What is the recommended treatment for a middle-aged adult patient with suspected osteoarthritis (OA), a history of physical inactivity or previous musculoskeletal injuries, and symptoms of hip and lower back stiffness?

Treatment of Osteoarthritis in a Middle-Aged Adult with Hip and Lower Back Stiffness

All patients with suspected osteoarthritis must begin with three core non-pharmacological treatments—exercise therapy (local muscle strengthening and general aerobic fitness), weight loss if overweight or obese, and patient education—before adding any pharmacological interventions. 1

Initial Assessment and Diagnosis

Confirm the diagnosis clinically in adults over 40 years presenting with:

• Pain on joint usage affecting characteristic sites (hip joints in this case) 1
• Only mild morning or inactivity stiffness (typically less than 30 minutes) 1
• History of physical inactivity or previous musculoskeletal injuries (established risk factors) 1

Radiography is not required for diagnosis but may be considered if surgical referral is contemplated or if the diagnosis is uncertain. 2 Plain radiographs showing joint space narrowing, osteophytes, and subchondral sclerosis can confirm OA but do not correlate well with symptom severity. 2, 3

Assess the impact on the patient's function, quality of life, occupation, mood, relationships, and leisure activities to guide treatment intensity. 1

Core Treatment Protocol (Mandatory First-Line for All Patients)

Exercise Therapy (Highest Priority)

• Prescribe local muscle strengthening exercises targeting hip flexors, extensors, and abductors, plus general low-impact aerobic activities (walking, swimming, cycling). 1, 3
• Aim for at least 30 minutes of exercise most days of the week. 4
• Physical therapy and tai chi have demonstrated efficacy for reducing pain and improving function. 2, 3
• Initial supervised physical therapy ensures proper technique and prevents injury, particularly important given the patient's history of physical inactivity. 5

Weight Loss (If Applicable)

• If the patient is overweight or obese, weight reduction is mandatory. Even 5-10% body weight loss significantly reduces mechanical stress on weight-bearing joints and improves pain. 1, 4

Patient Education

• Provide written and oral information countering the misconception that OA is inevitably progressive and untreatable. 1
• Emphasize that OA symptoms are often intermittent and manageable with appropriate treatment. 1

Pharmacological Treatment Algorithm (Adjunct to Core Treatments)

First-Line Pharmacological Options

Start with acetaminophen (paracetamol) at regular dosing up to 4,000 mg/day in divided doses for pain relief. 1, 6, 4 This is the safest systemic analgesic option with the lowest risk profile. 4

For hip OA specifically, topical NSAIDs have limited applicability compared to knee or hand OA, but can be considered for any accessible painful joints. 1, 6

Second-Line: Oral NSAIDs or COX-2 Inhibitors (If Acetaminophen Insufficient)

If acetaminophen provides inadequate pain relief, escalate to oral NSAIDs or COX-2 inhibitors: 1

• Use the lowest effective dose for the shortest duration. 1, 7
• For osteoarthritis, typical ibuprofen dosing is 1,200-3,200 mg daily (400-800 mg three to four times daily). 7
• Mandatory co-prescription of a proton pump inhibitor for gastroprotection, selecting the lowest acquisition cost option. 1
• Assess cardiovascular, gastrointestinal, and renal risk factors before prescribing, particularly in elderly patients. 6, 4

Common pitfall to avoid: Do not use NSAIDs in patients on antiplatelet therapy (e.g., ticagrelor, clopidogrel) due to significantly increased bleeding risk. 4

Third-Line: Intra-articular Corticosteroid Injections

For moderate to severe pain flares, consider intra-articular corticosteroid injections into the hip joint. 1, 6

• Provides short-term relief (4-8 weeks) and is particularly effective when combined with exercise therapy. 5, 8
• Safe option with minimal systemic effects. 4

Opioid Analgesics (Use Sparingly)

Tramadol or other opioids may be added if NSAIDs are contraindicated or insufficient, but they have significant potential harms and should be avoided when possible. 1, 2, 3

Adjunct Non-Pharmacological Treatments

Consider the following as supplements to core treatments: 1

• Manual therapy (manipulation and stretching) is specifically recommended for hip OA. 1
• Local heat or cold applications for temporary pain relief. 1, 6
• Transcutaneous electrical nerve stimulation (TENS) for pain management. 1, 6
• Assistive devices (walking sticks, canes) to reduce joint load and improve function. 1, 6
• Shock-absorbing footwear to reduce impact forces. 1

Treatments to Avoid

Do not recommend: 1, 6

• Glucosamine or chondroitin supplements (insufficient evidence of benefit). 1, 6
• Electroacupuncture (not effective). 1, 6
• Hyaluronic acid injections (not recommended). 1, 2

Monitoring and Surgical Referral

Reassess at 6-12 weeks to determine treatment effectiveness and need for escalation. 5, 6

Refer for joint replacement surgery if: 1, 6

• Joint symptoms (pain, stiffness, reduced function) substantially affect quality of life despite 3-6 months of comprehensive conservative treatment. 1, 4
• Refer before prolonged and established functional limitation develops—early referral improves outcomes. 1
• Patient-specific factors (age, sex, obesity, comorbidities) should not be barriers to surgical referral. 1

Do not refer for arthroscopic lavage and debridement—this is not indicated for hip OA and should only be considered for knee OA with mechanical locking. 1