What are the management options for a patient over 50 with hip osteoarthritis, joint pain, and limited mobility?

Hip Osteoarthritis Management

For patients over 50 with hip osteoarthritis, joint pain, and limited mobility, begin immediately with the triad of patient education, structured exercise therapy, and weight loss if overweight, while initiating paracetamol (up to 4g daily) as first-line pharmacological therapy. 1

Core Treatment Foundation (Non-Negotiable for All Patients)

All patients with symptomatic hip OA must receive these three interventions simultaneously:

• Patient education with written and oral information to counter the misconception that OA is inevitably progressive and untreatable 1
• Structured exercise program including local hip muscle strengthening and general aerobic fitness training, with at least 12 supervised sessions initially for optimal outcomes 1
• Weight loss interventions if BMI >25, as obesity is directly associated with hip OA progression (OR=1.11) 1

The evidence strongly supports that these core treatments form the foundation, with all other interventions serving as adjuncts 1. Notably, manipulation and stretching are specifically recommended for hip OA (unlike other joints) 1.

Pharmacological Treatment Algorithm

Step 1: First-Line Analgesic

• Paracetamol (acetaminophen) up to 4000 mg/day with regular dosing, not as-needed 1, 2
• This is the preferred long-term oral analgesic due to superior safety profile in elderly patients 1

Step 2: If Paracetamol Insufficient

• Add or substitute oral NSAIDs at lowest effective dose for shortest duration 1
• Mandatory co-prescription of proton pump inhibitor (choose lowest acquisition cost) 1, 2
• Choose either COX-2 inhibitor (except etoricoxib 60mg) or standard NSAID based on individual risk factors 1
• Critical caveat: All NSAIDs have similar analgesic efficacy but vary significantly in gastrointestinal, hepatic, and cardiorenal toxicity—assess cardiovascular, GI, and renal risk factors before prescribing, especially in patients over 50 1, 2

Step 3: If NSAIDs Contraindicated or Ineffective

• Opioid analgesics with or without paracetamol as alternatives when NSAIDs are contraindicated, ineffective, or poorly tolerated 1

Step 4: Adjunct for Acute Flares

• Intra-articular corticosteroid injections (ultrasound or x-ray guided) for moderate-to-severe pain unresponsive to oral analgesics and NSAIDs 1

Adjunct Non-Pharmacological Interventions

Implement these based on specific functional limitations:

• Walking aids (cane or walking stick) to reduce joint load—76% of hip OA patients benefit, with 86% adherence when prescribed 1, 3
• Appropriate footwear with shock-absorbing properties to reduce impact forces 1
• Activity pacing to avoid peaks and troughs of activity that exacerbate symptoms 1
• Local heat or cold applications for temporary symptomatic relief 1
• TENS (transcutaneous electrical nerve stimulation) as an option for pain management 1
• Occupational therapy assessment for assistive devices (tap turners, etc.) when activities of daily living are impaired 1

Exercise Prescription Specifics

The exercise regimen must include:

• Aerobic training: Moderate-intensity for 30-60 minutes daily 1
• Progressive strength training: Major muscle groups including hip stabilizers, 2 days/week at 60-80% of one repetition maximum for 8-12 repetitions 1
• At least 12 directly supervised sessions initially, as this produces significantly better pain reduction (effect size 0.46 vs 0.28) and functional improvement (effect size 0.45 vs 0.23) compared to fewer supervised sessions 1
• Long-term integration into daily life after initial supervised period 1

Alternative evidence-based options include tai chi (effect sizes 0.28-1.67 for pain reduction) and aquatic exercise 1, 4.

What NOT to Use (Common Pitfalls)

Avoid these interventions that lack evidence or are explicitly not recommended:

• Glucosamine and chondroitin products are not recommended despite marketing claims 1, 5, 2
• Electroacupuncture should not be used 1, 2
• Standard acupuncture has insufficient evidence for firm recommendation 1
• Typical opioids (beyond tramadol) are generally not recommended except as outlined in Step 3 above 6

Surgical Considerations

Refer for orthopedic evaluation when:

• Refractory pain and disability despite optimal conservative management with radiographic evidence of hip OA—consider total joint replacement 1
• Young adults with dysplasia or varus/valgus deformity—consider osteotomy or joint-preserving procedures 1

Monitoring and Individualization

Treatment must be tailored based on:

• Hip-specific risk factors: obesity, adverse mechanical factors, physical activity level, dysplasia 1
• General risk factors: age, sex, comorbidities, co-medications 1
• Pain intensity, disability level, and degree of structural damage 1
• Patient wishes and expectations 1

Provide periodic review tailored to individual needs, as disease course and treatment response vary 1, 2. Assess impact on function, quality of life, occupation, mood, relationships, and leisure activities at each visit 1.

Critical Safety Point for Patients Over 50

In elderly patients taking low-dose aspirin, consider other analgesics before adding NSAIDs, and if NSAIDs are necessary, always co-prescribe a proton pump inhibitor 1. The combination of aspirin and NSAIDs significantly increases gastrointestinal bleeding risk 1.