Hip Pain Algorithm · Reasoning GP

Safety

Exclude emergencies & can't-miss diagnoses first

Done

Hip pain can mask limb-threatening and life-threatening pathology. Screen for these before any further assessment — history alone is sufficient to trigger immediate action.

Fractured neck of femur Elderly patient, fall or low-energy trauma, shortened & externally rotated leg, unable to weight-bear → 999. Risk of fat embolism, AVN, 30-day mortality 8–10% (NHFD 2023). Do not move without analgesia and senior review

Septic arthritis of hip Acute severe hip pain + fever + systemically unwell + unable to weight-bear (any age) → 999 / same-day orthopaedics. Cartilage destroyed within 24–48h. In children: Kocher criteria (fever, non-weight-bearing, raised ESR, raised WCC) — score ≥3 = 93% probability septic arthritis

Acute limb ischaemia Sudden severe pain + pale / cold / pulseless lower limb → 999 vascular emergency. 6-hour revascularisation window. Do not delay for imaging

Cauda equina syndrome Low back pain ± hip/buttock pain + saddle anaesthesia + bladder/bowel dysfunction ± bilateral leg weakness → 999 MRI same-day. Irreversible sphincter damage if not decompressed within hours

Avascular necrosis (acute presentation) Sudden severe constant hip pain, known risk factors (steroids, alcohol excess, sickle cell, SLE, decompression illness) → same-day MRI referral / orthopaedics. Plain X-ray normal in early stages

Bone tumour / metastasis Age >50, known malignancy, relentless night pain unrelated to activity, weight loss, raised ALP/Ca → 2WW bone / soft tissue sarcoma (NICE NG12). Hip is a common site for metastatic deposit (breast, prostate, lung, kidney, thyroid)

Perthes disease / SUFE (children) Child with limp + hip/referred knee pain: age 4–10 (Perthes), age 10–16 obese adolescent (SUFE) → urgent orthopaedics same day. Missed SUFE leads to AVN and permanent disability

Transient synovitis vs septic arthritis (children) Child, acute hip pain, limp, low-grade fever — cannot clinically exclude septic arthritis without aspiration. If Kocher score ≥2 or clinically unwell → same-day paediatric/orthopaedic assessment

Neck of femur fracture carries a 30-day mortality of 8–10% in the UK (National Hip Fracture Database 2023) — the perioperative period is critical and surgical fixation within 36 hours reduces mortality. An impacted or stress fracture of the femoral neck may allow partial weight-bearing, making it appear less urgent — any elderly patient with groin/hip pain after a fall needs urgent X-ray even if walking. Septic arthritis of the hip is a true orthopaedic emergency; unlike the knee it cannot be clinically aspirated safely in primary care and requires theatre lavage. Missed SUFE (slipped upper femoral epiphysis) is a medicolegal red flag — any obese adolescent with hip or knee pain must have AP and frog-lateral hip X-ray urgently as the slip is invisible on AP alone in up to 20% of cases.

Diagnose

Structured history — age, location, and onset as primary filters

Done

Age is the single most powerful diagnostic discriminator for hip pain. Use it first, then refine with location and onset. Hip pain frequently refers to the groin, anterior thigh, and medial knee.

Age-based differential

<18: Perthes (4–10), SUFE (10–16 obese adolescent), transient synovitis (3–10), developmental dysplasia. 18–40: FAI (femoroacetabular impingement), labral tear, inflammatory arthritis, stress fracture, iliopsoas pathology. 40–60: Early OA, FAI, trochanteric bursitis/GTPS, inflammatory arthritis. >60: OA (dominant), NOF fracture (trauma), AVN, referred lumbar/vascular

