What is the best management approach for an older patient with hip osteoarthritis?

Management of Hip Osteoarthritis in Older Patients

Optimal management of hip osteoarthritis requires combining non-pharmacological core treatments (education, exercise, and weight loss if overweight) with pharmacological therapy starting with paracetamol/acetaminophen, escalating to NSAIDs with gastroprotection, and considering joint replacement for refractory cases with radiographic evidence and severe disability. 1

Core Non-Pharmacological Treatments (Foundation for All Patients)

Every older patient with hip OA must receive these three interventions regardless of disease severity: 1

Education and Self-Management

• Provide both oral and written information to counter the misconception that OA is inevitably progressive and untreatable 1
• Implement regular follow-up with feedback on progress toward explicit goals to achieve long-term behavioral changes 1
• Emphasize that exercise can improve symptoms even when pain is present 2

Exercise Therapy (Most Critical Component)

Strengthening exercises: 2

• Perform isometric exercises for quadriceps and hip girdle muscles bilaterally, holding contractions for 6-7 seconds, repeated 5-7 times, performed 3-5 times daily 2
• Include gluteal strengthening exercises with the same duration and frequency 2
• Start at 30% of maximal voluntary contraction intensity, progressing to 75% as tolerated 2
• Perform 2-4 sets of 8-12 repetitions at 60-80% of one-repetition maximum, at least 2 days per week 2
• Critical warning: Joint pain lasting more than 1 hour after exercise or joint swelling indicates excessive activity and requires immediate modification 2

Aerobic exercise: 2

• Choose low-impact activities (swimming, cycling, walking) that minimize joint loading 2
• Target moderate-intensity training (70% of maximal heart rate) for 30-60 minutes per day, at least 3 days per week 2

Flexibility work: 2

• Perform static stretches daily when pain and stiffness are minimal (e.g., before bedtime) 2
• Hold each stretch for 30-60 seconds, repeating 2-4 times per muscle group 2

Supervision requirements: 2

• Provide twelve or more directly supervised sessions for significant improvement in pain and function 2
• After initial instruction, patients should self-manage exercises integrated into daily routines 2

Manual Therapy

• Consider manipulation and stretching specifically for hip OA, as this provides additional benefit beyond exercise alone 1, 3

Weight Reduction (If Overweight/Obese)

• Target a minimum 4 kg weight loss through structured programs 2
• Programs with explicit weight-loss goals achieve mean changes of -4.0 kg compared to -1.3 kg without explicit goals 1
• Consider meal replacement bars or powders to achieve structured low-calorie intake with adequate vitamins and minerals 1

Assistive Devices

• Prescribe walking sticks for those with specific problems in activities of daily living 1
• Recommend footwear with shock-absorbing properties 1, 2
• Consider insoles for biomechanical joint pain or instability 1

Pharmacological Treatment Algorithm

First-Line: Paracetamol/Acetaminophen

Start with paracetamol up to 4 grams daily in divided doses as the preferred initial and long-term oral analgesic for mild-moderate pain due to its efficacy and safety profile. 1, 4

• Regular dosing may be needed rather than as-needed administration 1

Second-Line: NSAIDs (If Paracetamol Insufficient)

Add or substitute NSAIDs at the lowest effective dose for the shortest possible duration when paracetamol provides inadequate pain relief. 1

Critical prescribing requirements for older patients: 1

• Always prescribe with a proton pump inhibitor for gastroprotection 1, 4
• Choose either a COX-2 inhibitor (other than etoricoxib 60 mg) or a standard NSAID 1
• In patients with increased gastrointestinal risk, use non-selective NSAIDs plus gastroprotective agent, or a selective COX-2 inhibitor 1
• Consider topical NSAIDs before oral NSAIDs, particularly in elderly patients, as they provide effective pain relief with minimal systemic exposure 4
• All oral NSAIDs and COX-2 inhibitors have similar analgesic effects but vary in gastrointestinal, liver, and cardiorenal toxicity 1
• Take into account individual risk factors including age and assess/monitor these risk factors ongoing 1

Third-Line: Opioid Analgesics

Use opioid analgesics (with or without paracetamol) only when NSAIDs are contraindicated, ineffective, or poorly tolerated. 1

• Tramadol is conditionally recommended if NSAIDs are contraindicated or ineffective 4
• Avoid long-term opioid use; reserve for patients unwilling to undergo or not candidates for surgery 4

Adjunctive Pharmacological Options

Intra-articular corticosteroid injections: 1

• Consider for moderate to severe pain or flares unresponsive to analgesics and NSAIDs 1
• Must be guided by ultrasound or x-ray for hip injections 1
• Provide temporary but significant short-term pain relief 5

Topical capsaicin: 1

• Consider as an adjunct for localized pain relief 1

Duloxetine: 5

• Has demonstrated efficacy for OA pain 5

NOT Recommended

Do not prescribe glucosamine, chondroitin, or hyaluronic acid products. 1, 4

• These have small effect sizes, suitable patients are not well defined, and clinically relevant structure modification is not established 1
• Glucosamine and chondroitin are conditionally recommended against 4

Surgical Referral Criteria

Timing for Joint Replacement Consideration

Refer for total hip replacement when the patient has radiographic evidence of hip OA with refractory pain and disability despite comprehensive non-surgical treatment. 1

Specific indications: 4, 5

• Joint symptoms substantially affect quality of life despite comprehensive non-surgical treatment 4
• Refer before prolonged and established functional limitation and severe pain develop 4
• Total joint replacement effectively relieves pain in advanced disease 5

Alternative Surgical Options for Younger Patients

Consider osteotomy and joint-preserving surgical procedures in young adults with symptomatic hip OA, especially with dysplasia or varus/valgus deformity. 1

Treatment Tailoring Based on Patient Factors

Adjust treatment intensity according to: 1

• Hip risk factors: obesity, adverse mechanical factors, physical activity level, dysplasia 1
• General risk factors: age, sex, comorbidity, co-medication 1
• Level of pain intensity, disability, and handicap 1
• Location and degree of structural damage 1
• Patient wishes and expectations 1

Common Pitfalls to Avoid

Do not delay exercise initiation due to pain presence - clinical trials demonstrate patients with OA pain can still achieve improvements 2

Do not focus solely on the affected hip - bilateral strengthening is recommended regardless of which hip is symptomatic 2

Do not prescribe NSAIDs without gastroprotection in older patients - this significantly increases gastrointestinal bleeding risk 1

Do not use electroacupuncture - it should not be used for hip OA 1

Do not offer arthroscopic procedures - joint lavage and debridement are not indicated for hip OA 4

Avoid exercising muscles to fatigue - use submaximal resistance to prevent joint damage 2