Pain in Primary Care

Managing Hip Pain: Clinicians Debate

Charles P. Vega, MD

Disclosures

September 16, 2021

Last month, I posted a case from my own practice to highlight issues of pain management in primary care. To recap: The patient was a 66-year-old woman with lifestyle-limiting hip pain and several medical comorbidities, including obesity and type 2 diabetes. I asked for, and received, numerous comments about my management of this patient.

Thank you for the great insights I've received. They are helpful and thought-provoking. I would like to address some emerging themes from your comments.

The case as originally presented had significant gaps, in large part because no one wants to read a five-page case online. But many of you are absolutely right in that we should not assume that older adults who present with hip pain automatically have osteoarthritis. The pain of osteoarthritis is usually anterior, but labral tears also produce this type of pain. However, if her pain is posterior, lumbar radiculopathy and sacroiliac dysfunction are more likely. Lateral hip pain, as suggested by readers, is often associated with inflammation of the greater trochanter. This patient needs a better history and good physical examination before cinching a diagnosis and recommending treatment.

The Surgery Question

Next up, the law of the instrument: If all you have is a hammer, then it is tempting to treat everything like a nail. I am not a surgeon and have never even performed an intraarticular injection of the hip. My bias is to use medications as conservative therapy to reduce pain, maintain function, and either delay or avoid major surgery in cases such as this one. But I was surprised at how many readers recommended an immediate evaluation for surgery, or at least an intraarticular injection as a diagnostic and therapeutic intervention. Most of the comments in favor of invasive interventions were from proceduralists or individuals who had joint replacement surgery themselves.

A 2021 study from the Netherlands provides enlightening information on the natural history of hip osteoarthritis. Researchers followed a cohort of 588 adults with hip complaints over 10 years. Only 30% of patients with clinical hip osteoarthritis had radiographic evidence of hip osteoarthritis at baseline, and the mean age of participants (55 years) was younger than the age of our patient (66 years).

As expected, radiographic findings worsened over 10 years, and 12% of the cohort received total hip arthroplasty (THA) during follow-up. However, among participants who did not receive surgery, measurements of pain and physical function remained stable during the follow-up period. There was a moderate increase in analgesic use over time.

So it appears that most middle-aged adults with hip pain can be successfully managed over the long term without surgery. Still, there is no doubt that surgery will probably be considered for this case patient at some point. What can she expect after THA? A study that followed 250 patients for an average of 16 years found that health-related quality of life was lower and pain scores higher among adults with a history of THA vs no THA, but THA was associated with better outcomes vs untreated hip osteoarthritis. The rate of satisfaction after THA was 96%, although 12% of participants had undergone revision of a previous surgery.

Acetaminophen: Yea or Nay?

The comments also included voices supporting and disparaging the use of acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDs) for this patient. One of the most frequently cited concerns regarding acetaminophen use was the risk for liver toxicity. Although there is no doubt about the risk for liver toxicity associated with overdosage of acetaminophen, there are mixed results with respect to transaminitis associated with regular doses of acetaminophen. However, in a clinical trial of 145 healthy adults, treatment with 4 g daily of acetaminophen was associated with serum alanine aminotransferase (ALT) elevations more than three times above normal in 31%-44% of participants through 14 days of treatment. No participant receiving placebo experienced a serious elevation of ALT. Nonetheless, the clinical relevance of transaminitis has been questioned; long-lasting hepatic damage associated with acetaminophen used at the recommended dosage is very rare.

The final concern that was frequently raised was that this patient would be unlikely to take acetaminophen routinely because she had tried it previously and would be unfavorable to a recommendation for an over-the-counter medicine. But a comment from Dr Burns provides a counterpoint to this argument, stating that many patients feel like they need permission to use analgesics routinely.

These divergent patient attitudes are common in clinical practice. We probably all have experience with both patient concerns. But I tend to agree with Dr Burns. Many of my patients are scared to take analgesics routinely for fear of side effects, included becoming "addicted" to acetaminophen or NSAIDs. But some empathic listening and discussion of the true risks of analgesics usually makes a difference and helps the patient manage pain much more effectively. Our case patient needs to understand that her chronic illnesses and current medications limit the therapeutic options for analgesia, but that does not mean that she cannot use certain medications regularly and safely.

Overall, there was clearly a lot of concern for this patient's welfare and some great suggestions regarding pharmacologic and nonpharmacologic therapy. She is in a good position to feel better and gain function, regardless of the precise means of treatment.

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