Persistent pain

Persistent pain after hip arthroscopy is a symptom with several potential causes. First determine whether the patient never improved, improved and then plateaued, had a pain-free interval followed by recurrence, or developed a new pain pattern. The timeline often narrows the differential before additional imaging is obtained. 1,2

Timing / pattern	Think first about
Early, escalating, systemic, or unable to progress	Infection, hematoma, wound problem, fracture or stress injury, VTE, traction-related neuropraxia, fluid extravasation, or early instability.
Weeks to months, pain with rehabilitation or specific loading	Inadequate rehabilitation, hip-flexor/abductor overload, iliopsoas, capsular irritability, adhesions, heterotopic ossification, or extra-articular/referred pain.
Late, recurrent mechanical groin pain or failed return to function	Residual FAI, labral/chondral pathology, adhesions, instability/capsular insufficiency, dysplasia/version issues, progression of chondral disease/OA, or a competing diagnosis.

Evaluation

Re-read the pre-op diagnosis, imaging, operative report, procedure images, implant record, and rehabilitation course. Identify what was treated and what was intentionally not treated.
Repeat a full history and hip/regional examination. The current pain map may differ from the pre-operative map.
Obtain current radiographs. Use CT with three-dimensional assessment when residual cam/pincer morphology or version is a key question. Use MRI/MRA selectively for soft tissue, cartilage, capsule, or alternative pathology.
Treat postoperative MRI/MRA cautiously. Labral signal, capsular change, and paralabral findings may occur in asymptomatic patients. 3,4
Use selective intra-articular or extra-articular injections when they will answer a localization question. Reassess activity, rehabilitation, lumbar, pelvic, and psychosocial contributors in parallel.
If infection is possible, obtain inflammatory markers and aspirate when indicated before antibiotics in a clinically stable patient. See the infection section.

Revision is not synonymous with “more arthroscopy.” Residual bony impingement, adhesions, instability, and labral/chondral pathology may be treatable arthroscopically in selected patients. Dysplasia, marked version abnormality, advanced arthritis, or a non-hip diagnosis may call for periacetabular/femoral osteotomy, arthroplasty, non-operative care, or another specialty pathway instead. 1,2,5

Important considerations:

Rapidly worsening hip pain, fever, wound drainage, pain out of proportion, inability to bear weight, a new neurologic deficit, calf or chest symptoms, and suspected fracture or instability require urgent assessment.

References