What is the recommended treatment plan for a 68-year-old male with left hip pain?

Treatment Plan for a 68-Year-Old Male with Left Hip Pain

Initial Diagnostic Workup

Begin with anteroposterior pelvis and frog-leg lateral hip radiographs to identify osteoarthritis, fractures, osteonecrosis, or structural abnormalities. 1, 2

• Plain radiographs should assess for joint space narrowing, femoral head collapse or sclerosis, cam or pincer morphology, acetabular dysplasia, fractures, or bone tumors 2
• If radiographs are negative or equivocal but clinical suspicion remains high, obtain MRI of the hip without IV contrast to detect osteonecrosis, occult fractures, bone marrow edema, labral tears, and soft tissue pathology 1, 2
• Consider MR arthrography if femoroacetabular impingement or labral tear is strongly suspected clinically, as it provides superior visualization compared to standard MRI 1, 2

Key Clinical Features to Elicit

• Anterior hip/groin pain suggests intra-articular pathology (osteoarthritis, labral tear, femoroacetabular impingement) 3
• Lateral hip pain suggests greater trochanteric pain syndrome (gluteus medius tendinopathy, bursitis) 3
• Posterior hip pain suggests referred lumbar pathology, deep gluteal syndrome, or hamstring tendinopathy 3
• Pain with flexion, adduction, and internal rotation reproduces symptoms of femoroacetabular impingement 4
• Aggravating factors include prolonged sitting, leaning forward, getting in/out of cars, and pivoting movements 4

First-Line Pharmacologic Management

For symptomatic hip osteoarthritis, NSAIDs are the most effective first-line pharmacologic treatment, superior to acetaminophen. 1, 5

• NSAIDs provide effective pain relief for hip OA with category Ia evidence 1
• Acetaminophen may be considered when NSAIDs are contraindicated, though evidence shows it is not significantly better than placebo for knee OA and likely similar for hip OA 5, 1
• COX-2 selective inhibitors (coxibs) or conventional NSAIDs plus proton pump inhibitors should be used in patients with higher gastrointestinal bleeding risk to reduce GI complications 1
• Intra-articular corticosteroid injections could be considered for symptomatic hip OA and provide both diagnostic confirmation and therapeutic benefit 1, 2
• Intra-articular hyaluronic acid injection should NOT be used for symptomatic hip OA (strong recommendation) 1
• Oral opioids should NOT be used for treatment of symptomatic hip OA due to inferior efficacy compared to NSAIDs, more side effects (GI upset, constipation, dizziness), and higher withdrawal rates 1

Non-Pharmacologic Management

Physical therapy is a cornerstone of conservative management and should be initiated early. 1

• PT could be considered for mild-to-moderate symptomatic hip OA with high quality evidence and moderate strength of recommendation 1
• Exercise programs should include strength training, cardiovascular fitness, basic athletic movements, and load tolerance 1
• Physical activity (which may include sport) is recommended for people with hip-related pain 1
• Treatment should target return to desired functional activities, gradually introducing higher-level tasks while respecting individual symptoms 1

Patient Education and Shared Decision-Making

• Discuss the relationship between pain and hip joint structure, including that morphological findings are common in asymptomatic people 1
• Explain treatment options, risks and benefits of surgical versus non-surgical approaches, likely magnitude of improvement, and expected duration and cost 1
• Use oral, written, and visual educational tools tailored to the patient's health literacy 1

Surgical Considerations

Total hip arthroplasty should be considered when conservative measures (NSAIDs, PT, intra-articular injections) fail to provide adequate symptom relief in patients with end-stage hip OA. 1

• Preoperative optimization is critical: patients should optimize BMI, control diabetes (HbA1c), wean off narcotic pain medications, and quit smoking before elective THA 1
• Either formal PT or unsupervised home exercise is supported after THA (high quality evidence, moderate strength) 1
• Patients with poorly controlled diabetes, elevated BMI, or active smoking have higher risk of adverse events after THA 1

Common Pitfalls to Avoid

• Do not assume all hip pain is osteoarthritis—consider extra-articular causes (trochanteric bursitis, gluteus medius tendinopathy), referred pain from spine, and intra-articular pathology (labral tears, FAI) 3
• Do not rely solely on acetaminophen for symptomatic hip OA, as evidence shows it is ineffective compared to placebo in knee OA and likely similar for hip OA 5
• Do not prescribe opioids for chronic hip OA pain due to lack of superiority over NSAIDs and significant side effect burden 1
• When trochanteric bursa injection fails to relieve pain, reconsider the diagnosis using ultrasound or MRI to examine other soft tissue structures 6
• Use imaging guidance (ultrasound or fluoroscopy) for bursal injections when clinical examination is equivocal to ensure accurate anatomical targeting 6