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Hip osteoarthritis — MSRA MCQ

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HardHip and GroinHip osteoarthritisMSRA

A 74-year-old woman with clinically and radiographically established right hip osteoarthritis has worsening groin pain over 6 weeks. She completed a supervised therapeutic exercise programme but can no longer progress it because weight-bearing and hip rotation are painful. Topical diclofenac has provided no benefit and regular paracetamol was ineffective. Oral NSAIDs are unsuitable because she has stage 4 chronic kidney disease (eGFR 26 mL/min/1.73 m²) and a previous NSAID-associated upper gastrointestinal bleed. She remains independently mobile indoors and wishes to avoid opioids. What is the most appropriate next step to control her pain while supporting rehabilitation?

Educational content. Not a substitute for clinical judgement or local policy.

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Correct answer: A — Arrange an intra-articular corticosteroid injection to facilitate resumption of supervised exercise

Explanation lettering: C = shown as A · A = shown as B · B = shown as C · E = shown as D · D = shown as E

Intra-articular corticosteroid injection is the best next step. She has hip osteoarthritis in which pain is now preventing engagement with the core intervention of therapeutic exercise. Topical NSAID treatment has failed, paracetamol has not helped, and oral NSAIDs are unsuitable because both advanced chronic kidney disease and a prior NSAID-associated gastrointestinal bleed materially increase treatment risk. NICE recommends considering an intra-articular corticosteroid injection when other pharmacological treatments are ineffective or unsuitable, including when it is needed to support therapeutic exercise. She should be advised that benefit is short term, typically 2 to 10 weeks. A is incorrect because NICE advises against intra-articular hyaluronan for osteoarthritis. B is tempting where NSAIDs are contraindicated, but paracetamol and weak opioids should not be routinely used; if used at all, they should be infrequent short-term rescue treatment when other pharmacological options are unsuitable, ineffective or not tolerated. Deferring exercise also conflicts with the treatment aim. D is inappropriate because gastroprotection reduces gastrointestinal risk but does not mitigate NSAID-related renal toxicity. E is incorrect because strong opioids should not be offered for osteoarthritis: their risks outweigh benefits.

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) — Pharmacological management and intra-articular injections (19 October 2022) — https://www.nice.org.uk/guidance/NG226/chapter/recommendations Osteoarthritis in over 16s: diagnosis and management (NG226) — Treatments not routinely offered (19 October 2022) — https://www.nice.org.uk/guidance/NG226/chapter/recommendations