What are the treatment options for nocturnal hip pain?

Treatment Options for Nocturnal Hip Pain

For hip pain waking you at night, start with oral NSAIDs (like ibuprofen 400mg every 4-6 hours) combined with a structured exercise program lasting at least 3 months, and consider image-guided corticosteroid injection if conservative measures fail within the first few weeks. 1, 2, 3

Understanding Nocturnal Hip Pain

Nocturnal hip pain strongly correlates with hip joint effusion (fluid accumulation), with 92% of patients showing sonographic evidence of effusion experiencing night pain. 3 This is critical because:

• Night pain intensity is often higher than daytime pain (median pain scores of 49.5 vs 40.0 on visual analog scale), and patients with nocturnal pain report significantly worse overall pain scores. 4
• 75% of hip osteoarthritis patients experience nocturnal pain, which directly impacts sleep quality and correlates with worse functional scores on WOMAC, HOS, and modified Harris hip scores. 4, 5
• Pain patterns matter diagnostically: pain worse at night and relieved by activity can help narrow the differential diagnosis and guide imaging selection. 1

Initial Diagnostic Workup

Before treating, obtain plain radiographs first (AP pelvis and frog-leg lateral of symptomatic hip) to identify arthritis, fractures, tumors, or structural abnormalities. 1, 6

If radiographs are negative or equivocal:

• MRI hip without IV contrast is the next appropriate study (rated 9/9 by ACR) to evaluate intra-articular and soft tissue pathology. 1, 6
• Consider diagnostic injection (image-guided anesthetic + corticosteroid into hip joint, rated 8/9) when diagnosis remains unclear or concurrent spine/knee pathology exists. 6, 7

First-Line Treatment: Conservative Management

Exercise-Based Treatment (Highest Priority)

Exercise therapy should be the cornerstone of treatment for at least 3 months duration. 1

• Include hip, trunk, and functional strengthening components with resistance exercises. 1
• This recommendation has moderate-level evidence with consensus score of 9/9 from international expert consensus. 1
• Exercise programs should specify: load magnitude, repetitions, sets, duration, time under tension, rest intervals, and range of motion. 1

Oral Medications

NSAIDs are strongly recommended when not contraindicated: 2

• Ibuprofen 400mg every 4-6 hours as needed (do not exceed 3200mg daily). 2
• Take with meals or milk if gastrointestinal complaints occur. 2
• Use the lowest effective dose for shortest duration. 2

Acetaminophen may be considered as alternative if NSAIDs are contraindicated. 6

Avoid opioids and hyaluronic acid injections - these have strong evidence against their use. 6

Corticosteroid Injections

Image-guided intra-articular corticosteroid injection is appropriate (rated 5/9 for chronic hip pain, rated 8/9 when used diagnostically). 1, 6

This is particularly effective because:

• Aspiration of joint effusion combined with corticosteroid injection reduces both effusion and nocturnal pain. 3
• In the study of 50 patients with hip disease, 32 of 35 patients with effusion had nocturnal pain, and both pain and effusion decreased after aspiration with or without corticosteroid injection. 3

Dosing for intra-articular hip injection: 8

• Hip joint (large joint): 20-80mg methylprednisolone
• Inject into synovial space using sterile technique with 20-24 gauge needle
• May repeat at intervals of 1-5+ weeks depending on response
• Provides both diagnostic confirmation and therapeutic benefit

Algorithm for Treatment Selection

1. Week 0-2:

   • Start oral NSAIDs (ibuprofen 400mg q4-6h with meals) 2
   • Initiate structured exercise program with physiotherapist 1
   • Obtain plain radiographs if not already done 1, 6

2. Week 2-4:

   • If nocturnal pain persists despite NSAIDs and exercise initiation, obtain MRI without contrast 1, 6
   • Consider image-guided diagnostic/therapeutic corticosteroid injection, especially if effusion suspected 1, 3

3. Month 1-3:

   • Continue exercise program for full 3-month duration minimum 1
   • May repeat corticosteroid injection if initial response was good but symptoms recur 8
   • Monitor with patient-reported outcome measures (PROMs) 1

4. After 3 months:

   • If inadequate response to conservative management, consider surgical referral for conditions with good surgical outcomes (femoroacetabular impingement, labral tears, gluteus medius tears) 9

Common Pitfalls to Avoid

• Don't proceed to advanced imaging without plain radiographs first - this misses common diagnoses like arthritis or fractures. 1, 6
• Don't diagnose based on imaging alone - must correlate with clinical examination findings. 6
• Don't miss referred pain from lumbar spine, sacroiliac joints, or knee - screen these areas when hip imaging is negative. 1, 6
• Don't use peripheral nerve blocks (like obturator nerve blocks) - these are experimental/investigational with insufficient evidence. 7
• Don't underestimate the impact of nocturnal pain - it indicates more severe disease with joint effusion and requires aggressive treatment. 3, 4

Patient Education and Shared Decision-Making

Discuss expectations and use shared decision-making when presenting treatment options, as this improves outcomes (consensus score 9/9). 1 Physical activity and sport participation should be encouraged, not restricted, in patients with hip-related pain. 1