What is the recommended treatment for a patient with a left hip condition diagnosed via MRI?

Treatment Approach for Left Hip Pain Based on MRI Findings

The treatment strategy depends entirely on what the MRI reveals, but you should start with conservative non-surgical management for most hip conditions before considering invasive interventions. 1

Initial Conservative Management Framework

For Hip Osteoarthritis (if identified on MRI)

Implement a self-management program with exercise and weight loss (if overweight/obese) as the foundation of treatment. 1

• Physical therapy should be offered as part of comprehensive management and has clear evidence supporting its use for hip OA 1
• Start with topical NSAIDs for localized pain management, which avoid systemic side effects 1, 2
• Oral NSAIDs (ibuprofen 400mg) or acetaminophen (up to 1000mg) are first-line pharmacologic options for pain control 1, 3, 4
• Duloxetine is an evidence-based option for hip OA pain management 1
• Intra-articular corticosteroid injections have supporting evidence for hip OA and can provide diagnostic and therapeutic benefit 1, 5

For Femoroacetabular Impingement (FAI) Syndrome or Labral Tears

Begin with physical therapy and activity modification before considering surgical referral. 1

• The diagnosis should never be made on imaging alone but must incorporate clinical symptoms and examination findings 1
• Image-guided diagnostic hip joint injection (rated 8/9 appropriateness) can confirm the hip joint as the pain source, especially when concurrent spine or knee pathology exists 1, 5
• If conservative treatment fails after an adequate trial (typically 3-6 months), consider surgical consultation with MR arthrography or CT arthrography to better define intra-articular pathology for surgical planning 1, 5

For Soft Tissue Pathology (Tendinitis, Bursitis, Muscle Tears)

Physical therapy with targeted rehabilitation is the primary treatment. 1, 5

• Ultrasound-guided corticosteroid injections into the trochanteric bursa or iliopsoas bursa can be both diagnostic and therapeutic 1, 5
• Topical NSAIDs (such as diclofenac gel) provide effective pain relief with minimal systemic effects 2
• Oral NSAIDs or acetaminophen for pain control as needed 1, 3

What NOT to Do

Do not initiate opioid therapy for hip pain management - the VA/DOD guidelines specifically recommend against opioids or tramadol for hip OA 1

• Avoid using MRI findings alone to make treatment decisions without correlating with clinical presentation 1
• Do not proceed directly to surgery without an adequate trial of conservative management 1
• Avoid platelet-rich plasma (PRP) injections - evidence is insufficient and inconsistent for hip conditions 1
• Do not use stem cell injections - guidelines suggest against their use for hip pathology 1

Critical Pitfalls to Avoid

Incidental MRI findings are extremely common in asymptomatic individuals - do not treat imaging findings that don't correlate with the clinical picture 1

• Always screen for referred pain from the lumbar spine or pelvis as part of the clinical examination, as hip pain may originate elsewhere 1, 5
• Beware of occult fractures (stress fractures, femoral neck fractures) that may appear as "hip pain" - these require urgent orthopedic referral if identified 5, 6
• Asymptomatic labral tears and cartilage changes are common and should not automatically trigger surgical referral 1

Treatment Algorithm Based on MRI Results

Step 1: Correlate MRI findings with clinical symptoms and examination findings 1

Step 2: Initiate conservative management:

• Self-management program with exercise 1
• Physical therapy 1
• Topical or oral NSAIDs/acetaminophen 1, 3, 4
• Consider duloxetine for persistent pain 1

Step 3: If inadequate response after 6-12 weeks, consider:

• Image-guided intra-articular corticosteroid injection for diagnostic and therapeutic purposes 1, 5
• Ultrasound-guided bursal injections if periarticular pathology identified 1, 5

Step 4: If conservative management fails after 3-6 months and imaging shows surgically correctable pathology (FAI, labral tears):

• Refer to orthopedic surgery 1
• May need MR arthrography for surgical planning if not already performed 1, 5

Step 5: For refractory pain without surgical options:

• Multidisciplinary pain management approach 1
• Avoid long-term opioid therapy 1