Acute & MSK · Full case

Hip Pain

NICE NG226True hip vs lateral vs referredSeptic · # · cancer

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; screen for cauda equina symptoms (emergency); 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:

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

Question	Why it matters	Changes what?
🟢 OPEN QUESTION"Point with one finger to where it hurts most — and tell me what it stops you doing."	The single most useful question in hip pain is "where?". Groin/anterior (± thigh/knee radiation) = true hip joint; lateral over the trochanter = GTPS; buttock/posterior = referred spine/SIJ. Margaret points to the groin with thigh/knee radiation — the true joint. The functional impact (stairs, shoes/socks) both supports hip OA and frames management.In SCA: localising by site, and asking what the pain prevents, is efficient and diagnostic.	Groin → hip joint; lateral → GTPS; buttock → spine
Mechanical pattern (OA)"Is it worse with walking and better with rest? Any stiffness first thing, and how long does it last?"	Activity-related joint pain that eases with rest, with short-lived (<30 min) morning stiffness, in someone 45+, is the clinical picture of OA (NICE NG226) — diagnosable without imaging. Prolonged morning stiffness or inflammatory features point elsewhere (inflammatory arthritis, PMR).	Mechanical + brief stiffness → OA (clinical). Prolonged stiffness/inflammatory → other.	Clinical OA — imaging not mandatory
🚩 Sinister features"Any pain at rest or at night that wakes you? Fever? Weight loss? Ever had cancer? Any recent fall?"	The safety core. Constant rest/night pain, fever, weight loss or a cancer history shift the differential to septic arthritis, malignancy (metastasis/primary bone tumour — NG12) or fracture. Margaret has none — but they must be asked. A hot hip with fever is an emergency; deep unremitting bony pain needs imaging.	Rest/night pain, systemic features → cancer/septic work-up. Fall + can't weight-bear → fracture.	Hot hip + fever → emergencyNight/rest pain → imaging (NG12)
Risk factors for specific causes"Any steroid use or heavy alcohol? Previous hip problems as a child? Any back pain or sciatica?"	Steroids/alcohol → avascular necrosis (groin pain, normal early X-ray, needs MRI). Childhood hip disease → secondary OA. Back pain/radiation → referred spinal cause. These tailor the differential and investigation.	Steroids/alcohol → AVN (MRI). Back symptoms → spine. Childhood hip disease → secondary OA.	AVN risk → MRI if X-ray normal
Function, occupation & goals"How is this affecting walking distance, work, sleep, and things like stairs or getting dressed? What would you most like to be able to do again?"	Functional impairment and quality of life — not X-ray appearance — drive the management intensity and the threshold for arthroplasty referral. Eliciting Margaret's goals (and what she's lost) both guides the plan and answers her surgery question meaningfully.	Greater functional/QoL loss despite conservative care → arthroplasty referral.	Function/QoL → conservative vs surgical threshold
Comorbidity & analgesia history"What have you tried for the pain, and do you have any stomach, kidney or heart problems?"	Guides the analgesic ladder (topical NSAID first; oral NSAIDs limited by GI/renal/CV risk; cautious use of others) and flags fitness/risk for any future surgery.	Comorbidity → tailor analgesia; relevant to surgical risk.	Comorbidity → analgesia choice

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 (higher risk after a recent joint injection or with a prosthetic hip)	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. If X-rays are negative but fracture is still suspected, NICE CG124: offer MRI (CT if MRI not available within 24 hours or contraindicated).	Same day: ED / orthopaedics
Malignancy — deep rest/night pain, weight loss, cancer history	Bony metastasis, myeloma or primary bone tumour; pathological fracture risk. Bloods: FBC, calcium, ALP, PSA as indicated; aged 60+ with persistent bone pain (particularly back pain) or an unexplained fracture → FBC, calcium, ESR/plasma viscosity, serum protein electrophoresis and serum free light chains together (NICE NG12).	Urgent imaging + bloods; NG12 pathway
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 (ESR/CRP usually raised but not required)	Steroid-responsive; associated giant cell arteritis is sight-threatening.	ESR/CRP; treat/refer; screen GCA symptoms (new headache, scalp tenderness, jaw claudication, visual disturbance → same-day specialist assessment)
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

For an older adult, hip pain is rarely just about the joint — it is about independence, the fear of "slowing down", and a worry about a big operation. Many arrive having already decided they either need, or dread, a hip replacement. The consultation succeeds by taking the functional loss seriously, giving an honest account of the staged pathway (effective conservative care first, surgery when justified), and anchoring decisions in what the person wants to keep doing — rather than in an X-ray.

🚶 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."

