What is the management of a 44-year-old patient with right hip pain and a radiograph (X-ray) showing a small ossicle adjacent to the superior margin of the right acetabulum, with pain worsening upon walking?

Management of Right Hip Pain with Acetabular Ossicle

For a 44-year-old patient with right hip pain and a small ossicle adjacent to the superior margin of the right acetabulum that worsens with walking, a conservative approach with non-pharmacological interventions and appropriate pain management should be initiated before considering surgical options.

Initial Assessment and Diagnosis

The presence of an ossicle (small bone fragment) adjacent to the superior acetabular margin may represent:

• A stress fracture due to repetitive loading
• An unfused secondary ossification center
• A manifestation of femoroacetabular impingement (FAI)

This finding, especially when associated with pain during walking, suggests potential hip-related pathology that requires structured management.

Treatment Algorithm

First-Line Management

1. Non-Pharmacological Interventions

   • Exercise therapy: Focus on hip girdle strengthening and mobility exercises 1
     • Land-based exercises targeting hip musculature
     • Aquatic exercises if available (reduces joint loading while maintaining mobility)
   • Activity modification: Temporarily reduce activities that exacerbate pain
   • Physical therapy: Structured program focusing on hip stabilization 2
   • Weight management: If patient is overweight, even modest weight loss can reduce mechanical stress on hip joints 1

2. Pharmacological Management

   • NSAIDs: When not contraindicated, oral NSAIDs should be used for symptomatic hip pain 3
   • Acetaminophen: May be considered as an alternative if NSAIDs are contraindicated 3
   • Topical NSAIDs: Consider for localized pain with fewer systemic effects 1

Second-Line Management

If inadequate response to initial therapy after 4-6 weeks:

1. Intra-articular corticosteroid injection

   • Could be considered for symptomatic hip pain 3
   • Provides temporary relief while continuing rehabilitation

2. Advanced imaging

   • MRI to better characterize the ossicle and evaluate for associated labral pathology or cartilage damage
   • CT scan to better define bony morphology if surgical intervention is being considered

Third-Line Management

For persistent symptoms despite conservative management:

1. Surgical consultation
   • Consider referral to an orthopedic surgeon specializing in hip preservation
   • Arthroscopic intervention may be appropriate for acetabular rim disorders 4
   • The ossicle may represent a stress fracture due to femoroacetabular impingement that might benefit from surgical management 5

Important Considerations

• Avoid hyaluronic acid injections: Strong evidence recommends against their use for symptomatic hip osteoarthritis 3
• Limit opioid use: Opioids should not be used as first-line treatment for hip pain 3, 1
• Monitor for progression: Regular follow-up to assess symptom progression and response to treatment
• Rule out other causes: Ensure proper differential diagnosis to exclude other sources of hip pain

Rehabilitation Focus

• Emphasize proper biomechanics during daily activities
• Gradually increase activity as tolerated
• Consider assistive devices (walking stick used on contralateral side) if needed for pain relief during ambulation 1

Prognosis

The presence of an acetabular ossicle in a non-dysplastic hip may indicate underlying femoroacetabular impingement 5. With appropriate management, many patients can achieve significant symptom relief without surgical intervention. However, persistent symptoms may indicate the need for surgical management, particularly if the ossicle represents a manifestation of impingement that could lead to progressive joint damage over time.