What are the next steps for managing chronic hip pain post TENEX (percutaneous tenotomy) procedure that has not responded to methocarbamol (muscle relaxant) 500 mg twice a day (BID)?

Management of Chronic Hip Pain Post-TENEX Procedure After Failed Methocarbamol Trial

Escalate methocarbamol to the FDA-approved initial dosing of 1500 mg four times daily (6 grams/day) for 48-72 hours, then reduce to maintenance dosing of 4 grams/day, as the current 500 mg BID regimen is substantially below therapeutic levels. 1

Immediate Medication Optimization

Correct Methocarbamol Underdosing

• The patient is receiving only 1000 mg/day (500 mg BID), which is far below the FDA-recommended initial dosage of 6 grams/day for the first 48-72 hours 1
• For severe conditions, up to 8 grams/day may be administered initially 1
• After the loading period, reduce to maintenance dosing of approximately 4 grams/day 1
• This represents a 4-6 fold increase from current dosing, which likely explains the treatment failure

Add Multimodal Analgesia

Initiate paracetamol (acetaminophen) combined with NSAIDs or COX-2 selective inhibitors as foundational therapy. 2, 3

• This combination represents Grade A evidence for musculoskeletal pain management 2, 3
• NSAIDs/COX-2 inhibitors have demonstrated significant reductions in pain scores and opioid consumption in hip-related pain 2
• Continue these agents regularly (not as-needed) for optimal anti-inflammatory effect 2

Diagnostic Reassessment

Ultrasound Evaluation

• Obtain ultrasound imaging to assess for persistent iliotibial band (ITB) tendinopathy (hypoechogenicity or thickening >6 mm) 4
• Evaluate for other peritrochanteric pathology that may have been inadequately treated by the initial TENEX procedure 4
• The TENEX procedure shows 70% pain relief at one year, meaning 30% of patients have persistent symptoms requiring further intervention 4

Rule Out Complications

• Assess for iatrogenic nerve damage, which occurs at higher rates with minimally invasive hip procedures 5
• Evaluate for incomplete tenotomy or recurrent tendinopathy 4

Physical Therapy Intervention

Initiate movement-pattern training (MPT) with task-specific functional training and hip muscle strengthening. 6

• MPT programs should include 6 one-hour supervised sessions focusing on:
  • Task-specific training for basic functional tasks and symptom-provoking activities 6
  • Progressive strengthening of hip musculature 6
• This approach shows 89% adherence rates and significant functional improvements in chronic hip pain 6
• Home exercise programs should be performed at least once daily 6

Opioid Considerations

Reserve opioids strictly for rescue analgesia only, not scheduled dosing. 2, 3

• Opioids carry Grade D recommendation (use only when other options exhausted) 2
• The multimodal approach above should minimize or eliminate opioid requirements 2, 3

Common Pitfalls to Avoid

• Do not continue subtherapeutic methocarbamol dosing - the 500 mg BID regimen has no evidence base and represents gross underdosing 1
• Do not use femoral nerve blocks, lumbar plexus blocks, or epidural analgesia for chronic hip pain management due to adverse effects outweighing benefits 3
• Do not assume TENEX failure without proper medication optimization - 70% success rates mean many patients respond when given adequate multimodal therapy 4
• Do not delay physical therapy - movement-pattern training is evidence-based and shows high adherence with functional improvement 6

If Pain Persists After Optimization

• Consider repeat TENEX procedure if ultrasound confirms persistent ITB pathology 4
• Evaluate for alternative diagnoses including intra-articular hip pathology requiring different interventions 7
• Refer to orthopedic surgery if conservative measures fail after 3-6 months of optimized treatment 4, 7