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 tendinopathy 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 (Osteoarthritic Hip Pain CRG).

MRI requests can be made by the Extended Scope Physiotherapist (ESP) or Integrated Clinical Assessment and Treatment (ICAT) clinician; GPs are no longer able to order MRI through the Any Qualified Provider (AQP) process.

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

DRSS will review the referral letter and direct to Orthopaedics if:

  • Under 16 years of age
  • Arthroscopy recommended by an orthopaedic specialist in those under 18 years of age
  • Recent surgery same joint less than six month ago
  • Metal work in situ in the area
  • Previous arthroplasty same joint/joint replacement
  • Inflammatory Arthritis
  • Suspected serious pathology (see Red Flags)
  • Leaking wound/possible infections
  • The following hip condition:
    • Protrusio acetabula

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 (these should receive urgent referral to secondary care, bypassing community assessment):

  • 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
  • Avascular necrosis/osteonecrosis
  • The following hip condition:
    • Protrusio acetabula

Investigations

**ADDENDUM 24/5/21 – Due to the current waits for plain X-rays in some areas, an attached X-ray report will no longer be mandated. However, all referral letters must state that an X-ray has been done or that it has been requested. Please do attach reports if possible as they improve the efficiency of referral triage) **


  • A plain A-P X-ray of the pelvis report should ideally accompany all hip referrals in all those over 55 years of age (independent of suspected aetiology) or younger when OA is suspected.
  • The clinical indications for this are:
    1. to rule OA in or out as a differential for the patient's symptoms
    2. to ensure that deterioration in symptoms isn't due to potential Red Flag conditions e.g., avascular necrosis (an indication for expedited referral).
    3. deterioration in OA can result in more complex and time-consuming operations. If this is known, then the appropriate surgical list time can be allocated, hence avoiding cancellations of procedures later in the list

In addition, an up-to-date X-ray is extremely beneficial for remote/virtual consultations.

Please consider repeating an X-ray if a significant time has elapsed since the last one, or there has been a significant change/progression in your patient’s symptoms. This will aid in remote/virtual consultations and help to avoid delay in diagnosis of differentials/red flag conditions.


  • No further imaging (e.g., MRI or bone scan) is appropriate before referral. MRI requests can be made by the Extended Scope Physiotherapist (ESP) or Integrated Clinical Assessment and Treatment (ICAT) clinician; GPs are no longer able to order MRI through the Any Qualified Provider (AQP) process.
  • If inflammatory diagnosis is suspected please check 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 or topical agents
  • 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:

Referral

Referral Criteria

  • Red Flags will bypass the Community Assessment Service (should be referred urgently to secondary care/Emergency Department) 
  • Referral to specialist secondary care:

DRSS will review the referral letter and direct to Orthopaedics if:

  • Under 16 years of age
  • Arthroscopy recommended by an orthopaedic specialist in those under 18 years of age
  • Recent surgery same joint less than six month ago
  • Metal work in situ in the area
  • Previous arthroplasty same joint/joint replacement
  • Inflammatory Arthritis
  • Suspected serious pathology (see Red Flags)
  • Leaking wound/possible infections
  • The following hip condition:
    • Protrusio acetabula

All referrals should include: 

  • History and duration
  • Presence and time of onset of any swelling
  • Instability symptoms or history of overuse
  • Relevant examination findings
  • Relevant investigations

All referrals must include:

  1. Details of persistent pain or disability that has not responded to up to 12 weeks of evidence based nonsurgical treatments. Please include details (including dates) of conservative treatment (e.g., analgesia, steroid joint injection)
  2. A recent course of physiotherapy will be expected unless this is not clinically appropriate (within the twelve months prior to referral). This clinical decision needs to be stated and if it is not then the referral will be returned.
  3. **ADDENDUM 24/5/21 – Due to the current waits for plain X-rays in some areas, an attached X-ray report will no longer be mandated. However, all referral letters must state that an X-ray has been done or that it has been requested. Please do attach reports if possible as they improve the efficiency of referral triage) **

A plain A-P X-ray of the pelvis report should ideally accompany all hip referrals in all those over 55 years of age (independent of suspected aetiology) or younger when OA is suspected.

  • The clinical indications for this are:
    1. to rule OA in or out as a differential for the patient's symptoms
    2. to ensure that deterioration in symptoms isn't due to potential Red Flag conditions e.g., avascular necrosis (an indication for expedited referral).
    3. deterioration in OA can result in more complex and time-consuming operations. If this is known, then the appropriate surgical list time can be allocated, hence avoiding cancellations of procedures later in the list

In addition, an up-to-date X-ray is extremely beneficial for remote/virtual consultations.

Please consider repeating an X-ray if a significant time has elapsed since the last one, or there has been a significant change/progression in your patient’s symptoms. This will aid in remote/virtual consultations and help to avoid delay in diagnosis of differentials/red flag conditions.

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

GP Information

NICE OA Guideline

Patient Information

Patient Information for pain arising from the hip in adults

MyHealth Devon - Hip Pain (Osteoarthritis)

MyHealth Devon - Hip Impingement (Femoroacetabular impingement))

Hip joint replacements

Hip replacement

Pathway Group

This guideline has been signed off on behalf of the NHS Devon Clinical Commissioning Group.

Publication date: April 2019

Updated: June 2021

Last updated: 24-06-2021

 

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