What is the best course of treatment for a patient with mild to moderate degenerative changes in the left hip and possible impingement type changes, as well as milder right hip degenerative changes?

From the Guidelines

The best course of treatment for a patient with mild to moderate degenerative changes in the left hip and possible impingement type changes, as well as milder right hip degenerative changes, should begin with conservative management. Initially, I recommend a combination of oral anti-inflammatory medications such as naproxen 500mg twice daily or ibuprofen 600mg three times daily with food for 2-3 weeks to reduce inflammation and pain, as suggested by the EULAR evidence-based recommendations for the management of hip osteoarthritis 1. This should be accompanied by physical therapy focusing on hip strengthening, core stability, and range of motion exercises twice weekly for 6-8 weeks. Weight management is crucial if the patient is overweight, as each pound lost reduces pressure on the hip joints by 3-4 pounds. Activity modification to avoid high-impact exercises while maintaining low-impact activities like swimming or cycling will help preserve joint function without accelerating degeneration. For breakthrough pain, acetaminophen up to 3000mg daily can be used, as it is the oral analgesic of first choice for mild-moderate pain 1. If conservative measures fail after 3-6 months, consider intra-articular corticosteroid injections (such as methylprednisolone 40mg mixed with lidocaine) or referral to orthopedics for surgical evaluation, particularly if impingement is significantly limiting function, as suggested by the ACR Appropriateness Criteria for chronic hip pain 1. These recommendations target inflammation reduction, joint protection, and muscle strengthening around the affected joints to improve stability and reduce mechanical stress on the degenerating cartilage. In terms of imaging, if symptoms persist, an outpatient MRI for follow-up evaluation may be considered, as it is a highly rated procedure for evaluating chronic hip pain 1. It's also important to note that total hip arthroplasty should be considered in patients with refractory pain or disability and radiographic evidence of structural damage, independent of age, as recommended by the ASAS/EULAR recommendations for the management of ankylosing spondylitis 1.

Some key points to consider in the management of this patient include:

• The importance of a multidisciplinary approach, including physical therapy and weight management, in addition to pharmacological treatment
• The need for regular follow-up and reassessment of the patient's condition to determine the effectiveness of the treatment plan and the need for any adjustments
• The potential benefits and risks of surgical interventions, such as total hip arthroplasty, and the importance of considering these options in patients with refractory pain or disability and radiographic evidence of structural damage.

Overall, the goal of treatment should be to reduce pain and inflammation, improve function, and slow the progression of degenerative changes in the hip joints, while also considering the patient's overall health and well-being.

From the Research

Treatment Options for Degenerative Hip Changes

• For patients with mild to moderate degenerative changes in the left hip and possible impingement type changes, as well as milder right hip degenerative changes, treatment options may include physical therapy and exercise programs 2.
• Physical therapy management, such as high-grade joint mobilization and exercise programs, has been shown to be effective in improving range of motion, reducing pain, and improving function in patients with hip impingement syndrome 2.
• Pharmacologic treatments, such as acetaminophen, nonsteroidal anti-inflammatory drugs (NSAIDs), and opioids, may also be considered for managing osteoarthritis pain, but their efficacy and safety vary 3.

Association between Leg Length Discrepancy and Degenerative Changes

• Research suggests that there may be an association between mild leg length discrepancy and degenerative joint disease in the hip and lumbar spine 4.
• This association highlights the importance of considering leg length discrepancy in the evaluation and treatment of patients with degenerative hip changes.

Regenerative Procedures for Tendinopathy

• Regenerative procedures, such as prolotherapy, platelet-rich plasma, and stem cells, are being explored as potential treatments for tendinopathy, but high-quality research is needed to evaluate their efficacy 5.

Physiotherapy Interventions for Adhesive Capsulitis

• Physiotherapy interventions, including manual therapy, mobilization, exercise, and education, have been shown to be effective in improving pain, range of motion, and functional status in patients with adhesive capsulitis 6.
• However, the efficacy of one treatment modality over another is uncertain, and further research is needed to determine the superior combination of treatment.