What is the best course of management for a 60-year-old man with worsening right hip pain, limited range of motion, and pain on internal and external rotation, currently taking ibuprofen for pain relief?

Management of Hip Osteoarthritis in a 60-Year-Old Man

This patient requires plain radiographs of the hip immediately to confirm osteoarthritis, followed by a structured conservative management protocol starting with oral NSAIDs (which he is already taking) and physical therapy, with intra-articular corticosteroid injection as the next step if symptoms remain refractory. 1, 2

Diagnostic Confirmation

Obtain anteroposterior pelvis and lateral hip radiographs now to confirm the diagnosis of hip osteoarthritis and assess disease severity. 2, 3 The clinical presentation—groin pain radiating to the buttock, activity-related pain relieved by rest, night pain, limited range of motion, and pain with internal/external rotation—is classic for hip osteoarthritis. 1, 2 Plain radiographs will identify joint space narrowing, subchondral sclerosis, osteophytes, and cystic changes that confirm the diagnosis. 2

Key examination finding: Pain with internal rotation of the hip is highly characteristic of intra-articular hip pathology and reproduces the patient's chief complaint in hip osteoarthritis. 1, 2 The absence of greater trochanteric tenderness effectively rules out greater trochanteric pain syndrome (lateral hip pain), making intra-articular pathology the primary concern. 3

Initial Conservative Management Algorithm

Step 1: Optimize Current NSAID Therapy

• Continue oral NSAIDs (ibuprofen) as the patient is already taking them—this is a strong recommendation from the American Academy of Orthopaedic Surgeons for symptomatic hip osteoarthritis when not contraindicated. 1
• NSAIDs provide superior pain relief compared to acetaminophen for osteoarthritis and are well-tolerated at standard doses for chronic use. 1, 4
• If NSAIDs are contraindicated or poorly tolerated, acetaminophen may be considered as an alternative (consensus recommendation). 1

Step 2: Add Physical Therapy Immediately

• Initiate physical therapy for mild-to-moderate symptomatic hip osteoarthritis—this is a moderate strength recommendation from the American Academy of Orthopaedic Surgeons. 1, 2
• Physical therapy should target hip muscle strengthening, particularly hip abductors, adductors, flexors, and rotators, which demonstrate consistent weakness in patients with hip-related pain. 1, 2
• Include functional performance tasks such as single-leg balance and squat depth assessment in the therapy protocol. 1, 2
• Physical therapy combined with NSAIDs often provides initial symptom relief in the early stages of osteoarthritis. 1

Step 3: Intra-Articular Corticosteroid Injection if Conservative Measures Fail

• If symptoms remain refractory after 6-8 weeks of NSAIDs and physical therapy, proceed with intra-articular corticosteroid injection—this is a moderate strength recommendation from the American Academy of Orthopaedic Surgeons. 1, 2
• This injection provides both diagnostic confirmation (if pain improves, the hip joint is the pain generator) and therapeutic benefit with transient symptom relief. 1, 2
• Image-guided injection is preferred for accuracy. 2

Step 4: Avoid Ineffective or Harmful Treatments

• Do NOT use intra-articular hyaluronic acid injections—this is a strong recommendation against from the American Academy of Orthopaedic Surgeons for symptomatic hip osteoarthritis. 1
• Do NOT prescribe opioids for chronic hip osteoarthritis pain—this is a consensus recommendation against opioid use for this condition. 1, 5

When to Consider Surgical Referral

Refer for total hip arthroplasty evaluation if:

• Symptoms become refractory to all conservative measures (NSAIDs, physical therapy, and corticosteroid injection). 1
• Radiographs demonstrate end-stage degenerative joint disease. 1
• Pain significantly limits activities of daily living and quality of life despite optimal conservative management. 1

The American Academy of Orthopaedic Surgeons case studies demonstrate that patients with progressive hip osteoarthritis who fail conservative therapy are appropriate candidates for total hip arthroplasty, which provides excellent pain relief and functional restoration. 1

Critical Pitfalls to Avoid

Do not diagnose based on clinical examination alone—plain radiographs are mandatory to confirm osteoarthritis and exclude other pathology such as osteonecrosis, occult fracture, or tumor. 2, 3 Incidental imaging findings are common in asymptomatic individuals, so clinical correlation is essential, but imaging is still required for definitive diagnosis. 1, 6

Do not proceed directly to advanced imaging (MRI) without obtaining plain radiographs first—this violates consensus guidelines and is not cost-effective. 2, 6 MRI is reserved for cases where radiographs are negative or equivocal but clinical suspicion for hip pathology remains high. 2, 5

Screen for lumbar spine pathology—referred pain from the lumbar spine can mimic hip pain, particularly when pain radiates to the groin or buttock. 2, 6, 3 However, this patient's positive findings on hip internal/external rotation and limited hip range of motion strongly suggest intra-articular hip pathology rather than referred pain. 1, 2