What is the next best step for a 58-year-old male patient with persistent bilateral hip pain despite completing physical therapy (PT), who has been taking Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) and Tylenol (acetaminophen) since 2020, and also has a left foot deformity due to a congenital absence of the 4th metatarsal, causing difficulty with ambulation?

Management of Persistent Bilateral Hip Pain with Left Foot Deformity

For this 58-year-old male with persistent bilateral hip pain despite physical therapy completion and long-term NSAID/acetaminophen use since 2020, orthopedic referral for surgical evaluation is the most appropriate next step, while simultaneously addressing the left foot deformity with prescribed orthotics. 1

Hip Pain Management Algorithm

Step 1: Evaluate Conservative Treatment Failure

• Patient has already tried:
  • NSAIDs and acetaminophen since 2020 (3+ years)
  • Completed physical therapy without adequate relief
  • Symptoms persist despite appropriate first-line treatments

Step 2: Orthopedic Referral for Surgical Evaluation

The American Academy of Orthopedic Surgeons (AAOS) guidelines support surgical evaluation when:

• Conservative measures have failed
• Pain persists despite appropriate non-surgical management
• Patient is of appropriate age (58) for potential surgical intervention 1

The case example in the AAOS guidelines describes a similar 58-year-old male with hip pain who had tried NSAIDs, acetaminophen, and PT with only transient relief, ultimately requiring surgical evaluation 1.

Step 3: Consider Intra-articular Injections While Awaiting Surgical Consultation

• Intra-articular corticosteroid injections could be considered as a bridge therapy
• The VA/DoD guidelines suggest offering intra-articular corticosteroid injections for persistent knee pain inadequately relieved by other interventions (weak recommendation) 1
• This approach may provide temporary relief while awaiting orthopedic evaluation

Step 4: Address Foot Deformity Simultaneously

• The prescribed Apex X520M shoes with gel insoles (size 10.5) are appropriate for the left foot deformity
• Proper footwear can improve gait mechanics and potentially reduce hip pain by correcting biomechanical abnormalities
• The VA/DoD guidelines support bracing and appropriate footwear as part of comprehensive management 1

Important Clinical Considerations

Imaging Recommendations

• Plain radiographs of the pelvis and hip should be obtained if not already done
• MRI may be necessary to evaluate for labral tears or other intra-articular pathology 2, 3
• The American College of Radiology recommends plain radiographs as the first imaging step 2

Pain Management During Transition

• Continue acetaminophen as needed, but monitor for signs of worsening pain that could indicate a serious condition 4
• Avoid initiating opioids (including tramadol) for pain associated with osteoarthritis of the hip 1
• Consider topical NSAIDs if oral medications cause gastrointestinal issues 1

Surgical Considerations

• Total hip arthroplasty (THA) has excellent outcomes for end-stage hip osteoarthritis 1
• Before surgery, optimization of any modifiable risk factors should be addressed:
  • BMI optimization if elevated
  • Smoking cessation if applicable
  • Diabetes control if present 1

Common Pitfalls to Avoid

1. Continuing ineffective conservative therapy: Prolonging non-surgical management when it has clearly failed can lead to unnecessary suffering and functional decline.

2. Overlooking the biomechanical relationship between foot deformity and hip pain: Addressing only the hip without correcting foot mechanics may limit treatment success.

3. Initiating opioids: The VA/DoD guidelines specifically recommend against initiating opioids for hip osteoarthritis pain 1.

4. Neglecting to evaluate for other causes of hip pain: Conditions such as labral tears, femoroacetabular impingement, or referred pain from the spine should be considered 5, 3.

The combination of orthopedic referral for surgical evaluation and appropriate orthotic management represents the most comprehensive approach to address both the persistent bilateral hip pain and the left foot deformity in this patient.