Acute & MSK · Full case
Hip Pain
Hip Pain · Clinical Reasoning Framework v2
GP & SCA · NICE CKS · Groin vs lateral vs buttock · OA · trochanteric pain · referred (spine/knee) · red flags (septic, fracture, cancer) · paediatric hip
Where is the pain?Location localises the cause: GROIN/anterior pain = true hip joint (OA, labral, fracture, AVN); LATERAL pain over the greater trochanter = greater trochanteric pain syndrome (gluteal tendinopathy/bursitis); BUTTOCK/posterior = referred from spine/SIJ. "Hip pain" pointing to the buttock is rarely the hip joint
Groin pain + restricted internal rotationTrue hip joint pathology characteristically causes groin pain and early loss of internal rotation of the hip. OA is a clinical diagnosis (NICE NG226) — persistent activity-related joint pain ± short-lived morning stiffness in someone 45+; imaging is often unnecessary to diagnose
Lateral hip = GTPSGreater trochanteric pain syndrome (gluteal tendinopathy ± trochanteric bursitis) causes lateral hip pain, tender over the trochanter, worse lying on that side and on stairs. It is a soft-tissue, not a joint, problem — load management and physiotherapy, not joint replacement
The knee can be the hipHip pathology refers to the knee (and the thigh) — always examine the hip in someone with knee pain and a normal knee, especially children. Conversely buttock pain is often the spine. Examine the joint above and below
Septic hip = emergencyA hot, very painful hip the patient won't move, with fever/systemic upset → septic arthritis: a surgical emergency needing urgent admission, aspiration and IV antibiotics. Don't be reassured by a "normal" X-ray
Can't weight-bear after a fallInability to weight-bear, a shortened/externally rotated leg, or groin pain after a fall (especially in the older/osteoporotic patient) → hip fracture; X-ray, and if negative but clinically suspected, MRI. An occult fracture is easily missed
Night pain / systemic = think cancerUnexplained deep bony pain, rest/night pain, weight loss or a cancer history → consider bony metastasis or primary bone tumour (NICE NG12). Steroid use / alcohol → avascular necrosis. Bilateral girdle pain + stiffness over 50 → polymyalgia rheumatica
The limping child is differentIn children, hip pain/limp has its own urgent differentials by age — DDH, transient synovitis vs septic arthritis, Perthes', and (the classic trap) SUFE in the older/overweight child with knee or thigh pain — all needing prompt assessment (see the Childhood Limp pathway)
📋 Clinical Stem — Hip Pain
A 68-year-old woman with months of deep groin pain and a worsening limp, struggling on stairs and to put on her shoes, asking whether she "needs a new hip"
Margaret Doyle, 68, has 6 months of gradually worsening right groin pain that radiates to the front of her thigh and occasionally the knee. It is worse with walking and weight-bearing, eases with rest, and she now limps, struggles on stairs, and finds it hard to put on her right shoe and sock. She has short-lived morning stiffness. There is no history of trauma, no fever, no rest or night pain that wakes her, no weight loss, and she is otherwise well aside from well-controlled hypertension. She is frustrated at slowing down and asks directly whether she needs "a new hip". On examination she has an antalgic gait and restricted, painful internal rotation of the right hip.
This stem tests the ability to: localise hip pain by site (groin/anterior = true hip joint; lateral = GTPS; buttock = referred spine) and recognise the classic clinical picture of hip osteoarthritis — activity-related groin pain referring to thigh/knee, restricted painful internal rotation, functional difficulty (stairs, shoes/socks) — diagnosing it clinically per NICE NG226 without mandatory imaging; exclude the red flags (septic arthritis, fracture, malignancy, avascular necrosis, polymyalgia) by history and examination; remember that hip pathology refers to the knee; manage OA conservatively first (education, exercise/physiotherapy, weight, analgesia by the topical-first ladder) and explain the role and threshold for joint-replacement referral honestly; and address the patient's specific question about surgery with shared decision-making. The SCA challenge is meeting the "do I need a new hip?" question with a staged, evidence-based plan rather than a premature yes/no.
Scenario A — Hip osteoarthritis (this stem) Groin pain, restricted internal rotation, functional loss. Clinical diagnosis (NG226); conservative first (exercise/physio, weight, analgesia ladder); arthroplasty referral when QoL/function significantly limited despite optimised conservative care.
Scenario B — Greater trochanteric pain syndrome Lateral hip pain, tender over trochanter, worse lying on it/stairs, internal rotation preserved. Load management, physiotherapy, relative rest, ± injection; not the joint.