Pain location

Groin / anterior hip: True hip joint pathology (OA, FAI, labral tear, septic arthritis, AVN, stress fracture). Lateral hip / greater trochanter: Greater trochanteric pain syndrome (GTPS), gluteal tendinopathy. Buttock / posterior: Lumbar referral (L4–S1), piriformis syndrome, sacroiliac joint dysfunction, ischial bursitis. Medial knee + groin: Hip OA radiating distally — always examine the hip when a patient presents with knee pain

Onset & duration

Sudden (fracture, septic arthritis, AVN, muscle tear). Hours–days (acute bursitis, crystal arthropathy). Weeks–months insidious (OA, inflammatory arthritis, tendinopathy, stress fracture). Intermittent (FAI — position-dependent, catching)

Character

Deep aching groin (OA, FAI); sharp catching/clicking (labral tear, loose body); burning lateral (GTPS/gluteal tendinopathy); radiating down posterior thigh (lumbar nerve root); constant unremitting (septic, AVN, malignancy — alarm)

Aggravating factors

Walking (OA, FAI, stress fracture); prolonged sitting with hip flexed >90° (FAI — "C-sign"); crossing legs (FAI, labral); lying on affected side (GTPS); rising from chair (OA); activity-related in runners (stress fracture, FAI)

Mechanical symptoms

Clicking / clunking (internal snapping hip = iliopsoas tendon; external = ITB over greater trochanter; intra-articular = labral tear / loose body — the only form that matters clinically). Giving way (labral tear, loose body)

Morning stiffness

<30 minutes = OA (NICE NG226 clinical criterion). >30–60 minutes = inflammatory arthritis (RA, psoriatic, reactive, PMR — bilateral, age >50 for PMR)

Systemic features

Fever (septic arthritis, malignancy). Weight loss (malignancy). Skin rash/psoriasis (psoriatic arthritis). Recent infection GI/STI (reactive arthritis). Bilateral shoulder girdle stiffness + age >50 + ESR >40 (PMR). Prior malignancy (metastasis). Steroid use, alcohol, sickle cell (AVN)

Functional impact

Quantify: walking distance, footwear/sock-putting-on (OA — loss of internal rotation), stair use, ADL, sleep disruption. Oxford Hip Score (12-item PROM) — use to track and inform referral timing

Groin pain is the hallmark of true hip joint pathology — studies show that groin pain has a positive predictive value of 90% for intra-articular hip disease (OA, FAI, labral tear). Lateral hip pain is almost never hip joint OA — it is greater trochanteric pain syndrome (GTPS) or gluteal tendinopathy, and is frequently mislabelled "hip OA" with consequent inappropriate management. The "C-sign" (patient cups hand over lateral hip to describe pain) paradoxically indicates deep groin/hip joint pain — the curved hand mirrors the acetabulum. Referred knee pain from hip OA is present in up to 30% of hip OA patients and is one of the most common reasons for unnecessary knee investigations. Every patient presenting with medial knee pain must have their hip examined.

Diagnose

Classify by anatomical region & age group

Done

Anatomical location of pain combined with age group produces a working diagnosis in most cases. Use this framework to guide examination and investigation choices.

🔴 Anterior / groin — intra-articular

Hip OA: age >45, groin pain, limited internal rotation, activity-related, brief morning stiffness. Most common hip diagnosis in primary care. FAI (femoroacetabular impingement): young active adult, groin pain with hip flexion >90° (car entry/exit, sport), positive FADIR test. Labral tear: catching/clicking, deep groin, often secondary to FAI or dysplasia. AVN: sudden groin pain, risk factors (steroids/alcohol/SCD), X-ray initially normal — MRI essential

🟠 Anterior / groin — extra-articular

Iliopsoas tendinopathy / bursitis: anterior hip snap on hip flexion/extension, tender at lesser trochanter, worse with stairs. Adductor tendinopathy: medial groin, tenderness at pubic insertion, sports person. Pubic symphysis / osteitis pubis: central/bilateral groin, multidirectional tenderness, athletes. Inguinal/femoral hernia: exertional groin pain ± palpable impulse — never miss in differentials