1E — PMH · drug history · social history: what changes management

Question	Why it matters	Changes what?
Blood pressure treatment"Which tablets do you take for your blood pressure — any water tablet, or one ending in '-pril' or '-sartan'?"	Margaret has hypertension. Oral NSAIDs raise blood pressure and cause fluid retention, and an NSAID added to an ACE inhibitor or ARB plus a diuretic (the "triple whammy") is a well-known cause of acute kidney injury. Knowing her regimen before any oral NSAID is started is part of the prescribing decision, not an afterthought.	ACEi/ARB + diuretic → caution with oral NSAID; check U&E, BP
GI, renal, cardiac history"Any stomach ulcers or bleeding, indigestion, kidney problems, heart problems or strokes?"	NG226 asks prescribers to take account of GI, liver, renal and cardiovascular toxicity and risk factors (age, current medication, comorbidity) before an oral NSAID, and to co-prescribe a PPI. A previous GI bleed, heart failure or reduced eGFR moves the plan towards topical treatment, injection and more intensive core therapy.	Shapes the whole drug ladder
Anticoagulants, antiplatelets, SSRIs"Do you take anything to thin the blood — aspirin, clopidogrel, warfarin, apixaban or similar — or an antidepressant?"	NSAID plus anticoagulant, antiplatelet or SSRI multiplies bleeding risk. It also matters if an injection or surgery is considered. The honest answer in many older patients is that an oral NSAID is not a safe option.	Bleeding risk → avoid or protect
Steroids, alcohol, bone medication"Have you ever taken steroid tablets for a long time? How much alcohol do you drink? Have you ever been on a bone-strengthening tablet like alendronate?"	Long-term or high-dose steroids and heavy alcohol use are the classic risk factors for avascular necrosis of the femoral head. Long-term bisphosphonate or denosumab use with new thigh or groin pain raises the possibility of an atypical femoral fracture (MHRA Drug Safety Update, June 2011, bisphosphonates; denosumab carries a similar warning). Steroids also affect bone health and fracture risk.	AVN / atypical fracture → imaging
Falls and bone health"Have you had any falls? Have you ever broken a bone from a simple fall? Did either parent break a hip?"	A painful, stiff hip and an antalgic gait raise the risk of falls, and a fall is how an occult hip fracture presents. NICE NG259 (July 2026; replaced CG146) advises considering fracture-risk assessment in all women aged 65 and over; FRAX without BMD, then the NOGG 2024 thresholds, decide whether a DXA or treatment is needed.	FRAX → NOGG → DXA if needed
Previous hip problems & family history"Any hip problems as a child — a clicky hip, a slipped hip, Perthes'? Does arthritis run in the family?"	Childhood hip disease (DDH, SUFE, Perthes') predisposes to secondary OA at a younger age. A family history of inflammatory arthritis or psoriasis widens the differential if the pattern is not purely mechanical.	Secondary OA / inflammatory
Home, support and roles"Who's at home with you? Any stairs to get to bed or the bathroom? Do you look after anyone, or drive?"	Stairs, a bath without a rail, caring for a partner or grandchildren and dependence on driving all change what "function" means for this person and what support (occupational therapy, aids, adaptations) would help most. They also frame the practical conversation about recovery from any future operation.	OT, aids, social support
Activity, weight and smoking"How active are you day to day? Has your weight changed? Do you smoke?"	Exercise and weight are core treatments (NG226). Smoking and weight matter for surgical risk, but NG226 is explicit that age, smoking, comorbidity and BMI are not reasons to exclude someone from referral for joint replacement — they are part of the risk discussion.	Core treatment targets; surgical optimisation

🎓 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

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 → same-day ED/orthopaedics; X-ray, then MRI if X-ray negative but still suspected (CG124)
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, age >50 (ESR/CRP supportive, not required); any GCA symptoms (esp. visual) → same day

🟢 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; screen for cauda equina symptoms (emergency)

🎓 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

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.

🦵 The hip

Step	What it shows
Gait (antalgic / Trendelenburg)	Antalgic in painful hip; Trendelenburg with abductor/gluteal dysfunction.
Look — deformity, leg length, wasting	Fixed flexion, shortening, quadriceps wasting.
Feel — trochanter, joint line, groin	Tender trochanter → GTPS; groin tenderness → joint.
Move — internal rotation especially	Restricted/painful internal rotation = true hip joint pathology (Margaret); reduced range in OA.
Thomas test / FABER	Fixed flexion; FABER provokes hip/SIJ.

🔎 Don't forget

Check	Why
Spine / SIJ	Buttock pain & referred radicular pain.
Knee	Hip refers to the knee; exclude knee pathology.
Neurovascular	Distal pulses, sensation, power.
Systemic / temperature	Septic arthritis; PMR girdle exam.

🎓 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)

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).

🦴 Imaging — when

Test	Indication
None (clinical OA)	Typical OA picture (45+, activity-related pain, brief stiffness) — diagnose clinically.
Plain X-ray (weight-bearing)	Diagnostic doubt or atypical features, suspected alternative diagnosis, trauma, or pre-surgical planning — not to grade severity or guide non-surgical care.
MRI	Suspected AVN, occult fracture (X-ray negative but suspected), tumour, labral/soft-tissue.
Ultrasound	Trochanteric/soft-tissue assessment; guided injection.

🧪 Bloods — selective

Test	When
FBC, CRP/ESR	Infection, inflammatory arthritis, PMR.
Calcium, ALP, bone profile	Bony metastasis, myeloma, metabolic bone disease.
PSA / myeloma screen	Where malignancy suspected. Myeloma (NG12, aged 60+ with persistent bone pain, particularly back pain, or unexplained fracture): FBC, calcium, ESR or plasma viscosity, serum protein electrophoresis and serum free light chains together (urine Bence Jones only if free light chains unavailable).
U&E, renal	Before NSAID prescribing.

💬 "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

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.

Diagnosis	Discriminating features	Site
Hip osteoarthritis	Groin pain ± thigh/knee radiation, activity-related, brief morning stiffness, restricted painful internal rotation, functional loss (Margaret).	Groin
Greater trochanteric pain syndrome	Lateral pain, tender trochanter, worse lying on it/stairs, internal rotation preserved.	Lateral
Referred spinal / SIJ	Buttock/posterior pain, normal hip exam, lumbar/SIJ signs.	Buttock
Avascular necrosis	Groin pain, steroid/alcohol risk, normal early X-ray → MRI.	Groin
Fracture / septic / malignancy	Trauma + can't weight-bear; hot + fever; rest/night pain + systemic features.	Red flag
Inflammatory / PMR	Bilateral girdle pain, prolonged stiffness; ESR/CRP usually raised (supportive, not required).	Girdle

🚩 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)

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.

Referral	Who / when	Urgency
🔴 Emergency	Septic arthritis; hip fracture.	Same day
Physiotherapy / MSK	First-line for hip OA and GTPS — exercise, load management.	Routine — first-line
Orthopaedics (arthroplasty)	Hip OA with significant impact on quality of life/function despite optimised conservative care; patient ready to consider surgery (NG226 — based on symptoms/function, not X-ray grade).	Routine
Orthopaedics (urgent)	Suspected AVN, occult fracture, tumour.	Urgent
Rheumatology	Inflammatory arthritis; PMR with diagnostic uncertainty.	Soon

🎓 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

Step 7

Management — Expectation · Goals · Exercise & Weight · Analgesia Ladder · Drug Cards · Psychosocial · Follow-Up · Safety-Netting

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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 — Address the patient's expectation first: validate → explain → negotiate

🤝

"Do I need a new hip?" — don't answer yes or no; answer with the pathway and when she would reach each step

Validate — name the expectation

Margaret has come expecting a referral for hip replacement, and possibly an X-ray "to see how bad it is". Her reasoning is sound: she has classic hip OA and real functional loss. Saying so first stops her feeling fobbed off when the plan starts with exercise rather than a surgeon.