Scenario C — Referred from spine Buttock/posterior pain ± radiation, normal hip exam, lumbar signs. Treat as back/radicular pain; examine the spine.
Scenario D — Red-flag hip Septic (hot, fever, won't move — emergency); fracture (fall, can't weight-bear, short/externally rotated leg); malignancy (night/rest pain, weight loss, cancer history → NG12); avascular necrosis (steroids/alcohol, groin pain, normal early X-ray → MRI).
Scenario E — Paediatric hip / inflammatory Child with limp (DDH, transient synovitis vs septic, Perthes', SUFE — knee/thigh pain); or inflammatory arthritis / PMR (bilateral girdle pain, stiffness, raised inflammatory markers).
Key variables to adapt for Pain location (groin/lateral/buttock); true joint vs soft tissue vs referred; OA clinical diagnosis; red flags (septic, fracture, cancer, AVN, PMR); referral to the knee; age (paediatric differentials, fragility fracture); function/QoL for arthroplasty threshold; analgesia ladder and comorbidity; the "do I need surgery?" question.
Steps:
1
Step 1
History — Locate the Pain · Mechanical vs Sinister · Function · Red Flags · ICE
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The history's first job is localisation — where exactly is the pain? — because groin points to the true hip joint, lateral to greater trochanteric pain syndrome, and buttock to the spine. Then characterise it as mechanical (OA) versus sinister (rest/night pain, systemic features), and quantify the functional impact that drives management. Margaret's groin pain, radiation to the knee, mechanical pattern and difficulty with shoes/socks are a textbook hip-OA story — but the red flags must still be excluded.
🎓 SCA framing — answer "do I need a new hip?" with a staged plan
"That's exactly the right question, and I'll be honest with you about where surgery fits. First let me work out what's causing it and how much it's affecting your life, because for most people we can do a lot before — and sometimes instead of — a replacement."
Margaret wants a yes/no on surgery. The skill is to honour the question while explaining the staged pathway — diagnosis, optimised conservative care, and replacement when function/quality of life justify it.
1A — Locate, characterise, function, red flags
1B — Red flags
🚨
Red Flags — the hip pain that isn't "just wear and tear"
| Red flag | Why dangerous | Action |
|---|---|---|
| Septic arthritis — hot, very painful hip, won't move it, fever/systemic upset | Joint destruction within days; significant mortality; a surgical emergency. A normal X-ray does not exclude it. | Same-day admission; aspiration + IV antibiotics |
| Hip fracture — fall, can't weight-bear, shortened/externally rotated leg, groin pain | Especially in the older/osteoporotic patient; occult fractures missed on plain film. | Urgent X-ray; if negative but suspected, MRI; orthopaedics/admit |
| Malignancy — deep rest/night pain, weight loss, cancer history | Bony metastasis or primary bone tumour; pathological fracture risk. | Urgent imaging (X-ray ± further); NICE NG12 pathway; bloods (FBC, calcium, ALP, PSA/myeloma as indicated) |
| Avascular necrosis — groin pain, steroid/alcohol use, normal early X-ray | Progressive joint collapse; early diagnosis (MRI) changes outcome. | MRI; orthopaedic referral |
| Polymyalgia rheumatica — bilateral shoulder/hip girdle pain & stiffness, age >50, raised ESR/CRP | Steroid-responsive; associated giant cell arteritis is sight-threatening. | ESR/CRP; treat/refer; screen GCA symptoms |
| Child with hip pain / limp (incl. knee/thigh pain) | Septic hip, Perthes', SUFE, DDH — time-critical; hip refers to the knee. | Urgent paediatric assessment per the childhood-limp pathway |
1C — ICE
💭 Ideas
"What do you think is going on with the hip — and where did the idea of a new hip come from?"
Margaret has concluded she needs surgery. Surfacing her idea lets you confirm the likely diagnosis (OA), validate her reasoning, and explain the staged pathway so the conversation about surgery is informed rather than a blunt yes/no.
😟 Concerns
"What worries you most about it — and what's it stopping you doing that matters to you?"
Her concern is losing independence and slowing down. Naming this lets you anchor the management in her goals and reassure her that much can be done — and that surgery, when needed, is effective.
🎯 Expectations
"What were you hoping we'd decide today about the hip?"
She may expect an immediate referral or X-ray. Naming this lets you explain that OA is a clinical diagnosis, that we optimise conservative care first, and that referral comes when function/quality of life justify it — setting realistic expectations.