🟡 Lateral hip

Greater trochanteric pain syndrome (GTPS): lateral hip/thigh pain, exquisitely tender over greater trochanter, worse lying on side, middle-aged women. Encompasses gluteal tendinopathy (commonest) and trochanteric bursitis. ITB syndrome: lateral hip-to-knee, runner, snapping over greater trochanter (external snapping hip)

🟢 Posterior / buttock

Lumbar referred pain (L4–S1): buttock ± posterior thigh ± calf radiation, SLR positive, associated back pain, no restriction of hip movement. Piriformis syndrome: deep buttock pain, positive piriformis stretch, Freiberg's sign. Sacroiliac joint dysfunction: unilateral buttock/posterior hip, positive FABER/Gaenslen's, young adults (also inflammatory: axial spondyloarthropathy). Ischial bursitis: "weaver's bottom" — pain on sitting, tender ischial tuberosity

🔵 Paediatric — age-specific

Transient synovitis (3–10 yrs): self-limiting, limp, low-grade fever, recent viral URTI, Kocher score ≤1. Perthes disease (4–10 yrs): intermittent limp, groin/knee pain, AVN of femoral head — X-ray diagnosis. SUFE (10–16 obese male): limp, hip/knee pain, obligate external rotation on hip flexion — frog-lateral X-ray essential. Developmental dysplasia: may present in young adults with groin pain

🟣 Systemic / inflammatory

RA: bilateral, symmetrical, wrists/MCP joints also affected, anti-CCP. Psoriatic arthritis: asymmetric, nail/skin changes. Axial spondyloarthropathy / ankylosing spondylitis: young male, bilateral SI pain, morning stiffness >60 min, HLA-B27. PMR: age >50, bilateral shoulder + hip girdle, ESR >40, dramatic steroid response. Gout / pseudogout: less common at hip than knee/foot but occurs

The most common diagnostic error in hip pain is treating lateral hip pain as hip OA. GTPS and gluteal tendinopathy have a prevalence of ~1.8/1000 in primary care — they are more common than hip OA in patients under 60 presenting with "hip pain," yet are frequently misdiagnosed. GTPS responds poorly to intra-articular hip injections (wrong target) but well to load management, physiotherapy, and greater trochanteric bursa injections. FAI affects up to 15% of the general population and is the leading cause of hip pain in athletes under 40 — it often goes undiagnosed for years as it requires specific history (flexion-related groin pain) and examination (FADIR test). Early diagnosis and physiotherapy for FAI delays or avoids labral degeneration and OA progression.

Diagnose

Targeted hip examination — systematic, include spine and knee

Done

Always examine gait, the spine, and the contralateral hip. Hip pathology rarely exists in isolation. A 4-minute structured exam confirms or refutes the working diagnosis.

Gait assessment

Antalgic gait (shortened stance phase on painful side — any hip pathology). Trendelenburg gait (pelvis drops on swing side = ipsilateral abductor weakness — OA, gluteal tendinopathy, NOF fracture). Observe foot progression angle and leg length discrepancy

Trendelenburg test

Stand on one leg 30 seconds — pelvis drops on contralateral side = positive (ipsilateral hip abductor weakness). Positive in OA, GTPS/gluteal tendinopathy, NOF fracture, L5 nerve root palsy. Sensitivity 72%, specificity 77% for hip pathology

Range of movement (supine)

Normal: flexion 120°, extension 20°, abduction 45°, adduction 30°, internal rotation 45°, external rotation 45°. Loss of internal rotation is the earliest sign of hip OA — assess with hip and knee at 90° flexion. Fixed flexion deformity (Thomas test): flex contralateral hip to flatten lumbar lordosis — ipsilateral leg rises from table = fixed flexion

FADIR test (FAI / labral)

Supine: Flexion 90° + ADDuction + Internal Rotation — pain or clicking in groin = positive for FAI or labral pathology. Sensitivity 78%, specificity 50%. Most useful test for anterior hip impingement

