What is the management for hip and buttock pain?

Management of Hip and Buttock Pain

The management of hip and buttock pain should follow a multimodal approach starting with conservative measures including exercise therapy, weight management, and non-opioid analgesics, with pharmacological options progressing from topical to oral medications based on pain severity and response to treatment. 1

Initial Assessment and Classification

Hip and buttock pain can be categorized based on location:

• Anterior groin pain: Often indicates intra-articular pathology (osteoarthritis, labral tears)
• Lateral trochanteric pain: Commonly associated with greater trochanteric pain syndrome
• Posterior buttock pain: May indicate piriformis syndrome, sacroiliac joint dysfunction, or referred pain from lumbar spine 2, 3

First-Line Management

Non-Pharmacological Approaches

• Self-management program (Weak recommendation) 1

  • Regular self-directed exercise
  • Weight reduction for overweight/obese patients
  • Bracing for knee OA (if applicable)

• Physical therapy (Weak recommendation) 1

  • Should be offered as part of comprehensive management
  • Exercise-based treatments should be at least 3 months in duration
  • Should include strengthening of hip, trunk and functional components

Pharmacological Approaches

1. Topical agents (for knee OA; limited evidence for hip) 1

   • Topical NSAIDs (Strong recommendation for knee OA)
   • Topical capsaicin (Weak recommendation for knee OA)

2. Oral medications (Weak recommendation) 1

   • Acetaminophen: Starting dose 325-650mg every 4-6 hours (maximum 3000mg/day)
   • Oral NSAIDs: Ibuprofen 400-800mg three to four times daily (maximum 3200mg/day) 4
   • Use the lowest effective dose for shortest duration to minimize adverse effects

Second-Line Management

For patients with inadequate response to first-line treatments:

1. Combination pharmacotherapy 1

   • Duloxetine as alternative or adjunctive therapy (Weak recommendation for knee OA)
   • Consider combining acetaminophen with NSAIDs

2. Intra-articular injections 1

   • Corticosteroid injection for persistent knee pain inadequately relieved by other interventions (Weak recommendation)
   • Limited evidence for hip injections

Important Considerations

• Avoid opioids (including tramadol) for initial management of hip and buttock pain (Weak recommendation against) 1

• Comorbidities assessment before finalizing treatment plan:

  • Cardiovascular disease
  • Gastrointestinal bleeding risk
  • Chronic kidney disease
  • Hypertension 1

• Complementary approaches (insufficient evidence):

  • Acupuncture
  • Massage
  • Tai chi
  • Yoga 1

Treatment Algorithm

1. Initial approach:

   • Self-management with exercise and weight management
   • Physical therapy referral
   • Topical agents for knee pain (NSAIDs, capsaicin)
   • Acetaminophen and/or oral NSAIDs

2. If inadequate improvement:

   • Reassess diagnosis and consider imaging if not previously done
   • Intensify physical therapy
   • Consider duloxetine as adjunctive therapy
   • Consider intra-articular corticosteroid injection (for knee)

3. For persistent symptoms:

   • Obtain weight-bearing radiographs
   • Consider surgical consultation if conservative measures fail 1

Common Pitfalls

• Misdiagnosis: Hip pain can be misdiagnosed as lumbar pathology, leading to unnecessary spine interventions 5
• Premature imaging: MRI should be performed only if history and plain radiographs are not diagnostic 3
• Inadequate trial of conservative therapy: Physical therapy should be continued for at least 3 months 1
• Over-reliance on opioids: NSAIDs and acetaminophen should be optimized before considering opioids 1
• Focusing only on pain: Address functional limitations and quality of life 1

By following this structured approach to hip and buttock pain management, clinicians can effectively address symptoms while minimizing risks associated with more invasive interventions.