"You've clearly thought about this, and you're right that this is arthritis in the hip joint. A replacement is a real option for you at some point, so it's a fair question. Let me explain how we decide when that point is."

Explain — the reasoning, in her terms

NICE NG226 says to consider referral for joint replacement when symptoms substantially affect quality of life and non-surgical management has been ineffective or is unsuitable. The decision is based on clinical assessment, not scoring tools or X-ray grade, and age, smoking, comorbidity and BMI are not reasons to exclude someone. NICE QS87 (statement 7) expects non-surgical core treatments for at least 3 months before referral for joint surgery where clinically appropriate — not an absolute barrier when non-surgical care is unsuitable or impairment is severe. The core treatments work for many people, and they also help whoever does go on to surgery, because stronger muscles make recovery easier.

"We decide on surgery by how much the hip is limiting your life once the simpler treatments have had a fair go, not by how the X-ray looks. The exercises aren't a hoop to jump through. They often help enough on their own, and if you do end up having the operation, being stronger beforehand makes the recovery quicker."

Negotiate — something concrete today, and a date

She leaves with physiotherapy (or self-referral details), a pain-relief plan, practical aids, and a booked review with a clear rule: if the hip is still substantially limiting her life despite this, the referral is made. NG226 itself sets no fixed trial period, but QS87 expects at least 3 months of core treatment first. If she already has severe limitation and non-surgical treatment clearly does not suit her, an earlier referral is a clinical judgement to document.

"Here's the deal I'd suggest: physio and exercises starting now, the right painkiller, and some help around the house. I'll see you again in about 6–8 weeks to see how it's going, and we'll make the decision at around three months: if it's still stopping you doing the things that matter, I'll refer you to the orthopaedic team, and you and the surgeon decide on the operation together. Does that feel fair?"

Key principle: The failure modes are opposites: "yes, I'll refer you" before any core treatment, or "you just have to live with it". Both lose marks and both let the patient down. The pathway answer ("not yet, and here's exactly what would make it yes") respects her question, is honest about surgery, and keeps her in charge of the timing.

7B — Why treatment matters: goals tailored to this patient

Treatment goals — Margaret's, not the X-ray's

Put on her own shoes and socks againManage the stairs at home safely Walk further before the groin pain stops herSleep without the hip waking her Therapeutic exercise done most days, long termWeight loss if overweight (10% better than 5%) Pain relief that is safe with her blood pressureClear, shared decision on referral at review

Motivational language — tailored to Margaret

"You told me the thing you hate most is not being able to put your own shoe on. Let's make that the test. If in a couple of months you can do it more easily, the plan's working. If you can't, that tells us it's time to talk to the surgeon."

"The muscles around your hip are like scaffolding. When they're strong, the joint takes less of the strain. Nothing we do will wear the joint out faster. Keeping still is what makes it stiffer."

≥45 · ≤30 min

Clinical OA diagnosis: aged 45+, activity-related joint pain, no morning stiffness or stiffness ≤30 min. No imaging needed for a typical case (NICE NG226)

10% > 5%

If overweight, any weight loss helps, but losing 10% of body weight is likely to be better than 5% (NICE NG226)

Do not offer

Strong opioids, glucosamine, intra-articular hyaluronan, acupuncture/dry needling, electrotherapy incl. TENS (NICE NG226)

2–10 weeks

Typical duration of relief from an intra-articular corticosteroid injection. Explain it is short-term only (NICE NG226)

24 h

Suspected hip fracture with negative X-rays: offer MRI; if MRI not available within 24 hours or contraindicated, consider CT (NICE CG124)

60+

Aged 60+ with persistent bone pain (particularly back pain) or unexplained fracture: FBC, calcium, ESR/PV, serum protein electrophoresis + serum free light chains together for myeloma (NICE NG12)

≤50 · 120

If someone is already on opioids: ideally ≤50 mg/day oral morphine equivalent; specialist advice before escalating towards 120 mg/day (local high-dose opioid guidance)

65+

Consider fracture-risk assessment in all women aged 65 and over (NICE NG259), with FRAX results interpreted against the NOGG 2024 thresholds

3 months

After a hip replacement, the DVLA needs to be told only if the person is still unable to drive 3 months after the operation (GOV.UK, surgery and driving)

7C — Non-medication management: the NG226 core — mechanism + evidence + target

📘 Education & self-management

Explain OA and its course; tailored advice; encourage activity and pacing; support devices (walking aid, raised seat/shoe-horn) and footwear where helpful. Reassure that exercise is protective, not harmful.

🏋️ Therapeutic exercise

The cornerstone. Muscle strengthening and aerobic exercise, ideally physiotherapy-guided; improves pain and function. Maintain long-term.

⚖️ Weight management

Where overweight, weight loss reduces load and improves symptoms; offer support.

NICE NG226 makes therapeutic exercise and, where relevant, weight management the core treatment for everyone with OA, whatever the joint, age or severity. Drugs are adjuncts to these, never a replacement. Manual therapy is only for hip or knee OA, and only alongside exercise. Walking aids support independent mobility. NG226 also lists treatments not to offer. Knowing that list saves patients money and false hope.

🏋️

Therapeutic Exercise (Core — NG226)

Target: most days, long term; physio-led programme to start

Mechanism

Strengthening the hip abductors, extensors and quadriceps improves joint control and shock absorption. Aerobic activity raises the pain threshold and improves general fitness, mood and sleep. Range-of-motion work slows the loss of internal rotation and flexion that makes shoes and socks so hard. Pain relief comes from better muscle function and less sensitisation, not from "repairing" cartilage.

