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Hip osteoarthritis — MSRA MCQ

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ModerateHip and GroinHip osteoarthritisMSRA

A 61-year-old woman presents with a 3-year history of right groin pain, worse after walking and when rising from a chair. Morning stiffness lasts 10 minutes. She has no trauma, fever, weight loss, night pain or neurological symptoms. Examination shows painful restriction of right hip flexion and internal rotation. She has completed supervised therapeutic exercise, but pain now prevents progression. Topical diclofenac has been ineffective. Oral NSAIDs are unsuitable because she has stage 3b chronic kidney disease and previously had an upper gastrointestinal bleed while taking naproxen. Her symptoms do not currently substantially affect her quality of life sufficiently for her to consider joint replacement. She asks about a privately offered injection described as a “joint lubricant”. What is the most appropriate next management step?

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Correct answer: B — Consider an intra-articular corticosteroid injection, explaining that relief is short term and may support therapeutic exercise

This is typical hip osteoarthritis: she is over 45 years old, has activity-related groin pain and brief morning stiffness, with restricted painful hip movement. In the absence of atypical features or red flags, osteoarthritis is diagnosed clinically and repeat imaging would not guide non-surgical management. She has already undertaken supervised therapeutic exercise, but pain is now a barrier. Topical NSAID treatment has failed, while oral NSAIDs are unsuitable because NICE advises consideration of renal and gastrointestinal toxicity; both are clinically important in this patient. NICE therefore supports considering an intra-articular corticosteroid injection when other pharmacological treatments are ineffective or unsuitable, including where short-term pain relief may facilitate therapeutic exercise. She should be counselled that benefit is limited to approximately 2 to 10 weeks. Hyaluronan is the plausible private-sector alternative, but NICE specifically advises against intra-articular hyaluronan injections for osteoarthritis. Regular paracetamol is not a preferred maintenance strategy; it is reserved for infrequent short-term use when other pharmacological options cannot be used or have failed. Strong opioids should not be offered because their risks outweigh benefits. Joint replacement referral is not currently indicated because her symptoms do not substantially affect her quality of life.

Reference: Osteoarthritis in over 16s: diagnosis and management (NG226), Recommendations (19 October 2022) — https://www.nice.org.uk/guidance/ng226/chapter/Recommendations Osteoarthritis in over 16s: diagnosis and management (NG226), Recommendations (19 October 2022) — https://www.nice.org.uk/guidance/ng226/chapter/Recommendations Osteoarthritis in over 16s: diagnosis and management (NG226), Rationale and impact: intra-articular injections (19 October 2022) — https://www.nice.org.uk/guidance/NG226/chapter/rationale-and-impact