What are the next steps for a patient with chronic hip pain and inflammation after TENEX (percutaneous tenotomy) procedure, who has been trialed on methocarbamol (muscle relaxant) 500mg twice a day (BID)?

Post-TENEX Chronic Hip Pain Management

For a patient with persistent chronic hip pain and inflammation following TENEX procedure who has trialed methocarbamol 500mg BID, escalate to a multimodal analgesic regimen combining NSAIDs or COX-2 inhibitors with acetaminophen, add dexamethasone 8-10mg IV as a single dose, and consider image-guided corticosteroid injection if conservative measures fail. 1, 2

Optimize Current Muscle Relaxant Therapy

• Increase methocarbamol to therapeutic dosing: The current 500mg BID is subtherapeutic. FDA labeling recommends initial dosing of 1500mg (three 500mg tablets) four times daily for the first 48-72 hours, then maintenance of 1000mg (two 500mg tablets) four times daily, or up to 4-6 grams daily. 3
• However, muscle relaxants alone provide insufficient analgesia for post-procedural inflammatory pain and should be combined with other modalities. 1

Implement Multimodal Analgesia (Primary Recommendation)

NSAIDs/COX-2 Inhibitors + Acetaminophen:

• Prescribe scheduled NSAIDs (e.g., naproxen 500mg BID or ibuprofen 600mg TID) or COX-2 inhibitors (e.g., celecoxib 200mg daily) combined with acetaminophen 1000mg TID-QID (max 4g/day). 1, 2
• This combination addresses both inflammatory and nociceptive pain components post-TENEX. 1
• Caution: Assess for contraindications including GI ulcer history, cardiovascular disease, renal impairment, and bleeding risk before prescribing NSAIDs. 1

Single-Dose Dexamethasone:

• Administer dexamethasone 8-10mg IV as a single dose to reduce inflammation, improve pain scores by >20mm on VAS, and facilitate early mobilization. 1
• This provides anti-inflammatory benefit without the risks of prolonged steroid use. 1
• Monitor blood glucose in diabetic patients as dexamethasone causes transient hyperglycemia. 1

Address Post-Procedural Recovery

Physical Therapy (Critical Component):

• Initiate structured post-procedure physical therapy immediately - this is associated with 60-68% reduction in pain and functional scores after percutaneous tenotomy procedures. 4
• Focus on hip strengthening, stretching, and progressive weight-bearing activities. 2, 4
• Post-procedure PT is the single most important factor for successful outcomes after TENEX procedures. 4

Expected Recovery Timeline:

• Average healing time post-TENEX is approximately 58 days, with most patients experiencing gradual improvement. 5
• Pain improvement may not be immediate; reassess at 2-4 weeks and again at 8-12 weeks. 2, 5

Interventional Options if Conservative Measures Fail

Image-Guided Corticosteroid Injection:

• If pain persists despite optimized medical management and PT, perform ultrasound-guided corticosteroid injection into the affected tendon or bursa. 2
• Ultrasound guidance ensures accurate placement and improves outcomes. 2
• This can be combined with local anesthetic for diagnostic confirmation that the hip is the pain source. 1

Consider Adjunctive PRP:

• Some patients who don't achieve complete relief from TENEX alone benefit from platelet-rich plasma injection as a secondary intervention. 5

Diagnostic Reassessment

Rule Out Alternative or Additional Pathology:

• If pain persists beyond 8-12 weeks or worsens, obtain MRI hip without contrast to evaluate for: 1, 2
  • Incomplete tenotomy or residual tendinopathy
  • Labral tears
  • Cartilage damage
  • Occult stress fractures
  • Greater trochanteric bursitis
  • Gluteal tendon tears
• Plain radiographs should have been obtained initially but repeat if not done to exclude arthritis or bone pathology. 1

Medications NOT Recommended

Avoid the Following:

• Gabapentinoids (gabapentin, pregabalin): Cause sedation, dizziness, and interfere with early mobilization critical for post-TENEX recovery. 1
• Opioids for chronic use: Limited evidence for chronic non-cancer pain and risk of dependence. Use only short-term (≤7 days) for severe acute exacerbations. 1, 2
• Intrathecal morphine: Not applicable to this outpatient scenario and has significant adverse effects. 1

Critical Pitfalls to Avoid

• Underdosing methocarbamol: 500mg BID is below therapeutic range; if continuing, dose appropriately per FDA guidelines. 3
• Monotherapy approach: Post-TENEX pain requires multimodal analgesia, not single-agent treatment. 1
• Neglecting physical therapy: This is the most important predictor of success and must be prescribed concurrently. 4
• Premature intervention: Allow 8-12 weeks for TENEX healing before considering repeat procedures. 5, 6
• Missing additional pathology: Persistent pain may indicate incomplete treatment, additional tendon involvement, or unrelated hip pathology requiring MRI evaluation. 1, 5

Specific Prescription Recommendations

Write for:

1. Naproxen 500mg PO BID with food (or celecoxib 200mg PO daily if GI concerns) 1
2. Acetaminophen 1000mg PO TID-QID (max 4g/day) 1
3. Methocarbamol 750mg PO QID (if continuing muscle relaxant) 3
4. Dexamethasone 10mg IV x1 dose (coordinate with office visit) 1
5. Physical therapy referral with diagnosis "s/p TENEX for hip tendinopathy" - 2-3x/week for 6-8 weeks 4