeks later with severe right groin and gluteal pain exacerbated by exertion and even disturbing his sleep. An MRI was then ordered. PHYSICAL EXAM: Anterior/lateral/posterior hip without swelling, erythema, or ecchymosis. No tenderness to palpation over the ASIS, iliac crest, greater trochanter, or ischial tuberosity. Active hip flexion 80°, passive 100°. Active hip abduction 35°, passive 45°. Active hip adduction 20°, passive 25°. Active internal rotation to 20°, passive 30°. Active external rotation 40°, passive 60°. Strength was intact in flexion, abduction, and adduction. FABER and FADIR tests were positive. Log roll and Stinchfield tests were positive. Straight leg raise test was negative. Sensations were intact to all dermatomes of his right lower extremity. DIFFERENTIAL DIAGNOSIS: Femoroacetabular impingement Hip osteoarthritis Acetabular labral tear Avascular necrosis Septic joint TEST AND RESULTS: X-ray hip: Normal alignment without acute fracture. No joint disease seen. Soft tissues are unremarkable. MRI hip #1: Bone edema in femoral head extending to femoral neck along with joint effusion. No appreciable fracture line is seen. No articular surface irregularity or collapse is seen. There is mild chondral thinning of the right hip joint. There is suggestion of an anterior acetabular labral tear. Iliopsoas tendon intact without surrounding fluid. Gluteal/hamstring/adductor tendons intact. #2: residual but much less prominent marrow edema of the right femoral head and neck. No joint effusion. No joint line collapse. #3: pending read FINAL/WORKING DIAGNOSIS: Idiopathic Transient Osteoporosis TREATMENT AND OUTCOMES: Advised to maintain protected weight-bearing with crutches for the next 6-8 weeks. NSAIDs as-needed for pain. Follow-up with serial MRIs at 3 and 6 months to monitor for proper healing.