1D — Psychosocial context
🚶 Independence & goals
Anchor the plan in what she wants to keep doing.
"What matters is keeping you doing the things you value — walking the dog, the stairs, getting dressed easily. Let's aim the treatment at those, and measure progress by them."🔧 The staged pathway
Explain conservative-first honestly.
"For most people we get good relief with exercises, managing weight and the right painkillers. If that isn't enough and it's really limiting your life, a hip replacement is a very effective operation — but it's a step we take when it's truly needed."🏋️ Exercise isn't harmful
Counter the fear that movement damages the joint.
"It's natural to worry that using it makes it worse, but the right exercise actually strengthens the muscles around the joint and reduces pain — keeping moving is part of the treatment, not against it."😟 Fear of surgery
Address worry about a big operation honestly.
"If we do get to a replacement, it's one of the most successful operations there is for pain and function — and you'd be fully involved in deciding when the time is right for you."🎓 SCA Checkpoint — Step 1TasksRelating to OthersGlobal Skills
Key phrases that score
"Point with one finger to where it hurts most." — localises groin vs lateral vs buttock.
"Any pain at rest or at night, fever, or weight loss?" — screens the red flags.
"For most people we can do a lot before a replacement — let me explain the steps." — staged honesty on surgery.
Deductions
- Not localising the pain (missing GTPS/referred causes)
- Not screening red flags (septic, fracture, cancer, AVN, PMR)
- Forgetting hip refers to the knee
- Promising or refusing surgery without the staged assessment
🔴 Red
No localisation; red flags missed; immediate "you need a new hip" or flat refusal; no function assessment
🟠 Amber
OA suspected; some red-flag screen; function partly assessed; staged pathway vague; ICE partial
🟢 Green
Localises groin → hip joint; clinical OA per NG226; red flags screened; function/goals elicited; staged conservative→surgical pathway explained; ICE all three
2
Step 2
Triage — Emergency (Septic/Fracture) · Urgent (Cancer/AVN/PMR) · Routine
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Most hip pain is mechanical and managed in primary care. Triage pulls out the septic joint and fracture (same day), the cancer/AVN/PMR group (urgent), and the paediatric hip (its own urgent pathway) — leaving OA and soft-tissue causes for routine care.
🔴 Emergency
Same day / 999
Immediate action- Septic arthritisHot hip + fever, won't move → admit; aspiration + IV antibiotics
- Hip fractureFall, can't weight-bear, short/ER leg → urgent X-ray; orthopaedics
- Child with acute limp + systemic upsetUrgent paediatrics (?septic/SUFE)
🟠 Urgent
Days
Don't delay- ?MalignancyRest/night pain, weight loss, cancer history → imaging + NG12
- ?Avascular necrosisSteroid/alcohol, normal X-ray → MRI
- ?PMR/GCAGirdle pain + stiffness + ↑ESR/CRP; screen GCA
🟢 Routine
GP Management
Primary care first-line- Hip OAEducation, exercise/physio, weight, analgesia; arthroplasty by function/QoL
- GTPSLoad management, physiotherapy, ± injection
- Referred spinal painTreat as back/radicular pain
🎓 SCA Checkpoint — Step 2Tasks
Triage rationale
"Reassuringly, there's no sign of infection, fracture or anything sinister — the pattern fits wear-and-tear arthritis of the hip joint, which we manage here, stepping up to a specialist only if conservative treatment isn't enough."
Deductions
- Missing a septic hip / fracture; being reassured by a normal X-ray
- Not recognising AVN/cancer/PMR patterns
3
Step 3
Examination — Gait · Look/Feel/Move · Internal Rotation · Trochanter · Spine & Knee
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Examination confirms localisation: gait, the look/feel/move of the hip with particular attention to internal rotation (lost early in true joint disease), palpation of the greater trochanter (GTPS), and — because of referral — examination of the spine and knee.
🎓 SCA Checkpoint — Step 3TasksGlobal Skills
Narration that scores
"I'll watch you walk, check the movement of the hip — especially rotating it inwards — feel over the side of the hip, and also check your back and knee, because hip problems can be felt in the knee."
Deductions
- Not testing internal rotation; not palpating the trochanter
- Not examining the spine/knee (referral)
4
Step 4
Investigations — Often Clinical · X-ray/MRI When Indicated · Bloods for Red Flags
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OA of the hip is a clinical diagnosis (NICE NG226) and often needs no imaging; investigations are targeted at red flags, surgical planning, and the specific alternatives (AVN, fracture, inflammatory, cancer).
