What are the treatment options for coxalgia (hip pain)?

Treatment Options for Coxalgia (Hip Pain)

The optimal management of hip pain (coxalgia) requires a combination of non-pharmacological and pharmacological treatment modalities tailored to the individual's specific condition, pain intensity, and functional limitations. 1

Treatment Algorithm

First-Line Treatments

• Non-pharmacological approaches should be initiated for all patients with hip pain and include:

  • Regular education about the condition and self-management strategies 1
  • Exercise therapy to improve function and reduce pain 1
  • Assistive devices such as walking sticks or canes when needed 1
  • Weight reduction for patients who are overweight or obese 1

• Pharmacological first-line treatment:

  • Paracetamol (acetaminophen) up to 4g/day is the oral analgesic of first choice for mild to moderate hip pain due to its efficacy and safety profile 1
  • Should be used as the preferred long-term oral analgesic if effective 1

Second-Line Treatments

• NSAIDs should be added or substituted when paracetamol provides inadequate pain relief:
  • Use the lowest effective dose (e.g., ibuprofen 1200-3200mg daily) 1, 2
  • For patients with increased gastrointestinal risk, use either:
    • Non-selective NSAIDs plus a gastroprotective agent 1
    • A selective COX-2 inhibitor 1
  • NSAIDs should be used with caution in patients with cardiovascular, renal, or hepatic conditions 2

Third-Line Treatments

• Opioid analgesics (with or without paracetamol) should be considered when:

  • NSAIDs are contraindicated
  • NSAIDs are ineffective
  • NSAIDs are poorly tolerated 1
  • Be aware that opioids may cause more side effects including constipation, dizziness, and drowsiness 1

• Symptomatic slow-acting drugs for osteoarthritis (SYSADOA) may be considered:

  • Options include glucosamine sulfate, chondroitin sulfate, diacerhein, avocado soybean unsaponifiable, and hyaluronic acid 1
  • These have symptomatic effects and low toxicity, but effect sizes are small 1

Interventional Treatments

• Intra-articular steroid injections (guided by ultrasound or x-ray) may be considered for patients with acute flares unresponsive to analgesics and NSAIDs 1

• Physical therapy interventions may include:

  • Manual therapy techniques 1
  • Targeted exercises for hip and trunk muscle strengthening 1
  • Functional movement training 1

Surgical Options

• Osteotomy and joint-preserving procedures should be considered in young adults with symptomatic hip OA, especially with dysplasia or varus/valgus deformity 1

• Joint replacement (total hip arthroplasty) should be considered for patients with:

  • Radiographic evidence of hip OA
  • Refractory pain and disability despite conservative management 1, 3

Special Considerations

• Treatment should be tailored according to:

  • Hip-specific risk factors (obesity, mechanical factors, activity level, dysplasia) 1
  • General risk factors (age, comorbidities, co-medications) 1
  • Pain intensity and functional limitations 1
  • Structural damage extent and location 1
  • Patient preferences and goals 1

• Monitoring treatment response:

  • Use appropriate patient-reported outcome measures to assess pain and function 1
  • Evaluate physical impairment measures (range of motion, strength) 1
  • Consider psychosocial factors that may influence pain perception and treatment outcomes 1

Common Pitfalls to Avoid

• Overreliance on medication alone without addressing non-pharmacological approaches 1
• Prolonged use of high-dose NSAIDs without monitoring for gastrointestinal, cardiovascular, or renal adverse effects 1, 2
• Inadequate pain control leading to reduced mobility and physical deconditioning 1
• Delayed referral for surgical evaluation when conservative measures fail to provide adequate relief 1
• Failure to diagnose specific causes of hip pain that may require targeted treatment (e.g., inflammatory arthritis, avascular necrosis, labral tears) 4