Practical

Refer to MSK physiotherapy, or give self-referral details where available, for a tailored programme combining local strengthening with general aerobic exercise. Group programmes such as ESCAPE-pain (hip and knee) are available in many areas. Warn that exercise may ache at first and takes weeks to help. An ache that settles within a day is acceptable. Cycling, swimming and water-based exercise suit painful weight-bearing.

NICE NG226: offer tailored therapeutic exercise to all people with OA

⚖️

Weight Management

Target: if overweight, a goal she chooses; 10% likely better than 5%

Mechanism

Load across the hip during walking and stair-climbing is several times body weight, so modest weight loss cuts joint load disproportionately. Adipose tissue is also metabolically active and contributes to low-grade inflammation and pain sensitivity.

Practical

Weigh her and ask permission to discuss it. Advise that weight loss improves pain, function and quality of life. Help her choose a realistic goal, and signpost to local weight-management services (e.g. NHS Digital Weight Management Programme if eligible). Weight is also part of the pre-operative conversation, but it is never a gate to referral.

NICE NG226: any loss helps; 10% of body weight likely better than 5%

🦯

Walking Aids, Aids & Adaptations

Target: safe independent mobility at home and outside

Mechanism

A walking stick held in the hand opposite the painful hip shifts load away from the joint and reduces abductor effort through each stride. Long-handled shoe horns, sock aids, raised toilet seats and chair raisers reduce the deep hip flexion that OA makes painful. Rails reduce fall risk.

Practical

Show her how to use a stick in the opposite hand and set it to wrist height. Refer to occupational therapy or social care for a home assessment if stairs, bathing or dressing are difficult. Suitable cushioned footwear helps. For Margaret, a sock aid and long shoe horn address her most frustrating limitation today.

NICE NG226: consider walking aids for lower-limb OA

📘

Information & Self-Management

Target: she can explain her condition and her plan back to you

Mechanism

Beliefs drive behaviour. The "bone on bone, worn out" story leads to fear of movement, inactivity, weakness and more pain. An accurate account (OA is common, variable, not inevitably progressive, and movement helps) builds self-efficacy and makes the exercise plan more likely to stick.

Practical

Give tailored verbal and written information at diagnosis and at follow-up (e.g. NHS and Versus Arthritis hip OA resources). Agree functional goals. Explain pacing: spread activity through the day rather than "boom and bust". Explain that flares happen and are not signs of damage. Ask about sleep and mood, which amplify pain.

NICE QS87: tailored information and self-management support

🤲

Manual Therapy (Adjunct Only)

Target: only alongside an exercise programme

Mechanism

Mobilisation, manipulation and soft-tissue techniques can give short-term improvements in pain and range of movement. That can make it easier to engage with exercise, but it does not replace it.

Practical

If her physiotherapist offers hands-on treatment, it should sit within an active programme. Paying for repeated passive treatment on its own is not supported by the evidence. Explain this gently if she mentions private manipulation.

NICE NG226: consider manual therapy for hip/knee OA only with exercise

🚫

What Not to Spend Money On

Target: redirect effort to exercise and weight

Evidence

NG226 says do not offer glucosamine, intra-articular hyaluronan, acupuncture or dry needling, or electrotherapy (including TENS, ultrasound and interferential) for OA. Arthroscopic lavage and debridement are also not offered. Many patients have already bought supplements or a TENS machine.

Practical

Ask what she has tried and bought, without judgement. Explain the evidence, and suggest putting the money and effort towards something that works, such as a gym or pool membership, an exercise class or a good pair of shoes. If she finds something harmless helpful, she can keep it alongside, not instead of, the core treatment.

NICE NG226 "do not offer" list — a frequent SCA and review point

7D — Prescribing guide: NICE NG226 analgesia ladder (adjuncts to the core) · surgery

NICE NG226 (2022) positions every drug as an adjunct to exercise and weight management, at the lowest effective dose for the shortest time. For the knee, a topical NSAID is offered first. For the hip, NG226 says only to consider a topical NSAID. It is a deep joint, so many patients go on to an oral NSAID with a PPI. Paracetamol and weak opioids are not for routine use. Strong opioids are not offered for OA at all. Doses per SPC.

Step 1 — Topical NSAID (Consider for the Hip)

Ibuprofen or diclofenac gel — dose per SPC

NG226: offer for knee OA; consider for OA of other joints, including the hip
Minimal systemic absorption, so a sensible first try in an older patient with hypertension or other comorbidity
Apply over the groin/anterior hip regularly for a fair trial of 2–4 weeks, then judge it by function
If no useful effect, don't persist. Move to Step 2 if suitable

Be honest: evidence for topical NSAIDs is strongest for superficial joints such as the knee. Margaret should know it may not reach the hip well.

Step 2 — Oral NSAID + PPI

e.g. naproxen or ibuprofen, with omeprazole or lansoprazole — choice and dose per SPC

NG226: when topical treatment is ineffective or unsuitable, consider an oral NSAID at the lowest effective dose for the shortest possible time, and offer a PPI alongside
Take account of GI, liver, renal and cardiovascular risk, age, and current medication before starting
For Margaret: check her antihypertensives (ACEi/ARB + diuretic = "triple whammy"), baseline U&E/eGFR and BP; recheck BP at review
Intermittent use around flares or activity is often better than continuous use

Avoid or seek alternatives with previous GI bleed/active ulcer, heart failure, significantly reduced eGFR, or anticoagulation (see drug cards).

Step 3 — Intra-articular Corticosteroid

Usually image-guided for the hip — via MSK interface / orthopaedics / radiology

NG226: consider when other drug treatments are ineffective or unsuitable, or to support therapeutic exercise
Explain relief is short-term, typically 2–10 weeks (NG226). Use the window to exercise
Transient rise in blood glucose in diabetes; small infection risk
If replacement is likely soon, discuss timing with the orthopaedic team. Many units prefer no hip injection in the months before surgery (local policy)

Unlike the knee, the hip is not a joint GPs routinely inject blind — refer for a guided injection.

