What is the treatment for hip pain with X-ray (X-ray) suggesting possible enthesopathy (inflammation of the entheses, the sites where tendons or ligaments insert into the bone)?

From the Guidelines

Treatment for hip pain with X-ray findings suggesting enthesopathy should begin with conservative measures, prioritizing exercise-based treatments, possibly with hip, trunk, and functional strengthening components, for at least 3 months duration, as recommended by the most recent and highest quality study 1. When managing hip pain with possible enthesopathy, it is essential to consider the patient's overall condition, including their level of pain intensity, disability, and handicap, as well as their wishes and expectations 1.

• Key considerations in treatment include:
  • Non-pharmacological treatment, such as regular education, exercise, appliances, and weight reduction if obese or overweight 1
  • Pharmacological treatment, starting with paracetamol (up to 4 g/day) for mild-moderate pain, and considering NSAIDs, opioid analgesics, or other options as needed 1
  • Physical therapy focusing on gentle stretching and strengthening exercises for the hip and core muscles, which is essential for long-term management 1
• According to the most recent study 1, exercise-based treatments should be prioritized, and the treatment duration should be at least 3 months.
• Additionally, maintaining a healthy weight and avoiding activities that exacerbate symptoms are crucial for preventing recurrence.
• For persistent pain, further evaluation with MRI may be warranted to rule out other conditions, and newer treatments like platelet-rich plasma injections or extracorporeal shockwave therapy might be considered in cases of severe, persistent enthesopathy.

From the FDA Drug Label

In patients with ankylosingspondylitis, naproxen has been shown to decrease night pain, morning stiffness and pain at rest. Naproxen has been studied in patients with mild to moderate pain secondary to postoperative, orthopedic, postpartumepisiotomy and uterine contraction pain and dysmenorrhea.

The treatment of hip pain with xray suggesting possible enthesopathy may be managed with naproxen, as it has been shown to be effective in reducing pain and inflammation in various conditions, including ankylosing spondylitis and orthopedic pain 2.

• Key benefits of naproxen include reduction in pain intensity scores and increase in pain relief scores.
• Important consideration: naproxen may be used safely in combination with gold salts, but its use in combination with salicylates is not recommended due to increased risk of adverse events.

From the Research

Treatment Options for Hip Pain with Possible Enthesopathy

• The treatment of hip pain with possible enthesopathy, as suggested by an X-ray, may involve a combination of non-surgical and surgical methods 3, 4, 5, 6, 7.
• Non-surgical methods may include:
  • NSAIDs to reduce pain and inflammation 3, 6.
  • Orthoses and physical therapy to improve mobility and strength 3.
  • Steroid injections, which may be reserved for more severe cases 3, 6.
• Surgical methods may be considered if conservative treatment fails, and may include:
  • Arthroscopy to treat intraarticular lesions 4, 7.
  • Various surgical techniques to correct the painful snapping, according to the patient's characteristics 7.

Diagnostic Imaging

• Radiography of the hip and pelvis should be the initial imaging test to diagnose hip pain 4.
• Ultrasonography and magnetic resonance imaging may be used to show alterations of the structures involved in enthesopathy 3.
• Diagnostic ultrasound may be advised to ensure the presence of inflammation that can potentially benefit from corticosteroid injection, as well as the absence of rupture 6.

Considerations for Entheseal Injection

• The decision to use entheseal corticosteroid injection should be made on an individual basis, with consideration of the use of CS injection as the last treatment option following more conservative measures 6.
• Entheseal injection should be avoided in high-risk patients, such as those who have rupture at the enthesis 6.
• Ultrasound guidance for needle placement is strongly encouraged 6.