What are the treatment options for an 82-year-old female patient with severe hip pain (10/10) not relieved by acetaminophen (Tylenol) or topical non-steroidal anti-inflammatory drugs (NSAIDs) with no evidence of fracture on hip X-ray?

Treatment Options for Severe Hip Pain in an 82-Year-Old Female

For an 82-year-old female with severe hip pain (10/10) not relieved by acetaminophen or topical NSAIDs and normal hip X-ray, a multimodal analgesic approach with regular intravenous acetaminophen as first-line treatment combined with peripheral nerve blocks is strongly recommended. 1

Initial Pharmacological Management

• First-line treatment: Regular intravenous acetaminophen every 6 hours 2, 1
• Second-line options (if pain persists):
  • Consider oral NSAIDs with gastroprotection (proton pump inhibitor) if no contraindications such as renal impairment, bleeding risk, or GI issues 2, 1
  • Duloxetine as an alternative or adjunctive therapy for patients with inadequate response to acetaminophen or NSAIDs 2

Interventional Pain Management

• Peripheral nerve blocks (femoral or fascia iliaca blocks) should be implemented as soon as possible to:

  • Provide superior pain control
  • Reduce opioid requirements
  • Can be administered by trained emergency department staff 1

• Regional anesthesia options:

  • Epidural or paravertebral blocks if skills are available 2
  • These techniques significantly reduce opioid consumption and associated complications 2

Opioid Considerations

• Opioids should be used cautiously: Only for breakthrough pain when other options fail, at the lowest effective dose for the shortest period 2, 1
• Avoid initiating opioid therapy (including tramadol) as recommended by VA/DoD guidelines 2
• Caution in elderly: Reduced doses due to high risk of accumulation, sedation, respiratory depression, and delirium 2, 1

Non-Pharmacological Interventions

• Physical therapy: Should be offered as part of a comprehensive management plan 2
• Proper positioning and immobilization of the affected limb 1
• Ice application to reduce local inflammation 1
• Self-management program: Including appropriate exercises 2

Further Diagnostic Considerations

If pain persists despite initial management:

• Advanced imaging: If X-rays are negative but clinical suspicion for pathology remains high:

  • MRI is the gold standard for detecting occult hip fractures and soft tissue pathologies 1, 3
  • CT scan as an alternative if MRI is unavailable 1

• Consider alternative diagnoses:

  • Greater trochanteric pain syndrome (gluteus medius tendinopathy, bursitis) 3
  • Labral tears or femoroacetabular impingement 3
  • Deep gluteal syndrome with sciatic nerve entrapment 3
  • Referred pain from intra-abdominal or intrapelvic causes 3, 4

Special Considerations for Elderly Patients

• Pain assessment: Use appropriate pain assessment tools for patients with cognitive impairment 2
• Monitor for adverse effects: Particularly with NSAIDs (renal function) and opioids (respiratory depression) 2, 1
• Avoid undertreatment: Inadequate pain control can lead to delayed mobilization, prolonged hospital stay, and increased complications 1

Treatment Algorithm

1. Begin with regular IV acetaminophen every 6 hours
2. If inadequate relief, add peripheral nerve block
3. Consider adding NSAIDs with gastroprotection if no contraindications
4. For persistent pain, consider duloxetine as adjunctive therapy
5. Use opioids only for breakthrough pain at lowest effective dose
6. Implement non-pharmacological measures throughout treatment
7. If pain persists, obtain advanced imaging (MRI preferred) to identify underlying pathology

Common Pitfalls to Avoid

• Overreliance on opioids, which increases risk of delirium and respiratory depression 1
• Undertreatment of pain, which can lead to delayed mobilization and increased complications 1
• Failure to consider occult fractures or soft tissue pathologies when X-rays are normal 1, 3
• Not providing gastroprotection when prescribing NSAIDs to elderly patients 2