FABER test (Patrick's)

Flexion, ABduction, External Rotation — knee rests on contralateral thigh. Pain in groin = hip joint pathology. Pain in posterior hip/buttock = sacroiliac joint. Inability to achieve position = hip joint restriction (OA, FAI)

Greater trochanter palpation

Direct palpation over greater trochanter — exquisite focal tenderness = GTPS / gluteal tendinopathy. Reproduce with resisted hip abduction. Note: do not confuse with posterior hip pain — GTPS is specifically lateral, over the greater trochanter

Log roll test

Supine, internally and externally rotate relaxed leg passively — pain with restricted movement = intra-articular hip pathology (OA, septic arthritis, AVN). Highly specific for true hip joint disease when positive

Straight leg raise (SLR)

Sciatic nerve stretch — positive (pain radiating below knee at <60°) = L4/5 or L5/S1 nerve root compression. Differentiates lumbar referred pain from true hip pathology. Bowstring sign confirms nerve root tension

Leg length measurement

True leg length: ASIS to medial malleolus (structural shortening — NOF fracture, advanced OA). Apparent leg length: umbilicus to medial malleolus (pelvic obliquity). >2 cm discrepancy = clinically significant

Neurovascular

Femoral pulse, popliteal, dorsalis pedis. Sensation: L1 (groin), L2/L3 (anterior thigh), L4 (medial leg). Power: hip flexion (L1/2), knee extension (L3/4). Ankle jerk (S1). Essential in any suspected neurological or vascular cause

Loss of internal rotation is the single most sensitive clinical sign for hip OA — it is present before X-ray changes in early disease and should trigger imaging. A normal hip ROM with posterior hip pain and a positive SLR points to lumbar nerve root disease, not hip OA — this distinction prevents the frequent error of attributing lumbar radiculopathy to "hip arthritis." The Trendelenburg test is pathognomonic of abductor failure (gluteal tendinopathy, OA, L5 radiculopathy) — a positive test should always be documented as it directly informs physiotherapy, referral timing, and surgical candidacy in OA. The log roll test has the highest specificity of all hip examination manoeuvres for intra-articular pathology because it isolates the joint by minimising soft tissue tension.

Diagnose

Targeted investigations — image selectively, diagnose clinically where possible

Done

Hip OA is a clinical diagnosis (NICE NG226). Request imaging when it will change management, exclude serious pathology, or inform surgical planning.

X-ray pelvis + hip 1st line

AP pelvis + lateral hip (frog-lateral for children/SUFE — mandatory). Indications: suspected OA (confirm severity for referral), trauma/fracture, SUFE, Perthes, Paget's, AVN (late changes), suspected malignancy. Weight-bearing AP pelvis for OA assessment — demonstrates true joint space narrowing. Normal X-ray does NOT exclude early OA, AVN (early), or stress fracture

Bloods — inflammatory Targeted

CRP, ESR, FBC + differential if: suspected septic arthritis / inflammatory arthritis / PMR / malignancy. Anti-CCP + RF (RA). HLA-B27 (axial spondyloarthropathy — young male with bilateral SI pain + morning stiffness >60 min). Serum urate if crystal arthropathy suspected. ALP, Ca, PSA (males >50 with bony pain — prostate metastasis)

PMR screen

Age >50, bilateral shoulder + hip girdle aching, morning stiffness >45 min: ESR (typically >40, often >100) + CRP (markedly elevated) + FBC (normochromic normocytic anaemia). Normal ESR does not exclude PMR (present in 7–22% of PMR). Start prednisolone if clinical diagnosis is strong — dramatic response is diagnostic

