Chronic hip pain and management in adults

Scope

450 patients per 100 000 population present to Primary Care annually with hip pain

25% resolve in 3 months – 35% at 12 months

Pain felt around and attributed to the hip can also be due to spinal or abdominal disorders which should be excluded.

Hip pathology may cause pain felt only at the knee.

In the young adult, Femoro-acetabular impingement (FAI), labral tears and hip dysplasia may cause hip pain, usually felt in the groin.

Trochanteric pain with local tenderness is often due to trochanteric bursitis or abductor tendinopathy. Isolated trochanteric pain due to bursitis or tendonopathy settles in 64% after one year and 71% after five years. Please do not request US guided injections of trochanteric bursitis.

Degenerative hip disease is the most common diagnosis in the adult and is the long-term consequence of predisposing conditions.

Osteoarthritis (OA) may not be progressive and most patients will not need surgery, with their symptoms adequately controlled by nonsurgical measures. Symptoms progress in 15% of patients within 3 years and 28% within 6 years.

Unless red flags are present all patients referred for consideration of arthroplasty due to osteoarthritis will be assessed by a community interface service which provide a holistic assessment of their symptoms and disabilities before being helped to make a decision on the possible treatment options. This assessment will include Oxford hip scoring and patient decision making aids. Treatment options will include lifestyle modifications, physiotherapy, improved general health and well being or surgery.

Please note pre-referral criteria are applicable in this referral and referrals may be returned if this information is not contained within the referral

Please note primary care is requested to follow In Shape for Surgery best practice which can be seen here.

Out of Scope

This policy does not cover:

  • Indications for referral such as infection, acute traumatic event, or malignancy, inflammatory arthritis
  • Paediatric presentations

Assessment

History

Please include detail such as:

  • Pain
  • In the groin, medial thigh or greater trochanter radiating to thigh or knee at rest and/or after activity
  • isolated knee pain
  • Impact on occupation, daily activity or sports (e.g. decrease in walking distance, difficulty in negotiating stairs or performing pedicure)
  • Duration and onset
  • Aggravating and relieving factors
  • Perthes
  • Details of previous surgery

NB: Isolated pain over the greater trochanter due to bursitis or tendonopathy settles in 64% of patients after one year and 71% after five years.

Examination

Examine the hip for tenderness and irritability on movement.

Differential Diagnoses

  • Osteoarthritis
  • Femoroacetabular impingement (FAI)
  • Trochanteric pain

Red Flags

Red Flags which will bypass the Community Interface Service (should be referred urgently to secondary care)

  • Fracture or trauma
  • Suspicion of tumour or evidence of any destructive lesion on radiograph
  • Unexplained, increasing or sudden onset severe pain in a previously replaced joint
  • Any features suspicious of infection, including:
    • Cellulitis over the joint
    • Large effusion and erythema
    • Inflamed scar/wound over a previously replaced joint
  • Inability to walk or weight bear
  • Evidence of new inflammatory arthropathy
  • The following hip conditions:
    • Protrusio acetabula
    • Avascular necrosis of femoral head

Investigations

  • A plain A-P radiograph of the pelvis may be requested to confirm the diagnosis after history and examination if the patient is over 50 years of age OR is younger than this if OA is suspected
  • No further imaging (e.g. MRI or bone scan) is appropriate before referral
  • If inflammatory diagnosis is suspected the patient will need FBC/CRP/ Rheumatoid factor
  • If a reactive cause is considered chlamydia testing should also be added

Management

Mild Symptoms

  • Offer verbal and written information about condition
  • Offer information to support weight loss if people are overweight or obese (BMI greater than 30) as a core treatment
  • Advise on local muscle strengthening and general aerobic exercise as a core treatment
  • Use of shared decision making tools
  • Suggest oral simple analgesia and anti-inflammatory medication
  • Assess need for aids and devices (refer to occupational therapy or physiotherapy) including instruction in using a walking aid
  • Prescribe supervised and evidence based physical therapies - refer to Local Physiotherapy Service

Moderate Symptoms:

Surgery

  • Primary Hip Replacement
  • Hip Resurfacing is commissioned in line with NICE TA 304 (Total Hip Replacement and resurfacing arthroplasty for end-stage arthritis of the hip). Other forms of arthroscopic or open hip surgery are low priority procedures and will only be funded through exceptional cases panel approval

Referral

Referral Criteria

Please note pre-referral criteria are applicable in this referral and referrals may be returned if this information is not contained within the referral.

Consider referral for persistent pain and disability that has not responded to up to 12 weeks of evidence based nonsurgical treatments. This time to include any manual therapy (including physiotherapy) received in primary care (British Association orthopaedics commissioning guide 2016 ).

Unless red flags are present all patients referred for consideration of hip arthroplasty due to osteoarthritis will be assessed by a community interface service which provide a holistic assessment of their symptoms and disabilities before being helped to make a decision on the possible treatment options. This assessment will include Oxford hip scoring and patient decision making aids. Treatment options will include lifestyle modifications, physiotherapy, improved general health and well being or surgery.

Please note primary care is requested to follow In Shape for Surgery best practice which can be seen here.

Referral Instructions

Where the circumstances of treatment for an individual patient do not meet the criteria described above exceptional funding can be sought. Individual cases will be reviewed by the appropriate panel of the CCG upon receipt of a completed application from the patient's GP, consultant or clinician. Applications cannot be considered from patients personally.

Referral Forms

DRSS referral form

Supporting Information

Patient Information

Patient Information for pain arising from the hip in adults

My Health Devon

Hip joint replacements

Hip replacement

NICE OA Guideline

Pathway Group

This guideline has been signed off by the Eastern Locality on behalf of NEW Devon CCG.

Publication date: March 2018

 

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