Hip Pain

Overview

Abnormalities found on scans in asymptomatic people

(Copyright: Lee Higginbotham)

Hip pain is very common, and most often represents a benign mechanical problem. Over the age of 45/50 there is commonly a degree of osteoarthritic changes, and it often presents a grumbling course with periodic exacerbations and remissions. Most can be managed in primary care.

Remember hip problems may present as knee pain, and also consider spinal referred pain. Patients often refer to their iliac crest as hip pain, which is a common source of spinal referred pain. There are also numerous medical cases of groin pain.

Consider the patients age to help guide diagnosis eg. osteoarthritis is the most common cause of hip pain in the over 50’s.

For further information and more detailed clinical examination consider using: https://www.physio-pedia.com/Hip_Examination

Imaging

Imaging is not always helpful as it is common to find ‘abnormalities’ on x-ray, ultrasound and MRI scans in the asymptomatic population (including labral injuries, CAM and Pincer deformities-see image). It should only be considered in the presence of red flags, or if it is likely to change management.

If the patient has signs of OA (over 50, gradual onset, stiff hip) MRI is not indicated. Consider XR if suspicious of OA, x-ray within 6-12 months of referral is required.

Ultrasound in rarely useful in the early management of hip pain.

Most GPs will be able to use their FCP (First contact Practitioner) or Sirona Musculoskeletal Interface (MSKI) Service for further evaluation and appropriate imaging if required. Those GPs who have had further training and are particularly confident in MSK, may wish to order MRI scans direct, but would need to be asking a specific question which might change management, otherwise they may find radiology reject their request.

Please see: Remedy Imaging Guidelines for Primary Care

Who to refer

Physiotherapy and MSK

Persistent pain not responding to conservative measures: consider Sirona Musculoskeletal Interface (MSKI) Service or Sirona Musculoskeletal Physiotherapy Service for physiotherapy referrals. Details of referral criteria can be found on both these pages.

Most GPs will be able to use their FCP (First contact Practitioner) or Sirona Musculoskeletal Interface (MSKI) Service for further evaluation and appropriate imaging if required. Those GPs who have had further training and are particularly confident in MSK, may wish to order MRI scans direct, but would need to be asking a specific question which might change management, otherwise they may find radiology reject their request.

Hip Osteoarthritis:

Prior to referral for consideration for surgery, the patient should have tried appropriate conservative management including:

• Weight reduction where appropriate
• Education and self management
• Exercise and physiotherapy
• Appropriate analgesia

Referrals are subject to Criteria Based Access (CBA) policy. Please look at https://bnssg.icb.nhs.uk/directory/hip-replacement-surgery-including-referral-for-surgical-assessment-of-osteoarthritis/ for more detail.

Please also use this shared decision making tool: https://www.england.nhs.uk/wp-content/uploads/2022/07/Making-a-decision-about-hip-osteoarthritis.pdf

 Acute exacerbation of hip osteoarthritis:

These can sometimes respond to an image guided intra-articular steroid injection although intra articular hip injection can be linked to increased risk of infection in future hip replacement. There is also concern over local anaesthetic toxicity intra-articular. Only complete injections if appropriately trained and confident in technique. Alternatively refer to the MSK team for consideration of an injection.

Trauma:

If significant trauma, and suspicion of fracture (non-weight bearing, shortened and externally rotated), refer to A&E 

Red Flags

Red flags should be considered for:

• Infection (septic arthritis or osteomyelitis).
• Tumours (bone tumour, soft-tissue sarcoma, metastases, haematological cancer, or neuroblastoma).
• Inflammatory polyarthritis
• Insufficiency fracture
• Inability to weight bear

 Atraumatic acute hot/swollen/red hip:

If suspected infection/septic arthritis refer to A+E (call orthopaedic on-call first). Note in a new presentation of an acute mono-arthritis it can often be difficult to determine if infection or inflammatory. If concerns about infection this needs to be ruled out first.

If there is multi joint pathology and a systemic arthritis is suspected, consider referral to rheumatology via the EIA (Early Inflammatory Arthritis) pathway.

As with all musculoskeletal presentations, pain that is persistent/constant, progressively worsening, non-mechanical, worse at night, or with systemic symptoms……consider investigation.

Before referral

Initial management should be patient led conservative intervention. It can include but is not limited to;

1. OTC pain medication (NSAIDs preferable if patients can tolerate)
2. Rest from painful activities
3. Exercise gently (see links below)
4. If hip osteoarthritis, consider using the shared decision making tool: https://cks.nice.org.uk/topics/osteoarthritis/diagnosis/assessment/
5. The GetUBetter app: https://remedy.bnssg.icb.nhs.uk/adults/orthopaedics/getubetter-app/
6. Weight loss can have a significant impact on lower limb pain, and there is a wealth of evidence on the benefits of exercise, particularly in lower limb OA.
7. Escape Pain is a useful exercise programme for knee and hip OA
8. Advice, then physio, then referral to MSKI prior to any lateral hip injection

http://www.sirona-cic.org.uk/advice-information/leaflet-library/musculoskeletal-msk-services/leaflet-corticosteroid-injections/

https://www.nhs.uk/conditions/steroid-injections/

Common Hip Pain Presentations

Hip osteoarthritis:

Usually from age 50. Insidious onset of ache, common in the groin region, together with stiffness. Rarely may present as knee pain. Often exacerbations and remissions. Usually reduced active and passive range of movement, and a limp can become common. Best managed in primary care. Some evidence that exacerbations in more advanced OA can be managed with guided hip joint injections.

https://www.nice.org.uk/guidance/ng226

Lateral Hip Pain syndrome/Greater Trochanteric Pain Syndrome (used to be called trochanteric bursitis).

Pain is usually on the lateral aspect of the hip, usually worse after waking, prolonged standing, and often tender to lie on the affected side. Usually managed with exercises, activity modification and physiotherapy if needed. A local steroid injection in conjunction with exercise management can sometimes help. Refer to MSKI for consideration of this.

https://cks.nice.org.uk/topics/greater-trochanteric-pain-syndrome/

 Anterior hip pain

Other potential MSK causes include hip impingement syndromes and iliopsoas syndromes. MSK practitioners will be adept at diagnosing these.

 Polymyalgia Rheumatica

Can present as usually bilateral hip pain, though the shoulder girdle is more commonly affected. This presents with progressively worsening pain and stiffness. See Remedy Polymyalgia Rheumatica page for further information.

Referred Pain and Medical Causes

Please remember it is extremely common for spinal pain to present as pain over the lateral hip region, as well as gluteal region, and sometimes the groin. There are also a number of potential medical causes including renal referred pain and local causes in the groin.

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