Management of Hip Pain After Fall with Mild Degenerative Changes and No Fracture

Immediate Assessment and Monitoring

Plain radiographs miss 24.1% of hip fractures, so normal X-rays do not completely exclude injury 1
If pain persists or worsens over the next 1-2 weeks, obtain CT hip without IV contrast (94% sensitivity, 100% specificity for occult fractures) or MRI to evaluate for radiographically occult fractures, muscle tears, or hematomas 1, 2
Do not rely on preserved range of motion or ability to bear weight to exclude fracture—patients with minimally displaced fractures can maintain function initially 1
New inability to bear weight or worsening edema at 1-week follow-up requires urgent re-evaluation with advanced imaging 1

Allow weight-bearing as tolerated with an assistive device (crutches or walker) for the first 2-3 weeks to reduce pain while preventing deconditioning 1, 5
Do not prescribe complete bed rest or restricted weight-bearing—immobility increases complications including pressure ulcers, pneumonia, and deconditioning 3, 4, 1
Early mobilization as tolerated is the standard of care and promotes healing 1, 5
Begin gentle range-of-motion exercises (hip flexion, abduction, adduction) after initial pain subsides, typically 3-5 days after injury 1
Progress to resistance exercises and strengthening only after pain-free range of motion is achieved, typically 3-4 weeks 1
Return to full activity only after complete pain-free function is restored, typically 6-8 weeks for severe contusions 1

Repeat clinical evaluation at 1-2 weeks to confirm clinical improvement 1
If pain or edema worsens or fails to improve by 2 weeks, obtain MRI to evaluate for occult fracture, muscle tear, or hematoma requiring intervention 1, 6
Perform multifactorial falls risk assessment incorporating evaluation of gait, mobility, balance, lower limb strength, medication review, cognitive capacity, footwear, and environmental factors 6
Use standardized tests such as the Timed Up and Go test to evaluate mobility 6
Address modifiable fall risk factors including orthostatic hypotension, medication effects, and cardiac causes 5
Each patient aged 50 years and over with a recent fracture should be evaluated systematically for risk of subsequent fractures 3, 4
Consider referral to a Fracture Liaison Service or Bone Health Clinic for evaluation including vitamin D, calcium, and parathyroid hormone levels, and outpatient DEXA scan 6, 5
Recommend weight-bearing impact exercise and/or resistance training to promote bone health 6
Ensure adequate calcium intake and vitamin D supplementation 6

Do not assume normal radiographs exclude fracture in a patient with significant trauma—proceed to CT or MRI if symptoms persist or worsen 1, 2
Do not recommend complete immobilization—early mobilization as tolerated prevents complications and promotes healing 3, 4, 1
Do not ignore worsening symptoms at 1-week follow-up—this raises concern for occult fracture, particularly isolated greater trochanter fractures that can extend to the femoral neck 1
Do not delay advanced imaging beyond 2 weeks if pain fails to improve or worsens 1