Paracetamol & Weak Opioids — Not Routinely (NICE NG226)

NG226: do not offer paracetamol or weak opioids routinely for OA, unless they are used infrequently for short-term pain relief and all other pharmacological treatments are contraindicated, not tolerated or ineffective
This is a change from older practice, when paracetamol was the default first step. The evidence showed little benefit for OA pain
If Margaret already takes paracetamol and finds it helps occasionally, discuss it rather than stopping it abruptly. It should not be the plan
Weak opioids (codeine, co-codamol) cause constipation, drowsiness, falls and dependence (MHRA Drug Safety Update, September 2020, on dependence and addiction) with limited benefit

Strong Opioids — Do Not Offer for OA (NICE NG226)

NG226: do not offer strong opioids to manage osteoarthritis. Risks outweigh benefits
If someone arrives already on regular opioids: review functional benefit. If it isn't documented, agree a slow, supported taper rather than another repeat
Where opioids are being prescribed for any reason, Opioids Aware (2026) advises ideally no more than 50 mg/day oral morphine equivalent, with specialist advice before escalating towards 120 mg/day
When pain is uncontrolled despite optimised core treatment, the answer is referral (injection or surgical opinion), not escalating opioids

💊 Analgesia ladder

Step	Detail
Topical NSAID	NG226: offer for knee OA; for the hip (another joint) it is "consider" — a deep joint, so benefit is less certain. Reasonable first try, especially with comorbidity.
Oral NSAID	Lowest effective dose, shortest possible time, with a PPI (NG226); mind GI/renal/CV risk.
Paracetamol / weak opioids	NG226: do not offer routinely — only if used infrequently for short-term relief and all other drug treatments are contraindicated, not tolerated or ineffective.
Intra-articular steroid	Short-term relief option for a flare (often image-guided for hip).
Avoid	Strong opioids — NG226: do not offer for OA (any duration); glucosamine — do not offer; chondroitin not recommended.

🦴 Surgery & follow-up

Element	Detail
Joint replacement	Highly effective for pain/function; refer when QoL/function significantly affected despite optimised conservative care; decision based on symptoms not X-ray.
Shared decision	Discuss benefits/risks, recovery, timing; patient-led.
Review	Reassess response, function, analgesia tolerability; adjust; safety-net for red flags.
Optimise for surgery	Manage comorbidity, weight, smoking before any operation.

7F — Drug reference cards: hip OA analgesia (adjuncts to the core)

Topical NSAID

Ibuprofen gel · Diclofenac gel

Consider first (hip)Dose per SPC and local formulary

✓ Prefer when

A first drug to try alongside exercise, particularly in older people or with comorbidity that makes oral NSAIDs risky

NG226: offer for knee OA; consider for other joints including the hip

✗ Avoid / caution

Broken or inflamed skin at the site; hypersensitivity to NSAIDs or aspirin (including NSAID-exacerbated asthma)

Avoid sun exposure on treated skin with some preparations (per product/SPC); don't combine with occlusive dressings

⚠ Side effects

Local skin irritation or rash; systemic effects are rare because absorption is low

🔬 Monitor

Function-based response at 2–4 weeks. If no useful effect, stop it rather than continuing indefinitely

💬 Counselling

"Rub it gently over the front of the hip and groin as directed, and wash your hands afterwards. The hip is quite deep, so this works better for some people than others. Give it a couple of weeks and judge it by what you can do, like the stairs and your shoes."

Say "consider", not "offer", for the hip, and be honest about the limited evidence for deep joints. Doing that, and using the patient's functional goal as the test, scores on both Tasks and Relating to Others.

Oral NSAID

Naproxen · Ibuprofen (others per SPC/local formulary)

Step 2 — with PPILowest dose, shortest time — per SPC

✓ Prefer when

Topical treatment ineffective or unsuitable, and GI, renal and CV risk is acceptable after assessment (NG226)

Intermittent use around flares or planned activity (e.g. before physiotherapy)

✗ Avoid / caution

Active peptic ulcer or GI bleeding; severe heart failure; NSAID hypersensitivity; significantly reduced renal function (per SPC)

Age 65+; previous GI bleed; anticoagulant, antiplatelet or SSRI; ACE inhibitor/ARB plus diuretic ("triple whammy" AKI risk); established CVD; uncontrolled hypertension; dehydration or intercurrent illness (sick-day advice)

⚠ Side effects

Dyspepsia, peptic ulceration and GI bleeding; fluid retention and raised BP; acute kidney injury; increased cardiovascular thrombotic risk

🔬 Monitor

Baseline U&E/eGFR and BP; BP and GI symptoms at review; periodic U&E if used regularly; review need at every repeat

💬 Counselling

"Take it with food, and take the stomach-protecting capsule with it every day you're taking the anti-inflammatory. Stop it and contact us if you get indigestion, black or tarry stools, vomiting, or swollen ankles. If you're ever unwell with vomiting or diarrhoea, stop it until you're better. We'll check your blood pressure and kidney test."

Naming the PPI, the blood pressure and kidney check, and sick-day rules in one breath shows the examiner you have weighed risk. It matters more for Margaret because she has hypertension.

Proton Pump Inhibitor (Gastroprotection)

Omeprazole · Lansoprazole

With any oral NSAIDDose per SPC and local formulary

✓ Prefer when

NG226: offer a PPI alongside an oral NSAID for OA

Stop the PPI when the NSAID stops, unless there is another indication

✗ Avoid / caution

Interactions (e.g. omeprazole with clopidogrel; check SPC); long-term use without a continuing indication

⚠ Side effects

Headache, GI upset; with long-term use, hypomagnesaemia, C. difficile infection and a small increased fracture risk (relevant in an older woman with a painful hip)

🔬 Monitor

Review the indication at every NSAID review. Consider magnesium if long-term use is combined with digoxin or diuretics

💬 Counselling

"This capsule protects your stomach from the anti-inflammatory. Take it every day you take the other tablet. When you stop the anti-inflammatory, you can usually stop this too."

