What is the best approach for managing hip pain in a 63-year-old patient in primary care, including conservative management and imaging?

Management of Hip Pain in a 63-Year-Old Patient in Primary Care

Start with plain radiographs of the hip and pelvis as your initial imaging, then implement a multimodal conservative management approach centered on scheduled acetaminophen, physical therapy referral, and cautious use of NSAIDs with gastroprotection.

Initial Imaging Strategy

Obtain anteroposterior and lateral radiographs of the hip and pelvis as the first-line imaging study 1, 2. This screens for common pathology including osteoarthritis, fractures, avascular necrosis, and bone tumors, and may be the only imaging needed for conditions like advanced osteoarthritis 1.

When to Advance Beyond Plain Films

• Consider MRI (preferably with intra-articular contrast/MR arthrography) if radiographs are normal but pain persists, particularly when suspecting labral tears, femoroacetabular impingement, or early avascular necrosis 1, 2, 3.
• Ultrasound can evaluate superficial structures like greater trochanteric bursitis, gluteus medius tendinopathy, iliopsoas tendon pathology, and can guide diagnostic/therapeutic injections 1, 2.
• MRI is the preferred method for diagnosing avascular necrosis in patients with persistent hip pain and normal radiographs; image both hips as bilateral involvement is common 1.

Conservative Pain Management Approach

First-Line Pharmacologic Treatment

Prescribe scheduled intravenous or oral acetaminophen every 6 hours as your foundational analgesic 1, 4. This provides effective pain relief with minimal adverse effects in older adults and forms the cornerstone of multimodal analgesia 1.

Second-Line: NSAIDs with Caution

Add NSAIDs only for severe pain, and always co-prescribe a proton pump inhibitor 1, 4. In patients aged 63, NSAIDs carry significant risks:

• Acute kidney injury and gastrointestinal complications are major concerns 1.
• Exercise particular caution if the patient takes ACE inhibitors, diuretics, or antiplatelet agents due to dangerous drug interactions 1.
• Despite these risks, NSAIDs remain one of the most evidence-supported options for hip osteoarthritis 4.

Opioids: Last Resort Only

Reserve opioids exclusively for breakthrough pain, using the lowest effective dose for the shortest duration 1. In patients over 60, consider a 20-25% dose reduction to prevent morphine accumulation, over-sedation, respiratory depression, and delirium 1.

Medications to Avoid

Do not prescribe glucosamine, typical opioids for routine use, or viscosupplementation injections 4. Tramadol may provide short-term benefit but can cause confusion in older patients and lowers seizure threshold 1, 4.

Physical Medicine and Rehabilitation Referral

Refer to Physical Medicine and Rehabilitation (PMR) for development of an individualized physical therapy program 5. This is a strong evidence-based treatment for mild-to-moderate hip osteoarthritis and should precede surgical consideration 5.

Benefits of PMR Approach

• PMR specialists use validated outcome measures (Hip and Groin Outcome Score, International Hip Outcome Tool) to objectively monitor treatment response 5.
• Shared decision-making and patient education improve treatment adherence and outcomes 5.
• PMR can optimize patients preoperatively if surgery ultimately becomes necessary 5.

Interventional Options

Consider ultrasound-guided intra-articular corticosteroid injection for diagnostic and therapeutic purposes 1, 5, 4. This is well-supported for hip osteoarthritis and can help confirm intra-articular pathology as the pain source 1, 4.

Platelet-rich plasma shows potential benefits but evidence remains incomplete 4.

Non-Pharmacologic Adjuncts

Recommend immobilization techniques, ice packs, and dressings as adjuncts to pharmacologic therapy 1. While evidence quality is low, these interventions carry minimal risk and may provide additional relief 1.

Critical Pitfalls to Avoid

• Do not proceed to surgery without exhausting conservative options first 5. Physical therapy and conservative management should be thoroughly attempted before surgical referral.
• Do not overlook referred pain from the lumbar spine, sacroiliac joints, or knee 1, 2, 6. The differential diagnosis is broad and includes extra-articular and intra-articular pathology.
• Do not forget to evaluate for comorbidities that influence treatment choices, including cardiovascular risk factors, renal function, and gastrointestinal history before prescribing NSAIDs 1.
• In patients with persistent hip pain despite normal radiographs, do not delay MRI as conditions like avascular necrosis, labral tears, and femoroacetabular impingement require early diagnosis for optimal outcomes 1, 2, 7.

Location-Based Diagnostic Considerations

• Anterior hip pain: Consider intra-articular causes (labral tear, femoroacetabular impingement, osteoarthritis), hip flexor injuries, or referred intra-abdominal/pelvic pathology 2, 6.
• Lateral hip pain: Most commonly greater trochanteric pain syndrome (gluteus medius tendinopathy, bursitis, iliotibial band friction) 2, 6.
• Posterior hip pain: Consider lumbar spine pathology, deep gluteal syndrome with sciatic nerve entrapment, or hamstring tendinopathy 2, 6.