What are the recommended treatments for hip pain?

Hip Pain Treatment

For hip pain, initiate treatment with a combination of NSAIDs (or COX-2 inhibitors) plus paracetamol as the foundation, combined with structured exercise therapy and patient education, reserving opioids strictly for rescue analgesia when other measures fail. 1

Initial Conservative Management

Pharmacological Foundation

• NSAIDs or COX-2-selective inhibitors form the cornerstone of medical management and should be started immediately, as they demonstrate superior efficacy compared to paracetamol alone for hip osteoarthritis 1, 2
• Add paracetamol to the NSAID regimen, though evidence shows limited additional benefit when combined with NSAIDs; however, it remains recommended as part of basic analgesia due to its favorable safety profile 1
• For ibuprofen specifically, use 1200-3200 mg daily divided into 3-4 doses (400-800 mg per dose), with the lowest effective dose for the shortest duration 3

Critical caveat: Recent high-quality evidence demonstrates that paracetamol alone shows no significant improvement over placebo for knee OA 4, and when added to NSAIDs, provides minimal clinically relevant additional benefit 1. Despite guideline recommendations including paracetamol, NSAIDs demonstrate clear superiority 4, 2.

Exercise-Based Rehabilitation

• Refer to Physical Medicine and Rehabilitation (PMR) or physical therapy for a minimum 3-month structured exercise program that includes hip strengthening, trunk strengthening, and functional exercises 1, 5, 6
• Pre-operative exercise and education are strongly recommended even if surgery is eventually needed, as they improve postoperative outcomes and functional recovery 1
• Exercise prescriptions must specify: load magnitude, repetitions, sets, duration of contractile elements, time under tension, rest periods between repetitions and sessions, and range of motion 1, 6

Patient Education and Shared Decision-Making

• Educate patients that pain does not necessarily correlate with structural hip damage, as morphological findings are common in asymptomatic individuals 1, 6
• Discuss realistic expectations: meaningful improvement requires at least 3 months of consistent therapy 1, 6
• Use validated patient-reported outcome measures (Copenhagen Hip and Groin Outcome Score or International Hip Outcome Tool) to objectively monitor treatment response 5, 6

Interventional Options for Persistent Pain

Intra-articular Injections

• Corticosteroid injections are strongly supported by multiple societies (American Academy of Orthopaedic Surgeons, American College of Rheumatology) for hip osteoarthritis when conservative measures provide inadequate relief 5, 2
• Platelet-rich plasma shows potential benefits but evidence remains incomplete and cannot be routinely recommended 2
• Viscosupplementation injections are NOT recommended for hip OA 2

Medications to AVOID

• Do not prescribe glucosamine - multiple societies recommend against its use 2
• Avoid typical opioids for chronic hip pain - the addition of codeine 180 mg daily to paracetamol causes unacceptable adverse effects (87% adverse reaction rate) with high dropout rates (36% in first week) in elderly patients 7
• Reserve opioids strictly as short-term rescue medication only 1
• Tramadol may provide short-term pain relief but should not be used long-term 2

Treatment Duration and Monitoring

Evidence-Based Timeframes

• Expect meaningful improvement within 3 months of structured exercise therapy; if no improvement occurs after 6 weeks, reassess rather than continuing the same approach 1, 6
• For physical therapy visits, evidence supports approximately 14 visits for hip pain; exceeding this without documented functional improvement represents overutilization 6
• Treatment plans proposing 3 times weekly for extended periods (>14-18 visits total) lack high-quality supporting evidence for non-postoperative hip pain 6

When to Escalate Care

• If conservative management fails after 3-6 months of appropriate treatment, consider advanced imaging (MRI hip without contrast for suspected soft tissue pathology) and surgical consultation 6, 8
• Patients with 2-year histories of gradual-onset hip pain require evaluation for osteoarthritis, which may necessitate different management strategies 6

Surgical Context (Post-Total Hip Arthroplasty)

For patients ultimately requiring surgery, the postoperative pain management protocol differs significantly:

• Continue NSAIDs/COX-2 inhibitors plus paracetamol as baseline 1
• Add single intraoperative dose of IV dexamethasone 8-10 mg for analgesic and anti-emetic effects 1
• Consider fascia iliaca block or local infiltration analgesia 1
• Avoid epidural analgesia, femoral nerve blocks, lumbar plexus blocks, and gabapentinoids - adverse effects outweigh benefits 1
• Intrathecal morphine 0.1 mg remains controversial due to significant side effects (nausea, vomiting, pruritus, delayed ambulation, respiratory depression) that conflict with early rehabilitation protocols 1

Common Pitfalls to Avoid

• Do not proceed to surgery without exhausting conservative options first - this includes adequate trial of NSAIDs, structured exercise therapy for minimum 3 months, and consideration of intra-articular injections 5
• Do not continue ineffective therapy beyond evidence-based thresholds - if no improvement after 6 weeks to 3 months, reassess the diagnosis and treatment approach 6
• Do not overlook the differential diagnosis - hip pain has numerous intra-articular, extra-articular, and referred causes that require different management strategies 9
• Do not rely on paracetamol monotherapy - it lacks efficacy compared to NSAIDs for hip/knee osteoarthritis 4, 2