What conservative treatments are available for a patient with hip osteoarthritis to manage pain?

Conservative Treatment of Hip Osteoarthritis Pain

For hip osteoarthritis pain, start with oral NSAIDs (when not contraindicated) as they demonstrate strong evidence for efficacy, combined with physical therapy and weight loss if overweight—topical agents are not recommended for hip OA due to joint depth. 1

First-Line Core Treatments

Every patient with hip OA should receive these foundational interventions before escalating therapy:

• Self-management program including regular self-directed exercise is essential and should be initiated immediately 1
• Physical therapy should be offered as part of comprehensive management, particularly for mild-to-moderate symptomatic hip OA, with evidence supporting its role in pain reduction and functional improvement 1, 2
• Weight loss through comprehensive lifestyle intervention for overweight/obese patients, with structured goals of 4-7 kg reduction showing improvements in pain and physical function 1, 2
• Assistive devices such as canes should be prescribed when disease impacts ambulation 2

Pharmacological Management Algorithm

Initial Pharmacotherapy

• Oral NSAIDs (such as naproxen or ibuprofen) should be used first when not contraindicated, as they demonstrate superior efficacy compared to acetaminophen, particularly for moderate-to-severe pain 1, 3
• Acetaminophen may be considered as an alternative option, though evidence shows clinically insignificant differences versus placebo for hip OA 1
• Use oral NSAIDs at the lowest effective dose for the shortest duration, with consideration of gastrointestinal protection via proton pump inhibitors, especially in elderly patients or those with cardiovascular risk factors 1, 4

Important Caveat on Topical Agents

• Topical NSAIDs and capsaicin are NOT recommended for hip OA due to insufficient evidence—the depth of the hip joint makes it unlikely that topical agents would penetrate adequately to provide benefit 1

Second-Line and Adjunctive Options

• Duloxetine (60 mg daily) as alternative or adjunctive therapy when acetaminophen or NSAIDs are inadequate or contraindicated, showing significant pain reduction and functional improvement 2, 5
• Intra-articular corticosteroid injections for persistent pain inadequately relieved by other interventions—hip injections require image guidance and should be avoided within 3 months of planned joint replacement 1, 2

Medications to Avoid

• Opioids (including tramadol) should NOT be initiated for hip OA pain, with current guidelines recommending against their use due to limited benefit and high risk of adverse events 1, 5
• Glucosamine and chondroitin are not recommended due to insufficient evidence 1

Mind-Body and Complementary Interventions

• Tai chi is strongly recommended for hip OA, combining meditation with gentle movements, breathing exercises, and relaxation 2
• Cognitive behavioral therapy may reduce pain and improve coping in chronic hip OA 2
• Insufficient evidence exists for acupuncture, massage, yoga (for hip specifically), and TENS to make firm recommendations 1, 2

When to Consider Surgical Referral

• Obtain weight-bearing plain radiographs before surgical referral to document structural damage severity 2, 5
• Refer for surgical consultation when there is end-stage OA with minimal/no joint space on radiographs, or inability to cope with pain after exhausting all appropriate conservative options 2
• Ensure patients have been offered at least core treatment options (exercise, weight management, physical therapy, appropriate pharmacotherapy) before surgical referral 1, 5

Critical Clinical Pitfalls

• Do not prescribe topical agents for hip OA—unlike knee OA where topical NSAIDs have strong evidence, the hip joint's depth precludes meaningful penetration 1
• Avoid premature surgical referral—patients must exhaust conservative options including physical therapy completion and optimized pharmacotherapy for 6-8 weeks 5
• Screen for NSAID contraindications including history of GI bleeding, chronic kidney disease stage 3 or higher, heart failure, and uncontrolled hypertension before prescribing 5
• Consider cardiovascular risk when selecting NSAIDs—naproxen is not associated with increased myocardial infarction risk, making it preferable in patients with cardiovascular disease 4