What are the treatment options for hip ache and pain at night?

Treatment of Hip Ache and Pain at Night

For hip pain at night, begin with paracetamol (acetaminophen) up to 4 grams daily as first-line therapy, combined with a structured exercise program lasting at least 3 months, and consider NSAIDs at the lowest effective dose if paracetamol is insufficient. 1

Initial Diagnostic Approach

Before initiating treatment, proper diagnosis is essential:

• Obtain plain radiographs (AP pelvis and hip views) as the first imaging study to screen for common disorders like osteoarthritis, fractures, or bone tumors 1, 2, 3
• If radiographs are negative or equivocal and symptoms persist, MRI hip without IV contrast is the next appropriate imaging study (rated 9/9 by ACR) 3
• Image-guided diagnostic injection into the hip joint can confirm if pain originates from the hip joint itself versus referred sources 3

Pharmacological Treatment Algorithm

First-Line: Paracetamol (Acetaminophen)

• Paracetamol up to 4 g/day is the oral analgesic of first choice for mild-moderate pain due to its efficacy and safety profile 1
• This is the preferred long-term oral analgesic if successful 1

Second-Line: NSAIDs

• Add or substitute NSAIDs at the lowest effective dose if paracetamol provides inadequate relief 1
• For patients with increased gastrointestinal risk, use non-selective NSAIDs plus gastroprotective agent, or a selective COX-2 inhibitor 1
• NSAIDs should be used at the lowest dose possible for the shortest time needed due to cardiovascular and gastrointestinal risks 4

Third-Line: Opioid Analgesics

• Opioid analgesics (with or without paracetamol) are useful alternatives when NSAIDs are contraindicated, ineffective, or poorly tolerated 1

Adjunctive Options

• Symptomatic slow-acting drugs for osteoarthritis (SYSADOA) including glucosamine sulfate, chondroitin sulfate, and others have symptomatic effect with low toxicity, though effect sizes are small 1, 5

Non-Pharmacological Treatment (Essential Component)

Exercise-Based Treatment

• Exercise-based treatments are strongly recommended (moderate evidence, consensus score 9/9) 1
• Exercise programs should be at least 3 months duration to achieve optimal benefit 1
• Include hip, trunk, and functional strengthening components with resistance exercises 1
• Exercise descriptors should specify load magnitude, repetitions, sets, duration, and progression 1

Additional Non-Pharmacological Interventions

• Regular patient education is essential 1
• Weight reduction if obese or overweight 1
• Assistive devices (walking stick, insoles) as appropriate 1
• Physical activity and sport participation are recommended even with hip-related pain 1

Interventional Treatment Options

Intra-articular Corticosteroid Injections

• Image-guided intra-articular steroid injections (ultrasound or x-ray guided) may be considered for patients with flare unresponsive to analgesics and NSAIDs 1, 3
• Typical doses: 5-15 mg for larger joints like the hip 6
• Strict aseptic technique is mandatory 6

Monitoring and Shared Decision-Making

• Use patient-reported outcome measures (PROMs), physical impairment measures, and psychosocial factors to monitor treatment response 1
• Discuss patient expectations and use shared decision-making throughout the treatment process 1

Important Clinical Considerations

Nocturnal Pain Characteristics

• Patients with hip osteoarthritis frequently report nocturnal pain that may differ in character from daytime pain 7, 8
• Nocturnal pain correlates with worse hip function scores and reduced sleep quality 7
• Patients with nocturnal pain often have higher pain intensity scores at night compared to daytime 8

Common Pitfalls to Avoid

• Do not proceed to advanced imaging without obtaining plain radiographs first 1, 3
• Do not overlook referred pain from lumbar spine, sacroiliac joints, or knee as potential sources 1, 9
• Screen patients with poor hip metrics for sleep disturbance, as this significantly impacts quality of life 7
• Avoid peripheral nerve blocks (e.g., obturator nerve) as these are experimental with insufficient evidence 3

When to Consider Surgical Referral

• Joint replacement should be considered for patients with radiographic evidence of hip OA who have refractory pain and disability despite conservative management 1
• Osteotomy and joint-preserving procedures should be considered in young adults with symptomatic hip OA, especially with dysplasia or deformity 1