What is the recommended management approach for a patient over 50 years old with early osteoarthritic changes in the right hip, presenting with right hip pain, and radiographic findings of cortical ridging along the margin of the femoral head?

Management of Early Hip Osteoarthritis in Adults Over 50

For a patient over 50 with early osteoarthritic changes in the right hip and cortical ridging on radiographs, initiate a multimodal conservative treatment plan combining oral acetaminophen (up to 4g daily), NSAIDs at the lowest effective dose, and physical therapy referral, as this combination provides the strongest evidence-based approach before considering invasive interventions. 1

Initial Pharmacologic Management

Start with acetaminophen as first-line therapy:

• Acetaminophen up to 4g daily is the preferred initial oral analgesic for mild-to-moderate hip OA due to its efficacy and safety profile 1, 2
• This should be considered when not contraindicated, particularly for long-term use 1

Add or substitute NSAIDs if acetaminophen provides inadequate relief:

• Use the lowest effective dose of NSAIDs 1, 3
• For patients with increased gastrointestinal risk, combine non-selective NSAIDs with gastroprotective agents, or use selective COX-2 inhibitors 1
• NSAIDs have strong evidence supporting their use for symptomatic hip OA 1, 4

Critical medication pitfalls to avoid:

• Do NOT prescribe opioids for chronic hip OA pain - consensus guidelines explicitly recommend against their use 1, 2, 3
• Do NOT use intra-articular hyaluronic acid injections - high-quality evidence with strong recommendation states these should not be considered for symptomatic hip OA 1, 2, 3

Non-Pharmacologic Interventions

Refer to physical therapy immediately:

• High-quality evidence with moderate strength recommendation supports PT for mild-to-moderate symptomatic hip OA 1
• Exercise is strongly recommended for all patients with hip OA, with substantial evidence supporting pain and functional improvement 1
• PT should target hip muscle strengthening, particularly hip abductors, adductors, flexors, and rotators 2
• Exercise recommendations should focus on patient preferences and access to maximize adherence 1

Address modifiable risk factors:

• Weight reduction if the patient is obese or overweight 1
• Regular patient education about the condition and self-management strategies 1
• Consider assistive devices such as a walking stick if gait is affected 1

Invasive Options for Refractory Symptoms

If conservative measures fail after 3 months:

• Intra-articular corticosteroid injection (ultrasound or x-ray guided) can be considered for symptomatic relief 1, 4
• This has high-quality evidence with moderate strength recommendation 1
• Provides both diagnostic confirmation and therapeutic benefit, typically lasting 4-8 weeks 5

Avoid glucosamine and chondroitin:

• While these supplements have symptomatic effects with low toxicity, effect sizes are small and clinically relevant benefits are not well established 1
• Most major societies recommend against their routine use 4

Monitoring and Escalation

Reassess at 3 months of conservative treatment:

• 44% of patients with early hip pathology report satisfaction with conservative care alone 6
• Patients with more active lifestyles or persistent functional limitations despite maximal conservative therapy may require surgical consultation 6
• Joint replacement should be considered only in patients with radiographic evidence of hip OA who have refractory pain and disability despite conservative management 1

Key clinical pearls:

• Treatment must be tailored to hip risk factors (obesity, mechanical factors, physical activity), general risk factors (age, comorbidity), pain intensity, disability level, and patient expectations 1
• The broader impact of OA on mood disorders, sleep, and chronic pain should be addressed through a multimodal treatment plan rather than single medication prescription 1
• Preoperative optimization (if surgery becomes necessary) should address BMI, diabetes control, smoking cessation, and opioid weaning 1