💬 "Shouldn't I have an X-ray or scan?"
"For the typical wear-and-tear hip pain you've got, the diagnosis is clear from the history and examination, and an X-ray usually doesn't change what we'd do first — which is exercises, managing weight, and pain relief. We'd get an X-ray if we were planning surgery, or a scan if I were worried about something less common. So we're not skipping a step — we're doing the right one."
🎓 SCA Checkpoint — Step 4Tasks
Key reasoning
"Arthritis of the hip is something I can diagnose from examining you — we don't need an X-ray to start treatment, but we would get one if we were heading towards surgery."
Deductions
- Reflex X-ray for typical OA; or being falsely reassured by a normal X-ray in suspected septic/occult fracture/AVN
- Not doing inflammatory/bone bloods when red flags present
5
Step 5
Diagnosis — By Location & Pattern · The Mimics
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Name the cause from location, pattern and examination — and keep the red-flag mimics consciously in view.
🚩 Location first, red flags always
Most hip-pain diagnosis is done by asking "where?" and testing internal rotation: groin + restricted internal rotation = true joint (OA in the older patient). For Margaret the formulation is clinical hip OA with significant functional impairment and no red flags — a conservative-first plan with arthroplasty held in reserve for when function and quality of life justify it. The discipline is never to let a comfortable "wear and tear" label hide a septic joint, occult fracture, AVN or malignancy.
🎓 SCA Checkpoint — Step 5Tasks
Explaining it plainly
"This is osteoarthritis of the hip — wear of the joint — which fits your groin pain, the difficulty with stairs and shoes, and the stiffness on examination. The good news is there's a lot we can do, and a replacement is there as a very effective option if and when you need it."
Deductions
- Labelling OA without excluding red flags
- Calling lateral pain "hip arthritis" (it's GTPS)
6
Step 6
Referral — Emergency · Orthopaedics (Arthroplasty) · Physio · Rheumatology
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The everyday "referral" in hip OA is to physiotherapy; orthopaedic (arthroplasty) referral is driven by quality of life and function, not X-ray grade, after optimised conservative care — with the emergencies and the red-flag groups referred urgently.
🎓 SCA Checkpoint — Step 6Tasks
The honest threshold
"We refer for a replacement based on how much it's affecting your life despite treatment — not on how bad the X-ray looks. When the pain and the limits on what you can do outweigh the bother of an operation, that's the time, and you'll decide that with the surgeon."
Deductions
- Referring to surgery before optimising conservative care
- Using X-ray grade rather than function to decide referral
7
Step 7
Management — Education · Exercise · Weight · Analgesia Ladder · Surgery
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Hip OA management rests on the NICE NG226 core: education and self-management, therapeutic exercise (the cornerstone), weight management, and a stepped analgesic ladder (topical first, then cautious oral) — with joint replacement reserved for those whose quality of life and function justify it.
7A — The core (NG226)
7B — Analgesia & surgery
🎓 SCA Checkpoint — Step 7TasksRelating to OthersGlobal Skills
A plan that scores
"Here's the plan: physiotherapy-led exercises which are the most effective treatment, a topical anti-inflammatory to start with, support around the home, and managing weight. We'll review how you get on, and if it's still really limiting your life, I'll refer you to discuss a hip replacement — a decision we'll make together."
Deductions
- Jumping to opioids or to surgery without core conservative care
- Not offering exercise/physiotherapy as the cornerstone
- Recommending glucosamine; long-term strong opioids
Hip Pain — SCA Consultation Scorecard
Localise (groin/lateral/buttock) · clinical OA (NG226) · red flags · exercise-first · arthroplasty by function
0/ 33 pts
Global Skills
Structure, language, responsiveness
0/7
Tasks
Clinical reasoning, diagnosis, management
0/15
Relating to Others
Communication, rapport, shared decisions
0/11
RAG Self-Assessment
🔴 Red
No localisation; red flags missed; reflex imaging or opioids; surgery promised/refused; no exercise
🟠 Amber
OA diagnosed; some red-flag screen; exercise offered; analgesia/surgery threshold partly addressed; ICE partial
🟢 Green
Localises pain; clinical OA (NG226); red flags screened; internal rotation tested; exercise-first + analgesia ladder; arthroplasty by function/QoL; ICE all three; safety-net
Complete the checklist to see your score and feedback
"Doctor, my hip's been getting worse for months — the pain's right here in the groin, I'm limping, and I can hardly get my shoe and sock on. I think I probably need a new hip, don't I?"
