Lateral hip pain in a manual worker: tendinopathy, osteoarthritis, or both?
Mr A, 58, is a secondary-school caretaker. For 10 weeks he has had lateral hip pain, worst over the greater trochanter and when lying on the left side. Pain is 5/10 on walking 500 m, 8/10 on stairs, and he now takes paracetamol most evenings. He reports 20 minutes of morning stiffness in the hip and no fever or weight loss. He walks 8,000 steps daily at work and has recently started a lunchtime walking group. Examination: tenderness over the lateral trochanter, pain at 30° of single-leg stand, FABER reproduces lateral pain, hip internal rotation 20° (right 35°), and no pain at end-range hip flexion. He asks for an MRI because his brother had a hip replacement at 60.
1. What is the most likely diagnosis, and how do the positive and negative examination findings alter the probability of the main alternatives?
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The leading diagnosis is gluteal tendinopathy, with hip osteoarthritis as a co-existing possibility rather than an either/or answer.
- Gluteal tendinopathy is supported by focal greater-trochanter tenderness, lateral pain in side-lying, pain on single-leg stand, and FABER reproducing lateral pain. These tests are sensitive but not specific; they raise probability rather than confirm the diagnosis.
- Hip osteoarthritis is supported by age, reduced internal rotation (20° versus 35° on the other side), and lateral pain referred from the hip. Reduced internal rotation is more discriminating than FABER or single-leg stand.
- Inflammatory arthritis is less likely: 20 minutes of stiffness is short, and there is no fever, weight loss, or systemic feature. Fracture is unlikely without trauma or inability to weight-bear, though the new walking group is a load change worth noting.
The examination does not cleanly separate the two common conditions, so I would treat the tendinopathy while arranging a plain radiograph if the reduced rotation and night pain persist. The MRI request is driven by the brother's history, not by the clinical findings.
2. Would you arrange imaging now? Justify what you would request, what you would not request, and what you would do while waiting.
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I would not arrange MRI now. The presentation is mechanical, there are no red flags, and MRI findings of tendon change and labral tears are common in asymptomatic people; a scan is unlikely to change first-line management and may increase anxiety about the brother's hip replacement.
I would request a plain AP pelvis and lateral hip radiograph if symptoms fail to settle after 6–8 weeks or if reduced internal rotation and night pain persist, because it is cheap, available, and identifies moderate-to-severe osteoarthritis that would alter referral thresholds. I would not request ultrasound or MRI for tendon diagnosis at this stage.
Meanwhile:
- Explain that pain does not equal structural damage and that the walking group is a useful load stimulus but may need temporary reduction.
- Advise load management: reduce walking to a pain-monitoring level (pain ≤3/10 during and the next morning), avoid side-lying on the affected hip, and use topical NSAID if medically appropriate.
- Start isometric or low-load hip abductor and pelvic-control exercise, then progress to loaded abduction.
- Review at 4–6 weeks with a single-leg stand and walking-distance marker.
3. He asks whether he will need a hip replacement. How would you answer, and what findings would make you refer him?
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I would say that pain alone does not indicate a hip replacement, and that his current symptoms are more consistent with a tendon problem that often improves with loading exercise. I would acknowledge the family history as a risk factor but explain that timing is driven by his function, examination, and imaging-not by his brother's operation.
I would refer for an orthopaedic opinion if he develops:
- Moderate-to-severe osteoarthritis on radiograph plus persistent night or rest pain, or
- Progressive loss of internal rotation and fixed flexion deformity, or
- Inability to walk 500 m or climb stairs despite 3–6 months of appropriate conservative care, or
- Rapidly worsening pain with systemic features.
I would document the shared decision, the trial of loading exercise, and the safety-net advice. This matters because early referral without a conservative trial can lead to unnecessary surgery, while delayed referral in progressive structural disease prolongs avoidable disability.