A 58-year-old man from Mumbai with a 5-year history of right hip pain presents with progressive loss of internal rotation and abduction. He reports pain that worsens with walking and is relieved by rest. On examination, there is a positive FABER test and limited hip flexion. X-ray of the right hip shows joint space narrowing, osteophytes at the femoral head–neck junction, and subchondral cysts. He is a former manual labourer. What is the most appropriate initial management?

Explanation

## Management of Hip Osteoarthritis: Conservative Approach First ### Clinical Context **Key Point:** Hip osteoarthritis (OA) is a progressive degenerative disease. Management follows a stepwise approach: conservative measures first, then interventional options only when conservative care fails. ### Why Conservative Management Is Appropriate Here | Aspect | Rationale | |--------|----------| | **Disease stage** | Radiographic OA present but patient is functionally limited (not end-stage) | | **Symptom duration** | 5 years suggests stable, chronic disease | | **First-line principle** | Conservative measures should be exhausted before surgery | | **Patient age** | 58 years: still relatively young for arthroplasty (longevity concerns) | ### Stepwise Management Algorithm ```mermaid flowchart TD A[Hip OA diagnosed]:::outcome --> B[Conservative measures]:::action B --> C[Weight loss, activity modification, PT]:::action B --> D[NSAIDs for pain control]:::action B --> E[Intra-articular corticosteroid injection]:::action F{Adequate symptom relief?}:::decision C --> F D --> F E --> F F -->|Yes| G[Continue conservative care]:::action F -->|No, persistent disability| H[Consider surgical options]:::decision H -->|Severe OA, failed conservative| I[Total hip arthroplasty]:::action H -->|Mild-moderate OA| J[Hip arthroscopy - limited role]:::action ``` ### Components of Conservative Management 1. **Physical therapy & exercise** → strengthens hip abductors and flexors, improves range of motion 2. **Weight management** → reduces load on hip joint 3. **Activity modification** → avoid high-impact activities (running, jumping) 4. **NSAIDs** → reduce pain and inflammation (e.g., indomethacin 25–50 mg BD) 5. **Intra-articular corticosteroid injection** → provides symptomatic relief for 3–6 months; can be repeated 6. **Walking aids** → cane in contralateral hand reduces hip load **High-Yield:** Intra-articular corticosteroid injection is a bridge therapy—it provides temporary relief while conservative measures are optimized. It can be repeated every 3–6 months. **Clinical Pearl:** Hip OA in a former manual labourer suggests secondary OA from occupational wear; conservative management may provide years of functional improvement before surgery becomes necessary. ### Why Surgery Is Not First-Line - **Total hip arthroplasty (THA):** Indicated only after failure of conservative measures; prosthesis longevity is 15–20 years, so early surgery risks revision in the future. - **Hip arthroscopy:** Has a very limited role in OA (mainly for loose bodies or labral tears); it does not alter the degenerative process. - **Methotrexate:** Used for inflammatory arthropathies (RA), not OA.