What is the best treatment approach for a 61-year-old patient with mild bilateral hip joint space loss, heterotopic ossification near the right hip, and complaints of uncontrolled hip and back pain?

Treatment Approach for Bilateral Hip Osteoarthritis with Uncontrolled Pain

For this 61-year-old patient with mild bilateral hip osteoarthritis and uncontrolled pain, initiate oral NSAIDs immediately (such as naproxen up to 1000 mg daily) combined with physical therapy referral, as these represent the strongest evidence-based first-line treatments for symptomatic hip OA. 1

Immediate Pharmacological Management

• Start NSAIDs at the lowest effective dose as the primary analgesic, given their strong evidence base for hip osteoarthritis and superior efficacy compared to acetaminophen for moderate-to-severe pain 1
• Naproxen 375-500 mg twice daily is well-studied for hip OA, with demonstrated efficacy in reducing joint pain and improving mobility 2
• If gastrointestinal risk factors exist (age >65, prior GI bleeding, concurrent anticoagulation), add a proton pump inhibitor or consider a selective COX-2 inhibitor 1
• Acetaminophen up to 4 grams daily may be added for breakthrough pain, though it has limited efficacy as monotherapy for moderate-to-severe symptoms 1
• Absolutely avoid opioids - there is consensus-level evidence against their use for symptomatic hip OA due to poor risk-benefit ratio 1

Physical Therapy Referral

• Refer to physical therapy immediately (high-quality evidence, moderate strength recommendation) for mild-to-moderate symptomatic hip OA 1, 3
• PT should focus on hip muscle strengthening (abductors, adductors, flexors, rotators), range of motion exercises, and gait training 1, 3
• Consider Physical Medicine and Rehabilitation (PMR) referral for development of an individualized exercise program with proper exercise descriptors 3
• Regular exercise and physical activity should be emphasized as part of comprehensive management 1

Addressing the Back Pain Component

• The back pain requires separate evaluation, as it may represent referred pain from the hips, concurrent lumbar pathology, or sacroiliac joint dysfunction 4, 5
• Obtain AP and lateral lumbar spine radiographs if not already done, as hip pathology commonly coexists with spinal conditions 4, 5
• Physical examination should include lumbar spine range of motion, straight leg raise testing, and sacroiliac joint provocation tests 4
• If back pain persists despite hip treatment, consider MRI of the lumbar spine to evaluate for degenerative disc disease, stenosis, or nerve root compression 4

Intra-articular Corticosteroid Injection

• Consider intra-articular hip corticosteroid injection (high-quality evidence, moderate strength recommendation) if pain remains uncontrolled after 4-6 weeks of NSAIDs and PT 1
• This provides both diagnostic confirmation (if pain improves significantly, the hip is the primary pain generator) and therapeutic benefit 4, 5
• Ultrasound or fluoroscopic guidance improves accuracy and outcomes 1
• Do NOT use intra-articular hyaluronic acid - there is strong evidence against its use in hip OA 1

Management of Heterotopic Ossification

• The indeterminate heterotopic ossification near the right hip is likely an incidental finding and typically asymptomatic 6, 7
• Heterotopic ossification only requires treatment if it causes severe pain, ankylosis, or significant functional limitation - none of which are present in this case 6, 7, 8
• Monitor clinically; no specific intervention is needed at this time 6, 8

Weight Reduction and Assistive Devices

• If the patient is overweight or obese, weight reduction should be strongly encouraged as it reduces mechanical stress on the hip joints 1
• Consider a cane or walking stick for the contralateral hand to offload the more symptomatic hip 1
• Shoe insoles may provide additional cushioning and improve gait mechanics 1

Timeline for Reassessment and Surgical Consideration

• Reassess response to conservative treatment at 6-8 weeks 1
• If pain remains refractory to NSAIDs, PT, and intra-articular injection after 3-6 months of optimal conservative management, refer to orthopedic surgery for total hip arthroplasty evaluation 1
• Total hip arthroplasty is strongly recommended for patients with radiographic hip OA who have refractory pain and disability despite conservative treatment 1
• Given bilateral involvement, staged bilateral THA may eventually be required, with the more symptomatic side addressed first 1

Critical Pitfalls to Avoid

• Do not prescribe opioids for chronic hip pain - consensus guidelines strongly oppose this practice 1
• Do not use hyaluronic acid injections in the hip - strong evidence shows they should not be used 1
• Do not assume the hip is the sole pain generator without evaluating the lumbar spine and pelvis, as referred pain is common 4, 5
• Do not delay physical therapy referral - it is a cornerstone of conservative management with high-quality supporting evidence 1, 3
• Do not proceed to surgery without exhausting conservative options first, including NSAIDs, PT, weight management, and intra-articular injection 1