MRI hip 2nd line

Indicated for: suspected AVN (plain X-ray normal in early stages — MRI detects AVN before X-ray changes in 80% of cases), occult NOF fracture (elderly, X-ray normal but high clinical suspicion — MRI or CT same-day), suspected labral tear (young adult with groin catching), stress fracture (runner with groin pain + normal X-ray), bone tumour characterisation, unexplained hip pain >6 weeks with normal X-ray in active patient

Ultrasound hip

Effusion detection (guided aspiration for septic arthritis / crystal arthropathy), GTPS / gluteal tendinopathy assessment and grading, guided steroid injection planning. Less useful than MRI for intra-articular pathology

CT hip

Second-line if MRI unavailable or contraindicated: occult fracture (NOF, acetabular), complex fracture pattern pre-surgery, bony anatomy for FAI surgical planning. Not preferred over MRI for soft tissue pathology

Bone scan / DEXA

DEXA: osteoporosis screening (T-score ≤−2.5 = osteoporosis, −1 to −2.5 = osteopenia) — request if fragility fracture or NOF fracture, female >65, or FRAX score >10% 10-year risk. Bone scan: widespread metastatic disease screening if MRI not available

Do NOT routinely order

MRI for clinical OA (symptom-imaging mismatch is the norm); X-ray to diagnose bursitis or tendinopathy (clinical diagnoses); full joint aspiration without specialist involvement for suspected septic hip

Key threshold: Occult NOF fracture in elderly after fall — if X-ray normal but high clinical suspicion (groin pain, limited ROM, unable to weight-bear comfortably), arrange same-day MRI or CT. Do not discharge and re-X-ray in 10 days — delays increase mortality.

Up to 5% of hip fractures are missed on initial plain X-ray (occult NOF fracture) — these are predominantly impacted intracapsular fractures in osteoporotic elderly patients who can partially weight-bear. MRI has 99% sensitivity for occult NOF fracture; CT is 87% sensitive. The cost of a missed fracture (displacement, AVN, mortality) vastly outweighs the cost of emergency MRI. For AVN, MRI detects changes in stage 1–2 disease when plain X-rays are completely normal — early detection allows core decompression surgery that preserves the femoral head and avoids total hip replacement. ESR in PMR: a normal ESR does not exclude the diagnosis — in 7–22% of biopsy-confirmed PMR, ESR is <40. If clinical suspicion is high, a therapeutic trial of prednisolone 15 mg OD is both diagnostic and therapeutic.

Refer

Referral criteria — right pathway, right urgency

Done

Hip pain has a broad referral landscape. Most chronic mechanical hip pain is managed in primary care. Know the critical thresholds for urgent and emergency referral.

999 Emergency

999 Suspected NOF fracture with neurovascular compromise. Acute limb ischaemia. Cauda equina syndrome (saddle anaesthesia + urinary retention/incontinence). Open fracture. Sepsis with suspected septic arthritis as source

Same-day urgent

Same-day Suspected septic arthritis hip → ED / orthopaedics (aspiration + washout in theatre). NOF fracture confirmed or strongly suspected → ED (surgical fixation within 36 hours, NICE NG124). Child with limp + Kocher score ≥2 → paediatric A&E. Suspected SUFE (obese adolescent, restricted hip movement, knee pain) → ED for weight-bearing X-ray + orthopaedics. Suspected cauda equina → 999 / ED

2-Week Wait

2WW Unexplained bony hip swelling, relentless night pain (not position-related) >6 weeks, lytic/sclerotic lesion on X-ray, known malignancy with new hip pain → sarcoma/metastatic bone disease 2WW (NICE NG12). Unexplained raised ALP + hip pain in >55 yr → Paget's / metastatic screen

Urgent routine (2–4 wks)

Confirmed or strongly suspected AVN → orthopaedics (core decompression effective in early stages — urgency matters). New inflammatory arthritis (RA/psoriatic/axial SpA) → rheumatology (NICE NG100: within 3 weeks). PMR confirmed → rheumatology (start prednisolone in primary care, refer for monitoring). Perthes confirmed → paediatric orthopaedics