A PPI co-prescribed with an oral NSAID is a concrete NG226 point that examiners look for. Leaving it out is a common prescribing error.

Intra-articular Corticosteroid (Hip)

Methylprednisolone acetate · Triamcinolone — image-guided

Step 3 — targeted add-onAgent/dose per SPC & local practice

✓ Prefer when

Other drug treatments ineffective or unsuitable, or to give a window for exercise (NG226)

A bad flare in someone for whom oral NSAIDs are unsafe

✗ Avoid / caution

Suspected joint or skin infection; bacteraemia; hypersensitivity

Diabetes (transient hyperglycaemia); anticoagulation (per local procedural policy); replacement expected soon (discuss timing with orthopaedics)

⚠ Side effects

Post-injection flare; facial flushing; transient rise in glucose; rare septic arthritis; benefit wears off, typically within 2–10 weeks

🔬 Monitor

Diabetics: closer glucose monitoring for a few days. Safety-net for a hot, swollen, very painful joint or fever after injection. Review function at 4–6 weeks

💬 Counselling

"The injection is done under a scan to get it into the right place. It usually eases the pain for a few weeks up to a couple of months. That's the time to push on with your exercises. If the hip becomes hot, very painful or you feel feverish afterwards, get seen the same day."

Describing the injection as a short-term window for exercise, rather than a treatment on its own, matches NG226 and sets realistic expectations.

Paracetamol · Weak Opioids

Paracetamol · Codeine · Co-codamol

Not routinely (NG226)Dose per SPC and local formulary

✓ Only when

Used infrequently for short-term pain relief AND all other drug treatments are contraindicated, not tolerated or ineffective (NG226)

✗ Avoid / caution

Routine or regular use for OA (NG226)

Codeine: older people (falls, confusion, constipation), respiratory disease, co-prescribed sedatives; variable effect because of CYP2D6 metabolism. Paracetamol: low body weight, hepatic impairment, alcohol excess (dose per SPC)

⚠ Side effects

Opioids: constipation, nausea, drowsiness, dizziness, falls, dependence (MHRA Drug Safety Update, September 2020)

🔬 Monitor

Frequency of use; functional benefit; bowels; falls. Any regular use should prompt review and a plan to stop

💬 Counselling

"Paracetamol and codeine used to be the go-to tablets for arthritis. The research now shows they don't do much for arthritis pain, and codeine can cause constipation, drowsiness and falls. So they're not the plan. At most, they're for the odd bad day if nothing else suits you."

Candidates who reflexively start co-codamol lose Tasks marks. Explaining why NICE NG226 moved away from paracetamol, without dismissing what she already uses, keeps Relating to Others intact.

Strong Opioids · Glucosamine

Morphine, oxycodone, tramadol*, patches · Glucosamine (OTC)

Do not offer (NG226)—

✗ Do not offer for OA

Strong opioids: do not offer to manage OA (NG226)

Glucosamine: do not offer (NG226). Explain rather than prescribe if she is buying it

*The NG226 evidence review classes tramadol as a strong opioid, consistent with the SPC (by receptor activity it is sometimes called weak). Its serotonergic, seizure and dependence risks make it unsuitable as a "safer" option in older people

⚠ If already on a strong opioid

Review functional benefit; agree a slow, supported taper if it is not documented; don't stop abruptly. Opioids Aware (2026): ideally ≤50 mg/day OME, specialist advice before escalating towards 120 mg/day

🔬 Monitor

Total daily OME; sedation; falls; constipation; co-prescribed benzodiazepines or gabapentinoids (respiratory depression); mood

💬 Counselling

"Strong painkillers like morphine aren't used for arthritis now. They don't improve how far people can walk in the long run, and they bring real risks, especially falls at our age. If the pain gets beyond what we can manage safely, the next step is to see the specialist, not a stronger tablet."

Saying "no" to strong opioids, giving the reason, and naming what comes instead (injection or surgical opinion) is a clear Tasks point.

7G — Psychosocial impact: independence, driving, family & identity

🤝

Hip OA — the woman who is "slowing down" and afraid of what comes next

For Margaret the hip is a question about independence: can she still look after herself, her home and the people she cares for? The management plan works best when it is built around those things.

🏠

Independence & Home

Stairs, bathing, dressing and getting in and out of low chairs and cars are where hip OA bites first. Losing them feels like the start of losing independence. Practical aids and an occupational therapy assessment can restore a surprising amount quickly, and show her the plan is doing something today.

"Let's start with the things that frustrate you most at home. A sock aid, a long shoe horn and a raised seat can make a real difference this week while the exercises build up."

🚗

Driving and the DVLA

Hip OA itself rarely needs DVLA notification, but she must be able to control the car safely, including an emergency stop. After a hip replacement, the GOV.UK surgery-and-driving guidance says the DVLA needs to be told only if she is still unable to drive 3 months after the operation. She should also tell her insurer. The surgical team advise when she can return to driving. Many people resume at around 6 weeks, but it is individual.

"Right now, if you can get in and out and do an emergency stop comfortably, you're fine to drive. If you have the operation, the team will tell you when it's safe. You'd only need to tell the DVLA if you still couldn't drive three months afterwards."

👨‍👩‍👧

Family & Caring Roles

Many women of Margaret's age are carers, whether for a partner, grandchildren or a parent. Pain that limits lifting, walking or driving threatens that role and can bring guilt. Planning for any operation (who helps at home for the first weeks) is easier if it starts early. A carer's assessment may be needed if she is the main carer.

"Is there anyone who relies on you day to day? If we do head towards an operation, it helps to plan early for the first few weeks afterwards."

👤

Identity & "Getting Old"

"Slowing down" often means feeling old before her time. Framing OA as a common, manageable condition where movement helps, rather than a sign of inevitable decline, protects mood and motivation. Low mood and poor sleep amplify pain, so ask about them and treat them in their own right.

