What is the next step in managing hip pain that is not improving with therapy?

Work-Up for Hip Pain Not Improving with Therapy

When hip pain fails to improve with therapy, obtain plain radiographs of both the pelvis and hip immediately as the essential next step, followed by MRI without contrast if radiographs are negative or equivocal and soft tissue pathology is suspected. 1, 2

Imaging Algorithm

Initial Imaging

• Plain radiographs are mandatory and should include both anteroposterior (AP) pelvis and lateral femoral head-neck views (such as Dunn, frog-leg, or cross-table views), as these are complementary studies that together provide comprehensive evaluation of hip morphology 1, 2
• Radiographs may reveal common disorders like osteoarthritis, femoroacetabular impingement (FAI) morphology, or acetabular dysplasia that guide all subsequent management decisions 1, 2
• Never make a diagnosis based on imaging alone—always correlate with clinical symptoms and examination findings 1

Advanced Imaging When Indicated

• If radiographs are negative, equivocal, or nondiagnostic and extra-articular soft tissue pathology is suspected, MRI hip without IV contrast is the next appropriate study 2
• MRI/MRA or CT arthrogram should be obtained when three-dimensional morphological assessment is needed or to evaluate intra-articular structures (labrum, cartilage, ligamentum teres), particularly if non-surgical treatment has failed and surgery is being considered 1
• Be aware that incidental intra-articular findings are common in asymptomatic individuals and should not drive treatment decisions in isolation 1

Reassessing the Exercise Program

Duration and Intensity Concerns

• Exercise-based treatment should last a minimum of 3 months to demonstrate effectiveness—if therapy has been ongoing without meaningful improvement, the program itself may be inadequate rather than the diagnosis being wrong 1, 2, 3
• Studies show that exercise programs lasting 3 months have larger effects compared to shorter durations (3-7 weeks) 1
• If favorable outcomes are not observed after 6 weeks, reassess rather than continuing the same approach 3

Essential Exercise Components

• The program must include hip, trunk, and functional strengthening with progressive resistance training 1, 2
• Exercise prescription should specify: load magnitude, repetitions and sets, duration of contractile element, time under tension, rest periods between repetitions and sessions 1
• Exercise should be prescribed relative to symptom severity and irritability, with progressive loading as tolerated 2

Pharmacologic Optimization

Stepwise Medication Approach

• Add scheduled acetaminophen up to 4 grams daily (1000 mg every 6-8 hours) as first-line adjunctive therapy if not already prescribed, which can be safely combined with NSAIDs for additive analgesia 2, 4
• If NSAIDs plus acetaminophen provide inadequate relief, add duloxetine 30-60 mg daily as alternative or adjunctive therapy, particularly effective for hip osteoarthritis pain 2, 4
• Consider switching to a different NSAID if current medication is ineffective, using the lowest effective dose with gastroprotection if gastrointestinal risk factors exist 2, 4
• Do not initiate opioids (including tramadol) for hip pain due to poor risk-benefit ratio 1, 4

Interventional Options Based on Imaging

If Radiographs Confirm Osteoarthritis

• Consider intra-articular corticosteroid injection under ultrasound or fluoroscopic guidance if oral medications provide inadequate relief, which can provide both diagnostic information and therapeutic benefit lasting weeks to months 2, 4
• Do not offer intra-articular hyaluronic acid due to insufficient evidence for hip pain 4

If Imaging Shows FAI Syndrome, Labral Tears, or Dysplasia

• These conditions can be categorized after imaging and may require surgical consultation if conservative management fails after 3 months 1
• MRI/MRA becomes particularly important for surgical planning in these cases 1

Patient Education and Expectation Management

Critical Discussions

• Explain that pain does not necessarily correlate with structural damage—morphological abnormalities are common in asymptomatic individuals 2
• Set realistic expectations that meaningful improvement typically requires at least 3 months of consistent exercise therapy 1, 2
• Emphasize that physical activity and exercise are recommended and will not harm the hip joint 1, 2
• Use shared decision-making to align treatment with patient goals (pain reduction, functional improvement, return to activities) 1, 2

Monitoring and Outcome Measures

Systematic Tracking

• Use patient-reported outcome measures (PROMs) such as Copenhagen Hip and Groin Outcome Score (HAGOS) or International Hip Outcome Tool (IHOT) to objectively monitor response 1, 2, 3
• Track physical impairment measures and psychosocial factors alongside PROMs 1, 2
• Reassess at 4-6 week intervals initially to determine if symptoms are improving 2

When to Refer for Surgical Consultation

Clear Indications

• Radiographic evidence of hip osteoarthritis with refractory pain and disability despite 3+ months of optimal conservative management 2
• FAI syndrome, labral tears, or gluteus medius tendon tears identified on advanced imaging after failed conservative treatment, as these conditions typically have good surgical outcomes 5
• Structural abnormalities (cam morphology, acetabular dysplasia) with persistent symptoms despite appropriate rehabilitation 1

Common Pitfalls to Avoid

• Do not continue the same ineffective treatment approach beyond evidence-based thresholds—if no improvement after 6 weeks, the assessment or treatment plan needs revision, not more of the same 3
• Do not obtain MRI before plain radiographs, as this skips essential morphological assessment and may lead to overemphasis on incidental soft tissue findings 1, 2
• Do not rely on clinical examination tests alone (FADIR, FABER) as their diagnostic utility is very limited for ruling hip disease in or out 1
• Avoid attributing all hip pain to soft tissue dysfunction without ruling out intra-articular pathology, spine pathology, or pelvic ring involvement through appropriate imaging 1, 5