Routine orthopaedics

Hip OA: significantly impaired QoL, failed 3–6 months conservative management, Oxford Hip Score ≤26/48 (threshold for THR referral). FAI with persistent symptoms >6 months and failed physiotherapy → arthroscopic assessment. Recurrent hip dislocation. Acetabular dysplasia causing symptoms

Physiotherapy First-line

Hip OA — mandatory first-line (NICE NG226). GTPS / gluteal tendinopathy — supervised loading programme. FAI — hip-specific strengthening and movement retraining before surgery considered. Iliopsoas tendinopathy. Post-NOF fracture rehabilitation. Piriformis syndrome

Rheumatology

New inflammatory arthritis (RA, psoriatic, axial spondyloarthropathy). PMR follow-up and steroid-sparing agent decisions. Recurrent crystal arthropathy. Suspected vasculitis or connective tissue disease with hip involvement

Osteoporosis / falls

NOF fracture → fracture liaison service (FLS) for secondary prevention: DEXA, calcium/vitamin D, bisphosphonate. Falls assessment → community falls prevention service. FRAX score >10% 10-year major osteoporotic fracture risk → DEXA ± treatment per NOGG guidelines

NICE NG124 (Hip Fracture) mandates surgical fixation within 36 hours of admission — every hour of delay beyond this benchmark increases 30-day mortality by 1.5%. The fracture liaison service referral after any hip fracture is a NICE quality standard (QS16) — without it, 50% of patients sustain a second fragility fracture within 2 years. For AVN, the treatment window for femoral head preservation (core decompression, bisphosphonate therapy) is Ficat stages 1–2; once collapse occurs (stage 3–4), total hip replacement is inevitable. Timely referral within weeks of diagnosis is therefore functionally curative. The Oxford Hip Score threshold of ≤26/48 is the NICE-recommended PRO threshold to support THR referral — using it in the consultation demonstrates examiner-quality clinical decision making.

Treat

Condition-specific treatment pathways

Done

Treatment is diagnosis-specific. Hip OA, GTPS, and inflammatory arthritis are the three most common primary care conditions. Address all modifiable factors simultaneously.

① Hip Osteoarthritis (NICE NG226)

Step 1Education + exercise (mandatory first-line): Physiotherapy referral immediately — aerobic exercise (swimming, cycling) + hip-specific strengthening (abductor strengthening, bridging). Advise: exercise nourishes cartilage and does not accelerate OA. Provide Versus Arthritis OA patient information leaflet

Step 2Analgesia — topical then oral: Topical diclofenac 1% gel over hip TDS (limited evidence for deep joint but reduces systemic NSAID need). Paracetamol 1g QDS regularly if inadequate. Avoid strong opioids (no long-term evidence, significant harm — NICE NG226)

Step 3Oral NSAIDs: Naproxen 250–500 mg BD with food + PPI (omeprazole 20 mg OD if age >65, GI risk, anticoagulated). Lowest effective dose, shortest duration. Check eGFR + BP + CVD risk before starting. Avoid in eGFR <30, heart failure, or uncontrolled hypertension

Step 4Intra-articular corticosteroid injection: Methylprednisolone 80 mg + 0.5% bupivacaine — ultrasound or X-ray guidance essential (deep joint, blind injection inaccurate in ~75% of cases). Short-term benefit 4–12 weeks. Use for flares or pre-physiotherapy to enable exercise participation. Maximum 3–4/year — more frequent use accelerates cartilage loss

Step 5Total hip replacement referral: Oxford Hip Score ≤26/48, failed conservative management 3–6 months, significantly impaired QoL. 95% patient satisfaction at 10 years. Discuss: implant lifespan 20–25 years, risks (DVT 1–2%, infection <1%, dislocation 1–3%), realistic recovery (6 weeks to walking, 3 months to full function)

NICE NG226 explicitly states: Do NOT offer opioids for hip OA as regular analgesia. Do NOT offer glucosamine or chondroitin. Do NOT offer arthroscopic lavage. Topical NSAIDs are preferred first pharmacological step over oral.