"Arthritis in the hip is very common and it doesn't mean the rest of you is wearing out. Lots of people your age get back to walking the dog and gardening with the right plan, and some with a new hip."

😟

Fear of Surgery (and Fear of Being Refused)

Patients often hold two fears at once: dreading an operation, and fearing they will be told they are "too old" or "too heavy" for one. NG226 is clear that age, sex, smoking, comorbidity and BMI are not reasons to exclude someone from referral. They are factors in the risk conversation with the surgeon.

"Nobody will turn you down for a referral just because of your age or weight. Those are things you'd talk through with the surgeon when weighing up the risks, and the decision would be yours."

🤸

Falls, Confidence & Social World

A painful limp and fear of falling shrink a person's world: fewer trips out, less socialising, more isolation. Strength and balance work reduces falls as well as pain. Social prescribing, community exercise groups and ESCAPE-pain-type classes treat the loneliness as well as the joint.

"Have you found yourself going out less because of the hip? Some of the group exercise classes are as much about getting out and meeting people as the exercise. Would that appeal?"

7H — Follow-up schedule

Today — Diagnose, Plan, Start

Clinical diagnosis of hip OA (NG226); red flags documented as absent. Physiotherapy referral or self-referral; aids and OT if needed; weight discussion. Topical NSAID to try, or oral NSAID + PPI after risk check (baseline U&E/eGFR and BP if oral). Written information. Consider FRAX (woman 65+, NICE NG259). Safety-net given and recorded. Review booked.

Red flags documentedPhysio referral

1–2 Weeks — Medication Check (If Oral NSAID Started)

Telephone or pharmacist review: tolerability, GI symptoms, BP, PPI being taken, repeat U&E if risk factors (ACEi/ARB + diuretic, older age). Stop or switch if problems. Confirm physio appointment is booked.

NSAID safetyBP · U&E

6–8 Weeks — Functional Review

Judge by her goals: shoes and socks, stairs, walking distance, sleep. Exercise adherence (the highest-yield question). Weight progress. Analgesia: effect and harms; step down if possible. Consider a guided steroid injection if a flare is blocking exercise. Re-screen red flags. Revisit the surgery question honestly.

Function vs goalsAdherence

~3 Months — Referral Decision Point

If symptoms still substantially affect quality of life and non-surgical treatment is ineffective or unsuitable → refer to orthopaedics for consideration of joint replacement (NG226), using clinical judgement rather than a score. Include function, sleep, independence, treatments tried, comorbidities and her wishes in the letter. If improving → continue, agree the next review.

Refer on quality of lifeNo scoring-tool gate

Ongoing / Around Surgery

While waiting: keep exercising ("prehab"), optimise BP, weight, smoking, anaemia and diabetes control. After a hip replacement: wound and calf-pain safety-net, anticoagulation as prescribed by the hospital, driving advice from the surgical team (DVLA only if unable to drive at 3 months), and a low threshold for same-day review of a hot, painful replaced joint. At least yearly if on regular NSAID: BP, U&E, GI review.

PrehabProsthetic joint infection = same day

7I — Monitoring: function, drug safety and bone health

Memory rule — hip OA review

At every review: function against her goals (shoes/socks, stairs, walking distance, sleep); exercise adherence; weight; NSAID safety (BP, eGFR, GI symptoms, PPI); opioid use (any regular use → review and taper plan); mood and sleep; red-flag re-screen (night/rest pain, weight loss, fever, falls); and the referral question.

What	How	When	Action threshold
Function & quality of life	Patient's own goals; walking distance; stairs; dressing; sleep. Oxford Hip Score can track change	Each review	Still substantially limited despite optimised core treatment → consider orthopaedic referral (NG226). Don't use a score as the referral gate
Exercise adherence	Ask what she is doing and how often; physio feedback	Each review	Lapsed → re-motivate, re-refer, try group/pool options before concluding "exercise failed"
Weight	Weight/BMI	Each review if overweight	Revisit goal; signpost to weight-management support. Never a barrier to referral
Blood pressure	Clinic or home BP	Before and during oral NSAID	BP rising on NSAID → stop or switch; review antihypertensives
Renal function	U&E / eGFR	Baseline; after starting if at risk; periodically if regular use	Falling eGFR or AKI → stop NSAID; review triple-whammy combinations
GI symptoms	Dyspepsia, melaena, haematemesis, anaemia	Each NSAID review	Any GI bleed symptoms → stop NSAID; urgent assessment
Opioid use	Frequency; daily OME; functional benefit	Each review	Any regular use → review; taper if no functional benefit. Ideally ≤50 mg/day OME; specialist advice >90 (Opioids Aware 2026)
Falls & bone health	Falls history; FRAX	At diagnosis; after any fall	Assess fracture risk (NG259) and act on NOGG 2024 thresholds; fall + can't weight-bear → same day
Mood & sleep	PHQ-9 if concern; sleep history	As needed	Treat low mood and poor sleep in their own right. They amplify pain

7J — Safety-netting: exact phrases + medico-legal rationale

⚠ Three scenario-specific phrases — use these verbatim

Why safety-netting matters beyond clinical care

Red flags documented as asked and absent: "no trauma, fever, rest/night pain, weight loss, cancer history, steroid use"

Clinical diagnosis recorded with its basis: "age 68, activity-related groin pain, stiffness <30 min, painful restricted IR — clinical hip OA per NICE NG226; imaging not indicated"

Prescribing rationale: "oral NSAID with PPI, lowest dose shortest time; BP/U&E checked; GI and sick-day advice given"

Surgery discussion: "joint replacement discussed; referral criteria explained (quality of life despite non-surgical care); patient agrees review at 6–8 weeks"

Safety-net recorded: "advised 999/A&E if fall with inability to weight-bear or hot swollen hip with fever; return if night/rest pain or weight loss"

Opioid decisions: "strong opioids not offered in line with NICE NG226; alternatives agreed"

