What is the best course of treatment for a 64-year-old female with hip and lower back pain?

Management of Hip and Lower Back Pain in a 64-Year-Old Female

Begin with plain radiographs of both the pelvis and hip as the initial diagnostic step, followed by targeted treatment based on clinical presentation and imaging findings. 1

Initial Diagnostic Approach

Imaging Strategy

• Obtain X-ray pelvis (AP view) and X-ray hip (frog-leg lateral view) as complementary first-line imaging (both rated 9/9 appropriateness) to screen for common disorders such as osteoarthritis, fractures, or bone lesions. 1
• Do not routinely obtain advanced imaging (MRI or CT) initially unless red flags are present or radiographs are non-diagnostic. 1

Clinical Assessment Priorities

• Determine the exact anatomic location of pain: anterior hip/groin (suggests intra-articular pathology like osteoarthritis), lateral hip (suggests greater trochanteric pain syndrome), or posterior hip/buttock (suggests lumbar spine pathology or piriformis syndrome). 2, 3
• Assess for radicular symptoms including leg pain distribution, numbness, tingling, or weakness, which suggest nerve root compression. 4, 5
• Screen for red flags requiring urgent evaluation: severe or progressive neurologic deficits, bowel/bladder dysfunction, constant night pain, fever, unexplained weight loss, or history of cancer. 1, 4

Treatment Algorithm Based on Clinical Presentation

If Hip Pain Predominates (Anterior or Lateral)

For suspected osteoarthritis (most common in this age group):

• Initiate acetaminophen or NSAIDs as first-line pharmacologic therapy. 6, 7
• Prescribe exercise therapy (aerobic, aquatic, or resistance exercises), which reduces pain and improves function with sustained benefits for 2-6 months. 1
• Consider intra-articular corticosteroid injection for short-term pain relief if conservative measures fail. 1
• If radiographs show advanced osteoarthritis with persistent functional disability despite conservative treatment, refer for surgical evaluation. 2, 3

For lateral hip pain (greater trochanteric pain syndrome):

• Order MRI hip without IV contrast (rated 9/9) if radiographs are negative or equivocal and soft tissue pathology is suspected. 1
• Ultrasound hip (rated 7/9) is an alternative for evaluating superficial structures like gluteus medius tendinopathy. 1

If Lower Back Pain Predominates

For nonspecific low back pain without radiculopathy:

• Avoid bed rest—patients should remain active, as this is more effective than rest. 1, 5
• Apply heat therapy using heating pads for short-term pain relief. 4, 8
• Prescribe NSAIDs or acetaminophen as first-line medications. 1, 7
• Implement nonpharmacologic therapies: exercise therapy, spinal manipulation, massage, acupuncture, or cognitive-behavioral therapy. 1, 8, 7
• Do not obtain imaging unless symptoms persist beyond 4-6 weeks or red flags are present. 1, 5

For back pain with leg radiation (suspected radiculopathy):

• Perform straight-leg-raise testing (91% sensitivity for herniated disc) and neurologic examination assessing motor strength, reflexes, and sensory distribution. 5
• Most patients improve within 4 weeks with conservative management—continue activity modification, NSAIDs, and physical therapy. 5
• Order MRI lumbar spine only if symptoms persist beyond 4-6 weeks AND the patient is a candidate for epidural steroid injection or surgery. 5
• Consider epidural steroid injections for persistent radicular symptoms despite 4-6 weeks of conservative therapy. 5, 6

If Posterior Hip/Buttock Pain Predominates

• Consider lumbar spine pathology (most common), piriformis syndrome, or sacroiliac joint dysfunction. 2, 3
• Obtain radiographs of sacroiliac joints and spine if inflammatory etiology is suspected. 8
• If radiographs are negative and symptoms persist, order MRI lumbosacral plexus without IV contrast (rated 8/9). 8

Critical Pitfalls to Avoid

• Do not order routine imaging for nonspecific low back pain—this exposes patients to unnecessary radiation (equivalent to daily chest X-rays for over 1 year from a single lumbar spine series) and identifies abnormalities poorly correlated with symptoms. 1
• Assess psychosocial factors (depression, job dissatisfaction, passive coping strategies), as these are stronger predictors of outcomes than physical findings or pain severity. 1, 5
• Do not recommend bed rest—it is less effective than remaining active for both hip and back pain. 1, 8
• Avoid long-term opioids—evidence is insufficient to support their use in chronic low back pain, and nonpharmacologic/nonopioid therapies should be prioritized. 1, 7

Follow-Up Strategy

• Reassess in 2-4 weeks if symptoms persist or worsen. 4
• If pain persists beyond 4-6 weeks despite conservative treatment, consider advanced imaging (MRI) and specialist referral. 5, 6
• For patients with functional disability refractory to multiple nonsurgical treatments, surgical evaluation may be appropriate. 6, 7