In a 68-year-old obese man with hypertension and metabolic syndrome who has a six‑week history of right hip osteoarthritis–type pain (dull, aching, radiating to the groin, worsened by walking, stairs and at night, relieved by rest) with limited hip range of motion and pain on internal and external rotation, what is the most appropriate initial management step?

Initial Management of Hip Osteoarthritis in an Obese Patient

Physical therapy is the most appropriate initial step in management for this patient with hip osteoarthritis. 1

Rationale for Physical Therapy as First-Line Treatment

The clinical presentation—a 68-year-old obese man (BMI 32.1) with classic hip OA symptoms (groin pain, activity-related pain relieved by rest, limited range of motion, pain on internal/external rotation)—requires immediate initiation of a structured, supervised exercise program. 1

Why Physical Therapy Takes Priority

All major guidelines strongly recommend exercise as the cornerstone of initial hip OA management, with supervised physical therapy providing superior outcomes to unsupervised home programs. 1

• The American College of Rheumatology strongly recommends that all patients with symptomatic hip OA be enrolled in an exercise program commensurate with their ability. 1
• The 2019 ACR/Arthritis Foundation guideline provides a strong recommendation for exercise in hip OA patients, indicating benefits substantially outweigh risks. 1
• At least 12 supervised physical therapy sessions are required initially to obtain sufficient clinical benefit, with sessions twice weekly showing significantly greater pain reduction (effect size 0.46 vs 0.28, p=0.03) and functional improvement (effect size 0.45 vs 0.23, p=0.02) compared to fewer sessions. 1, 2

Components of the Physical Therapy Program

The physical therapist should prescribe:

• Sustained isometric strengthening exercises for both legs (not just the symptomatic side), targeting quadriceps and proximal hip girdle muscles. 1
• Low-impact aerobic activity such as walking, stationary cycling, or aquatic exercise for at least 30 minutes daily. 1
• Range-of-motion and stretching exercises to address the limited hip mobility noted on examination. 1
• Manual therapy techniques in combination with supervised exercise. 1

Concurrent Weight Loss Counseling

This patient's obesity (BMI 32.1) is a critical modifiable risk factor that must be addressed simultaneously with exercise. 1

• The ACR strongly recommends that all overweight patients with symptomatic hip OA be counseled regarding weight loss. 1
• The target should be at least 5-7.5% body weight reduction (approximately 10-14 kg for this patient), which produces clinically meaningful improvements in pain and function. 3, 4
• Weight-loss programs with explicit numerical goals achieve significantly greater weight reduction (mean -4.0 kg) compared to programs without defined targets (mean -1.3 kg). 1
• The physical therapist can coordinate with dietary counseling or refer to a structured weight-loss program that includes weekly supervised sessions, self-monitoring, and structured meal planning. 1

Why Other Options Are Inappropriate Initially

Intra-articular Corticosteroid Injection

• The ACR provides only a conditional recommendation for intra-articular corticosteroid injections in hip OA, indicating uncertain benefit-to-risk balance. 1
• Pharmacologic interventions, including injections, are reserved for patients who have inadequate response to nonpharmacologic modalities. 1
• This patient has not yet tried evidence-based nonpharmacologic therapy (supervised exercise and weight loss), making injection premature. 1

Prescription for Heel Lift

• There is no evidence supporting the use of heel lifts or insoles for hip OA. 1
• The EULAR guidelines explicitly state that no evidence exists to support the effect of specific shoes or insoles on pain or function in hip OA patients. 1

Referral to Physiatry

• While physiatrists can provide valuable care, direct referral to physical therapy is more appropriate as the initial step because it immediately initiates the strongly recommended exercise program. 1
• Physiatry referral may be considered later if the patient has inadequate response to initial physical therapy and requires more complex pain management or interventional procedures. 1

Surgical Arthroscopy

• Surgery is considered only after failure of comprehensive nonpharmacologic and pharmacologic management. 1
• This patient has only tried ibuprofen and has not undergone any structured conservative treatment. 1
• Hip arthroscopy has no role in the management of osteoarthritis and would be inappropriate for this degenerative condition. 1

Critical Implementation Details

The physical therapy prescription should specify:

• Minimum 12 supervised sessions over 6-8 weeks, twice weekly. 1, 2
• Progressive resistance training at 60-80% of one-repetition maximum for 8-12 repetitions. 1
• Transition to self-managed home exercise program after the supervised phase, with exercises linked to daily activities (e.g., before morning shower) to promote adherence. 1

Common pitfalls to avoid:

• Do not prescribe "rest" as primary therapy; inactivity worsens obesity and long-term joint outcomes. 3
• Do not limit strengthening to only the symptomatic right hip; bilateral strengthening is recommended regardless of which joint is painful. 1, 5
• Do not delay exercise initiation due to pain; clinical trials demonstrate that OA patients with pain still achieve meaningful improvements with exercise. 1, 5

Additional Considerations for This Patient's Comorbidities

This patient's metabolic syndrome (hypertension, obesity) represents a "metabolic OA phenotype" characterized by chronic low-grade inflammation that accelerates cartilage degradation. 6, 7, 8, 9

• Addressing metabolic risk factors through weight loss and exercise may slow OA progression beyond just symptom relief. 6, 8, 9
• The patient's blood pressure (152/88) requires optimization, and exercise combined with weight loss will provide cardiovascular benefits in addition to joint benefits. 6, 7
• Patients with OA and metabolic syndrome face increased cardiovascular mortality risk, making comprehensive lifestyle modification even more critical. 6