Who you are
Margaret Doyle, 68. Six months of gradually worsening right groin pain that goes down the front of the thigh and sometimes to the knee. Worse walking and weight-bearing, better resting. You now limp, struggle on stairs, and find it hard to put on your right shoe and sock. A bit of morning stiffness that wears off quickly. No injury, no fever, no pain at night that wakes you, no weight loss. Otherwise well (blood pressure controlled). You're frustrated at slowing down and have decided you probably need a hip replacement — you want to know if you'll be referred.
Hidden concerns (reveal if explored)
Independence (main): you're worried about becoming less able and reliant on others.
Fear of surgery: you both want and dread an operation; reassurance about its effectiveness and that you decide the timing helps.
Worry it's "something worse": if asked, you're mildly reassured to be told there are no warning signs of anything sinister.
Clinical details if asked
- Groin pain, radiating to front of thigh/occasionally knee; mechanical (worse walking, better rest)
- Short morning stiffness (<30 min); limp; hard to do stairs and shoes/socks
- No trauma, fever, rest/night pain, weight loss; no steroid use, minimal alcohol; no cancer history
- On examination: antalgic gait; painful, restricted internal rotation of the right hip
- Otherwise well; hypertension controlled; no stomach/kidney problems (so NSAIDs okay)
Reactions at key moments
- On "no need for an X-ray yet": initially surprised, reassured by the explanation.
- On exercise being the main treatment: a little sceptical ("won't using it make it worse?") → reassured.
- On the staged surgery pathway: accepts it once told surgery remains an effective option when needed and she'll decide the timing.
- Challenge line: "So you're not going to refer me for a new hip today?"
"So you're not sending me for a new hip then? I was sure that's what I needed — are you saying I just have to put up with it?"
Resolution: Margaret is satisfied if the GP: (1) localises the groin pain to the hip joint and diagnoses OA clinically (NG226) without an unnecessary X-ray; (2) screens and excludes the red flags and remembers hip refers to the knee; (3) explains the staged pathway honestly — exercise/physiotherapy as the cornerstone, weight, a topical-first analgesia ladder; (4) frames arthroplasty referral around quality of life/function after optimised conservative care, with her deciding the timing, rather than a blunt yes/no today; (5) anchors the plan in her goals and reassures that exercise is safe and surgery effective. She's unsettled if simply told to "put up with it", referred prematurely, or given an immediate yes/no without explanation.
Clinic Quick Reference
Hip Pain — Clinical Decision Framework
Localise · clinical OA (NG226) · red flags · exercise-first
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🔍 1 — Localise
Groin / anterior = true hip joint
OA (restricted internal rotation), labral, AVN, fracture. Refers to thigh/knee.
Lateral = GTPS · Buttock = spine
Lateral, tender trochanter, internal rotation preserved = GTPS. Buttock/posterior = referred spine/SIJ.
🚩 2 — Red flags · 💊 3 — Manage
Red flags: hot hip + fever (septic → admit); fall + can't weight-bear (fracture → X-ray ± MRI); rest/night pain + weight loss/cancer history (malignancy → NG12); steroids/alcohol + normal X-ray (AVN → MRI); girdle pain + stiffness + ↑ESR/CRP (PMR). OA management (NG226): education, therapeutic exercise (cornerstone), weight; topical NSAID first then cautious oral (avoid long-term opioids, glucosamine). Arthroplasty by quality of life/function despite optimised care, not X-ray grade.
SCA Quick Reference
Hip Pain — Consultation Playbook
Where is it? · clinical OA · exercise-first · honest surgery threshold
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🎯 The three pivots that pass this case
1 · Localise
Groin = joint (OA, restricted internal rotation); lateral = GTPS; buttock = spine. Hip refers to the knee.
2 · Red flags
Septic (emergency), fracture, malignancy (NG12), AVN, PMR — exclude before "wear and tear".
3 · Exercise-first, staged surgery
NG226 core (exercise, weight, topical-first analgesia); arthroplasty by function/QoL, not X-ray.
⛔ Don't skip localisation (lateral pain isn't the joint) · Don't be reassured by a normal X-ray in suspected septic/occult fracture/AVN · Don't forget hip refers to the knee · Don't jump to opioids or surgery before exercise-led care · Refer for replacement by function/quality of life, not X-ray grade