What is the best course of treatment for a patient with persistent hip pain?

Treatment of Persistent Hip Pain

For persistent hip pain, initiate a combination of physical therapy and oral NSAIDs or acetaminophen, with intra-articular corticosteroid injection reserved for patients who fail initial conservative measures. 1

Initial Conservative Management

First-Line Interventions

• Start with physical therapy as part of a comprehensive management plan, which has high-quality evidence showing sustained pain reduction for at least 2-6 months in hip osteoarthritis 1
• Prescribe oral NSAIDs (ibuprofen 1200-3200 mg daily in divided doses) or acetaminophen for pain control, as both demonstrate approximately 1 cm improvement on a 10-cm visual analog scale within 1-7 days 1, 2, 3
• Implement a self-management program including regular self-directed exercise and weight loss if applicable 1

Medication Dosing Specifics

• Ibuprofen: 400-800 mg three to four times daily (maximum 3200 mg/day), taken with meals or milk to minimize gastrointestinal complaints 3
• Acetaminophen: standard dosing as initial or combination therapy 1
• Pain relief occurs within 2 hours with immediate effect, and sustained reduction continues through 1-7 days with ongoing treatment 2

Second-Line Therapies for Refractory Pain

When Initial Treatment Fails

• Add duloxetine 30-60 mg daily as alternative or adjunctive therapy for patients with inadequate response to acetaminophen or NSAIDs, taken daily (not as needed) and tapered over 2-4 weeks when discontinuing 1
• Consider intra-articular corticosteroid injection for persistent pain inadequately relieved by other interventions, with improvement expected at 4-6 weeks 1, 2

Critical Injection Guidelines

• Limit corticosteroid injections to 3-4 per year maximum in the same joint due to risk of accelerated cartilage loss and increased need for arthroplasty 4
• Avoid corticosteroid injection within 3 months before planned hip replacement due to increased prosthetic infection risk (0.5% to 1.0%) 1, 4
• Hip injections should be image-guided for accuracy 1

What NOT to Use

Strongly Contraindicated

• Do not prescribe opioids (including tramadol) for hip osteoarthritis pain, as evidence shows limited benefit with high risk of adverse effects, physical dependence after just a few days, and increased long-term use risk 1
• Do not use intra-articular hyaluronic acid injection for symptomatic hip osteoarthritis (strong recommendation against) 1

Insufficient Evidence

• Avoid topical NSAIDs and topical capsaicin for hip pain as there is insufficient evidence for their use in hip osteoarthritis (evidence exists only for knee osteoarthritis) 1

Diagnostic Considerations for Persistent Pain

When Standard Treatment Fails

• Obtain weight-bearing plain radiographs before considering surgical referral 1
• For patients with normal radiographs but persistent pain, order MRI of both hips to evaluate for avascular necrosis, labral tears, or femoroacetabular impingement 1, 5
• Consider ultrasound-guided anesthetic injection to confirm intra-articular source of pain 5

Age-Specific Differential Diagnosis

• Younger adults (<50 years): suspect labral tear or femoroacetabular impingement 5
• Older adults (≥50 years): osteoarthritis is most common intra-articular cause 5
• Consider extra-articular causes: greater trochanteric pain syndrome (lateral), lumbar spine pathology (posterior), or hip flexor injuries (anterior) 5

Surgical Referral Criteria

When to Refer to Orthopedics

• Refer after failure of 2-3 months of conservative management including physical therapy and pharmacotherapy 1, 6
• Refer earlier for suspected labral tears, femoroacetabular impingement, or gluteus medius tendon tears as these have good surgical outcomes 5
• Optimize modifiable risk factors before surgery: BMI reduction, hemoglobin A1c control (<8.5%), smoking cessation, and opioid weaning 1

Common Pitfalls to Avoid

• Do not prescribe opioids for more than 3 days for acute exacerbations as each additional day increases long-term use risk without added benefit 2
• Do not use MRI for initial diagnosis of osteoarthritis; plain radiographs are sufficient 1
• Monitor diabetic patients for 1-3 days post-corticosteroid injection due to risk of transient hyperglycemia 4
• Do not inject patients with prosthetic hips unless performed by orthopedic surgeons after infection screening (infection risk 0.6%) 4