What are the next steps for managing pain in the top and inner thighs after hip surgery, now that physical therapy (PT) and orthopedic (ortho) care have been completed?

Management of Persistent Thigh Pain After Hip Surgery

For pain in the top and inner thighs persisting months after hip surgery with PT and orthopedic care completed, initiate a trial of neuropathic pain medication (gabapentin or pregabalin) combined with NSAIDs or COX-2 inhibitors plus paracetamol, while simultaneously evaluating for specific causes of persistent pain that may require surgical revision. 1, 2

Immediate Assessment Priorities

Rule Out Surgical Complications

• Evaluate for prosthetic loosening, infection, or component malposition through physical examination looking for warmth, effusion, restricted range of motion (particularly internal rotation), and pain with passive hip adduction/abduction 3, 2
• Consider imaging if not recently performed, as approximately 27% of patients report pain at 6 months post-THA, with 4% developing severe chronic pain requiring revision 2, 4
• The inner thigh pain distribution suggests possible obturator nerve involvement or referred pain from the hip joint itself 5

Identify Pain Characteristics

• Determine if pain is neuropathic (burning, shooting, electric-like) versus nociceptive (aching, throbbing), as 83% of patients with persistent post-orthopedic surgery pain have neuropathic components 1
• Assess for complex regional pain syndrome signs (10% prevalence in persistent post-surgical pain), including disproportionate pain, temperature changes, or skin changes 1

Pharmacologic Management Algorithm

First-Line Regimen

• NSAIDs or COX-2 inhibitors as baseline therapy, given their Grade A recommendation for post-THA pain management 5
• Paracetamol in combination with NSAIDs, though evidence shows limited additional benefit when added to NSAIDs alone, it remains part of standard multimodal analgesia 5
• Gabapentinoids (gabapentin or pregabalin) should be initiated given the high likelihood of neuropathic pain in persistent post-surgical cases 1

Medication Adjustment Based on Current Use

• If the patient is currently on opioids from prior management, develop an immediate weaning plan, as only 8% of patients in specialized pain services continue opioids long-term 1
• Transition from paracetamol/NSAIDs-only regimens (used by 48% pre-consultation) to neuropathic pain medications (86% post-consultation in specialized services) 1

Avoid Common Pitfalls

• Do not continue opioids beyond short-term rescue use, as chronic opioid therapy is associated with poor outcomes and is not recommended for persistent post-surgical pain 1
• Do not use muscle relaxants like cyclobenzaprine, as they are only indicated for acute muscle spasm (2-3 weeks maximum) and are not effective for post-surgical pain 6

Non-Pharmacologic Interventions

Resume Structured Exercise Program

• Reinitiate progressive hip and trunk strengthening exercises focusing on gluteus medius, as strength deficits persist beyond initial PT discharge 7
• Address specific impairments including altered gait mechanics, balance deficits, and hip muscle weakness that may contribute to ongoing pain 7
• Monitor for exercise intolerance signs (increased pain, effusion, limping) and adjust intensity accordingly 7

Consider Additional Interventions

• Movement retraining if pain correlates with specific functional activities or gait abnormalities 5
• Education to address pain catastrophizing, improve understanding that pain doesn't equal damage (especially months post-surgery), and promote self-efficacy 5

Referral Considerations

When to Refer Back to Orthopedics

• If pain is severe, worsening, or associated with mechanical symptoms suggesting hardware issues 2
• If conservative management fails after 4-6 weeks of optimized pharmacologic and exercise therapy 1

Pain Medicine Consultation

• Consider referral to an outpatient pain service specializing in post-surgical pain, as these services demonstrate improved adherence to evidence-based guidelines and reduced inappropriate opioid use 1
• Particularly important if neuropathic pain features are prominent or if complex regional pain syndrome is suspected 1

Expected Timeline and Monitoring

• Pain duration of 10 months (median in persistent post-surgical pain cohorts) suggests this is now chronic pain requiring neuropathic pain management rather than acute post-surgical analgesia 1
• Chronic pain after THA affects 28% of patients at 12-18 months, with 12% experiencing moderate to severe activity limitation 4
• Early post-operative pain intensity (which this patient experienced) is a significant predictor of chronic pain development, independent of pre-operative pain levels 4

Response Assessment

• Evaluate treatment response at 2-4 weeks using validated outcome measures rather than pain scores alone 7
• If no improvement with first-line neuropathic medications, consider alternative agents (tricyclic antidepressants, SNRIs) before escalating to interventional procedures 1