Hip pain: what can be done before surgery

Where hip pain really comes from

"My hip hurts" is an ambiguous phrase. For the patient it can mean pain in the lower back, in the buttock, on the outer thigh, in the groin, or all of the above at once. To identify the real source of the pain and choose the right treatment, you have to locate exactly where it hurts:

• Groin pain (in the groin crease, at the front of the thigh): usually points to a problem in the hip joint itself (the femoroacetabular joint).
• Pain over the trochanter (on the outer thigh): is generally soft-tissue pain — trochanteric bursitis, tendinopathy of the gluteus medius and minimus.
• Pain in the back of the buttock: can be sacroiliitis, referred lumbar pain, or piriformis syndrome.
• Pain in the lower back: is usually sacroiliitis or low back pain, not the hip strictly speaking.

Pinpointing the location of the pain is the first step. Many patients have hip surgery when the pain was actually coming from the spine or from the peritrochanteric soft tissues — and vice versa.

One nuance I find myself explaining at every visit: hip osteoarthritis shows up on many X-rays and MRIs of people who have little or no pain. The degree of wear on the image does not correlate linearly with the intensity of the symptom. That's why I'm careful about saying "it hurts because you have osteoarthritis": sometimes that's true, sometimes it's only part of the story. There are patients with significant degenerative changes who do very well with conservative treatment, and patients with less striking images who have a far more disabling condition. The clinical picture leads; the imaging supports.

Most common causes

Hip osteoarthritis

Wear of the hip's articular cartilage causes groin pain that worsens with activity, brief morning stiffness, and progressive limitation of hip rotation (especially internal rotation). It usually responds well to conservative treatment in the early stages and to intra-articular injections in moderate stages.

Trochanteric bursitis and gluteal tendinopathy

Pain on the outer thigh that worsens when lying on that side, when walking, when climbing stairs. It is very common and is often misdiagnosed as "hip osteoarthritis" when the joint is actually fine. It responds extremely well to ultrasound-guided injections and targeted physical therapy.

Femoroacetabular impingement

Atypical anatomy of the femoral neck or the acetabulum that creates friction and hip pain, common in young people and athletes. The diagnosis is made with MRI with intra-articular contrast. Depending on the degree, it can be managed with interventional or surgical treatment.

Piriformis syndrome

Tightness of the piriformis muscle that compresses the sciatic nerve. It causes deep buttock pain and sometimes pain radiating down the leg. It is treated with targeted physical therapy, image-guided injections and medication.

Referred lumbar pain

A herniated disc or a lumbar facet problem can refer pain to the buttock or thigh, mimicking hip pain. Telling them apart is essential so the wrong hip doesn't get operated on.

When the pain is not coming from the joint

A significant proportion of patients who come in for "hip pain" don't have a problem in the hip joint at all. They have peritrochanteric pain: bursitis, gluteal tendinopathy, iliotibial band. This is precisely the most common source of confusion.

How do you tell them apart?

• Pain from the hip joint is typically felt in the groin and worsens with hip rotation, especially internal rotation.
• Peritrochanteric pain is lateral; it worsens when lying on that side at night and when walking.
• A focused physical exam distinguishes one from the other in a few minutes.

When the pain is peritrochanteric, ultrasound-guided injections into the bursa or the gluteal tendons usually produce excellent results. You don't need a hip replacement to fix bursitis.

Non-surgical options with good evidence

Before moving on to hip replacement (which is an excellent resource when properly indicated), there are several intermediate options for hip pain with good supporting evidence:

• Personalized medication management: NSAIDs in short courses, adjuvant analgesics, joint supplements in some cases.
• Targeted physical therapy: strengthening of the gluteus medius and minimus, hip and core work, gait correction. There is solid evidence of benefit in hip osteoarthritis and peritrochanteric pain.
• Intra-articular injection guided by ultrasound or fluoroscopy: with corticosteroid and local anesthetic, or with hyaluronic acid, in patients with moderate hip osteoarthritis. It can provide months of significant relief.
• Peritrochanteric injection: for bursitis and gluteal tendinopathy, guided by ultrasound. Very good results.
• Regenerative medicine with platelet-rich plasma: for gluteal tendinopathies and selected cases of early hip osteoarthritis.
• Genicular radiofrequency ablation of the hip: a relatively new technique that neuromodulates the nerves supplying the hip, useful for patients with advanced hip osteoarthritis who are not candidates for hip replacement or who want to postpone it.

The ideal plan combines medical treatment, well-executed physical therapy and, when necessary, image-guided procedures. Many patients avoid or postpone hip replacement for years with this approach.

My approach to hip pain without a clear indication for surgery is to work in layers. First, physical therapy properly focused on strengthening the gluteus medius and core, weight management when needed, and adjustments to physical activity. In parallel, if the pain is disabling, I consider image-guided injections into the trochanteric bursa, intra-articular hip injections or specific nerve blocks depending on the condition. Hip replacement surgery has a very clear and very good place, but there is a wide territory before that step where the pain can improve substantially without going through the operating room. That territory is where pain medicine has the greatest impact.

When to consider hip replacement

Total hip replacement is one of the surgical procedures with the best outcomes in all of medicine. It should not be demonized. But there's also no reason to rush when intermediate options remain.

Hip replacement is clearly indicated when:

• The osteoarthritis is radiologically advanced (stage III-IV) and causes disabling pain.
• The pain does not respond to well-executed conservative and interventional treatment.
• Quality of life is significantly affected: difficulty walking, sleeping, doing everyday activities.
• The patient is in good overall condition for major surgery and the rehabilitation that follows.

Before that point, though, it is worth exhausting the remaining options. A second opinion from a pain specialist can bring tools that the traditional orthopedic consultation doesn't always consider.

When a patient with hip pain gets back to walking long distances, climbing stairs without thinking about it and sleeping on their side without waking up, the result was almost always built by combining several tools: pain treatment, consistent exercise and sustained lifestyle changes. Surgery remains an excellent option when indicated, but it is not the only possible ending. My job is to help each patient understand where they are in the story, what to expect from each treatment and when, eventually, it makes sense to take the surgical step. Rushing it or delaying it are the two most common mistakes.

Dr. Mauricio Casarsa

Anesthesiologist, specialist in Pain Medicine and Interventional Pain Management. Postgraduate training at UBA (Fundación Dolor) and UNLP (CAIDBA). Staff physician at Hospital Alemán de Buenos Aires.

MN 137756 · San Isidro · Villa Urquiza