1–2 WeeksNSAID tolerability; BP; U&E if at risk; physio booked

6–8 WeeksFunction vs goals; adherence; analgesia review; red-flag re-screen

~3 MonthsReferral decision on quality of life; or continue and agree next review

RAG — all three domains

Tasks

🟢

Localises groin pain to the joint; clinical OA per NG226 without reflex X-ray; red flags screened (septic, fracture, cancer, AVN, PMR); internal rotation tested; exercise + weight as core; topical considered then oral NSAID + PPI after risk check; no strong opioids/glucosamine; referral criteria stated correctly; FRAX considered; safety-net specific

🟠

OA recognised; partial red-flag screen; exercise mentioned but not central; NSAID without PPI or risk check; referral threshold vague; routine X-ray ordered "to see"

🔴

No localisation; red flags missed; co-codamol or strong opioid started; immediate referral without core treatment or flat refusal; no safety-net

Relating to Others

🟢

"New hip" expectation named and validated; independence concern explored; goals in her words become the test; honest pathway with a date; exercise-is-safe reassurance; surgery fears (and fear of refusal) addressed; checks understanding

🟠

Expectation acknowledged but not negotiated; goals generic; surgery explained in jargon; ICE partial

🔴

"You're not bad enough yet" or "you'll just have to live with it"; X-ray-led "bone on bone" language; no ICE

Key phrases

💭 Diagnosis without an X-ray

"From your story and the way the hip moves, I'm confident this is arthritis in the hip joint. An X-ray wouldn't change the first steps, so we don't need one to get started."

😟 Independence

"What worries you most is losing your independence, and that's exactly what this plan is aimed at: your shoes, your stairs, your walks."

🎯 The new-hip question

"Not today, and here's exactly what would make it yes: if, after we've given these treatments a fair go, the hip is still really limiting your life, I'll refer you, and you and the surgeon decide."

🛑 Declining strong painkillers

"Strong painkillers aren't recommended for arthritis now. They don't help people walk further and they cause falls. If we can't control it safely, the next step is the specialist, not a stronger tablet."

🏋️ Hurt isn't harm

"Exercise may ache a bit to begin with, but it isn't wearing the joint out. The stronger the muscles, the less strain on the hip."

📋 Safety-net

"If you fall and can't put weight on it, or the hip goes hot and swollen with a fever, that's the same day, via 999 or A&E. If the pain starts waking you every night or you lose weight, come back sooner."

Danger zones

Reflex X-ray "to see how bad it is"

Typical OA at 45+ is diagnosed clinically (NG226). X-ray grade correlates poorly with symptoms and doesn't decide referral.

Starting co-codamol as the first step

NG226: paracetamol and weak opioids not routinely. Core treatment first, then topical/oral NSAID + PPI.

Oral NSAID with no PPI and no BP/renal check

NG226: lowest dose, shortest time, with a PPI. Check the ACEi/ARB + diuretic combination in a hypertensive patient.

Refusing referral because of age, BMI or an Oxford score

NG226: refer on quality of life after non-surgical care; don't exclude for age, smoking, comorbidity or BMI; don't use scoring tools to decide.

Reassured by a normal X-ray after a fall

Suspected fracture with negative X-ray → MRI (CT if MRI not within 24 h) — NICE CG124.

"Wear and tear" with night pain and weight loss

Not OA until proven otherwise: imaging and bloods; myeloma bloods at 60+ with persistent bone pain or unexplained fracture (NG12).

Treating lateral pain as hip OA

Lateral, tender trochanter, preserved IR = GTPS: load management and physiotherapy, not joint replacement.

🎓 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; offering strong opioids (NG226: do not offer); routine paracetamol or weak opioids

"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, age >50 (PMR; ESR/CRP supportive, not required). OA management (NG226): education, therapeutic exercise (cornerstone), weight; topical NSAID considered first then oral NSAID at lowest dose for shortest time with a PPI (no routine paracetamol/weak opioids; no strong opioids or glucosamine). Arthroplasty by quality of life/function despite optimised care, not X-ray grade.

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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

Hip Pain · GP Clinical Reasoning Framework v2 · NICE NG226 Osteoarthritis · NICE NG12 Suspected cancer (updated April 2026) · greater trochanteric pain syndrome / childhood-limp guidance

Localise: groin/anterior = true hip joint (refers to thigh/knee); lateral = GTPS; buttock = referred spine · Hip OA is a clinical diagnosis (NG226) — activity-related groin pain + restricted internal rotation; imaging often unnecessary · Exclude red flags: septic (emergency), fracture, malignancy (NG12), avascular necrosis, polymyalgia · Manage with education, therapeutic exercise (cornerstone), weight, topical-then-oral NSAID + PPI (no routine paracetamol/weak opioids; no strong opioids or glucosamine) · Refer for joint replacement by quality of life/function, not X-ray grade

Teaching clinicians why each step matters — not just what to do · Always consult current NICE NG226, CG124, NG259 (replaced CG146) and NG12 (updated April 2026), and the SPC · Clinical judgement takes precedence over any framework

Hip Pain

Red Flags — the hip pain that isn't "just wear and tear"

🚶 Independence & goals

🔧 The staged pathway

🏋️ Exercise isn't harmful

😟 Fear of surgery

Same day / 999

Days

GP Management

🚩 Location first, red flags always

Validate — name the expectation

Explain — the reasoning, in her terms

Negotiate — something concrete today, and a date

Independence & Home

Driving and the DVLA

Family & Caring Roles

Identity & "Getting Old"

Fear of Surgery (and Fear of Being Refused)

Falls, Confidence & Social World

Today — Diagnose, Plan, Start

1–2 Weeks — Medication Check (If Oral NSAID Started)

6–8 Weeks — Functional Review

~3 Months — Referral Decision Point

Ongoing / Around Surgery

Memory rule — hip OA review

⚠ Three scenario-specific phrases — use these verbatim

Why safety-netting matters beyond clinical care

🎭 Patient actor brief — click to practise

Who you are

Hidden concerns (reveal if explored)

Clinical details if asked

Reactions at key moments