From the Guidelines
The hip with mild sclerotic changes is likely not a significant bone health concern requiring immediate referral, and conservative management should be initiated. The patient's low back and hip pain is more likely related to the extensive degenerative disease seen on the back X-ray, with the hip sclerotic changes representing a secondary finding or early osteoarthritis. I recommend starting with conservative management including:
- Physical therapy focusing on core and hip strengthening exercises
- Appropriate pain management such as acetaminophen up to 3000mg daily in divided doses or NSAIDs like ibuprofen 400-600mg three times daily if not contraindicated
- Weight management should be addressed if applicable The sclerotic changes in the hip likely represent bone remodeling in response to mechanical stress rather than a primary bone disorder. If pain persists despite 4-6 weeks of conservative treatment, or if symptoms worsen, further evaluation with an MRI of both the lumbar spine and hip would be appropriate to better characterize the pathology. Additionally, a DEXA scan would be reasonable to assess for osteoporosis given the patient's age and sex, as this could influence overall treatment approach, as recommended by the American College of Radiology 1. The use of DEXA scans for osteoporosis screening is supported by the World Health Organization and the National Osteoporosis Foundation, and is considered a clinically proven method of measuring BMD in the lumbar spine, proximal femur, forearm, and whole body 1. In patients with low bone mass, a fracture risk assessment tool, such as FRAX, is used to determine the need for pharmacologic treatment, as recommended by the National Osteoporosis Foundation 1. The American Academy of Orthopaedic Surgeons also recommends osteoporosis evaluation and treatment for patients with hip fractures, highlighting the importance of addressing bone health in older adults 1.
From the Research
Bone Health and Referrable Issues
- The patient's hip X-ray shows mild sclerotic changes, which may indicate osteoporosis or other bone health issues 2.
- Osteoporosis is a metabolic disease of the skeletal system that can significantly reduce a patient's quality of life, and its progression may be inhibited by proper diet, lifestyle, and treatment 2.
- The World Health Organization (WHO) criteria define osteoporosis as low bone mineral density, with a T-score ≤ -2.5 found in the spine, the neck of the femur, or during a full hip examination 2.
Osteoporotic Pain and Treatment
- Osteoporotic fractures can cause acute and chronic pain, mainly affecting elderly patients with multiple comorbidities and commonly on different drug regimens 3, 4.
- Antiosteoporosis drugs can partially control pain, but additional analgesics are always necessary for pain due to bone fractures 3, 4.
- A multifaceted approach, including a large spectrum of drugs and non-pharmacological treatment, is required for chronic pain after osteoporotic fractures 3, 4.
Referrable Issues and Treatment Gaps
- Individuals at high risk of fractures do not receive adequate treatment, and strategies to address this treatment gap are important challenges for the future 5.
- The patient's hip issue may be a referrable issue as far as bone health is concerned, and further evaluation and treatment may be necessary to prevent fractures and manage pain 2, 5.