What is the best course of treatment for a patient with left hip pain and radiographic evidence of osteoarthritic changes?

Management of Early Hip Osteoarthritis with Left Hip Pain

For a patient with left hip pain and early radiographic osteoarthritic changes (cortical ridging without subcortical cysts or sclerosis), begin with acetaminophen up to 4 grams daily as first-line therapy, combined with patient education, exercise, and weight reduction if overweight. 1

Initial Pharmacological Management

• Acetaminophen (paracetamol) is the preferred first-line oral analgesic for mild-to-moderate pain due to its efficacy and safety profile, and should be continued long-term if successful 1, 2
• If acetaminophen provides inadequate pain relief after an appropriate trial, add or substitute NSAIDs at the lowest effective dose 1, 3
• For patients with increased gastrointestinal risk, use either non-selective NSAIDs plus a gastroprotective agent, or a selective COX-2 inhibitor (coxib) 1, 3
• Topical NSAIDs are strongly recommended as first-line treatment and may be used alone or in combination with oral agents, with fewer systemic adverse effects 3

Non-Pharmacological Interventions (Mandatory, Not Optional)

• Regular exercise programs reduce pain and disability and should be prescribed concurrently with pharmacological treatment 1, 4
• Patient education and self-management programs are essential components of the treatment plan 1, 5
• Weight reduction if the patient is obese or overweight directly reduces mechanical stress on the hip joint 1
• Consider assistive devices such as a walking stick to offload the affected hip 1

Treatments to Avoid in This Early-Stage Patient

• Do not use glucosamine or chondroitin - they lack hip-specific evidence for structural modification despite theoretical benefits 6, 7
• Avoid hyaluronic acid injections - no RCT evidence supports its use in hip OA, only uncontrolled studies exist 6, 7
• Do not prescribe diacerhein - it may slow joint space narrowing but causes significant diarrhea (RR 3.73) and does not reverse existing damage 6, 7
• Intra-articular corticosteroid injections should be reserved for acute flares unresponsive to analgesics and NSAIDs, and must be image-guided (ultrasound or fluoroscopy) 1

When to Escalate Treatment

• If NSAIDs are contraindicated, ineffective, or poorly tolerated, opioid analgesics with or without acetaminophen are useful alternatives 1
• Duloxetine is a strongly recommended option for patients who cannot tolerate NSAIDs or need additional pain control 3
• Capsaicin and tramadol have controversial evidence with differing guideline recommendations, and should be considered only after other options fail 3

Critical Understanding About Disease Modification

• Hip osteoarthritis cannot be reversed - all current treatments focus on symptom control, pain management, and functional improvement, not structural restoration of damaged cartilage 6, 7
• This patient's cortical ridging represents irreversible structural change, making symptom management the realistic goal 6

Monitoring and Surgical Consideration Threshold

• Total hip replacement should be considered when patients have radiographic evidence of hip OA with refractory pain and disability despite optimal medical management 1
• THR achieves 43-84% pain-free outcomes at 9.4 years follow-up, with revision rates of 0.18-2.04 per 100 person-years 6, 7
• For this patient with early changes, surgery is premature - focus on the stepwise pharmacological and non-pharmacological approach outlined above 1

Common Pitfalls to Avoid

• Do not skip non-pharmacological interventions - the optimal management requires combination therapy, not medications alone 1
• Do not prescribe symptomatic slow-acting drugs for OA (SYSADOA) as first-line agents - their effect sizes are small, suitable patients are not well-defined, and structure modification is not established 1
• Do not delay weight-bearing exercise out of fear of "wearing out" the joint - exercise reduces pain and improves function 4
• Do not order MRI at this stage - radiographs showing osteoarthritic changes are diagnostic, and physical examination plus radiography have reasonable sensitivity and specificity for OA 1