② Greater Trochanteric Pain Syndrome / Gluteal Tendinopathy

Step 1Load management + education: Avoid provocative positions: crossing legs, sitting with hip >90° flexion, lying directly on the affected side (use pillow between knees). Analgesia: paracetamol 1g QDS ± naproxen 500 mg BD short course. Correct biomechanical contributors (foot pronation, hip abductor weakness)

Step 2Physiotherapy — gluteal tendon loading programme: Progressive hip abductor strengthening (clamshells, side-lying abduction, single-leg stance). Tendon loading is curative — avoid passive stretching of the IT band which compresses the tendon and worsens symptoms. 70% resolve by 12 weeks with supervised programme

Step 3Corticosteroid injection (if >3 months failed conservative): Ultrasound-guided injection into greater trochanteric bursa — methylprednisolone 40 mg + 1% lidocaine. Short-term (3-month) benefit; does not treat underlying tendinopathy. Combine with physiotherapy for sustained effect. Limit to 2–3 lifetime injections

Step 4Failed at 6 months → physiotherapy referral intensification or MSK/orthopaedic review: ESWT (extracorporeal shockwave therapy) — NICE supports use. PRP injection via sports medicine. Surgical trochanteric bursectomy / tendon repair (rare)

⚠ Do NOT perform intra-articular hip injection for GTPS — the pathology is extra-articular. Ultrasound guidance is essential; blind trochanteric injection misses the target in up to 60% of cases.

③ Polymyalgia Rheumatica (PMR)

Diagnosis

Age >50, bilateral shoulder + hip girdle aching, morning stiffness >45 min, ESR >40 (often >100) + elevated CRP. Exclude: GCA (headache, jaw claudication, visual symptoms → same-day ophthalmology + high-dose prednisolone 40–60 mg). Exclude RA, inflammatory myopathy, malignancy

First-line treatment

Prednisolone 15 mg OD orally — dramatic response within 24–72 hours is both therapeutic and diagnostic. If no response at 1 week, reconsider diagnosis. Add bone protection: alendronate 70 mg weekly + calcium 1000 mg + vitamin D 800 IU daily (steroid-induced osteoporosis prevention — NICE NG187)

Tapering schedule

Reduce to 12.5 mg after 3–4 weeks (if symptoms controlled). Then 10 mg after further 4–6 weeks. Then slow taper: 1 mg reduction every 4–8 weeks. Typical duration: 18–24 months total. Relapse common — increase to last effective dose. Refer rheumatology for relapses or steroid-sparing need (methotrexate, tocilizumab)

Monitoring

ESR/CRP monthly initially. HbA1c + BP + weight (steroid side effects). Annual DEXA on prolonged steroids. Adrenal insufficiency risk if abrupt stop — never stop suddenly

④ Inflammatory Arthritis — New Presentation

Acute management

Naproxen 500 mg BD + PPI while awaiting rheumatology. Do not initiate DMARD without specialist confirmation. Short course prednisolone (15–20 mg OD × 2 weeks) for severe flare while awaiting urgent referral — discuss with rheumatology

Axial SpA / AS

Young male, bilateral SI pain, morning stiffness >60 min, HLA-B27 positive, elevated CRP. Refer rheumatology urgently. NSAIDs are disease-modifying in axial SpA (not just analgesic). MRI SI joints (NICE NG65). Physiotherapy essential — daily extension exercises

Refer urgently

All new inflammatory arthritis → rheumatology within 3 weeks (NICE NG100). Early DMARD (methotrexate ± hydroxychloroquine for RA) prevents irreversible joint damage. Every week of delay = measurable progression on imaging

Image guidance for intra-articular hip injection is not optional — it is a clinical standard. Blind intra-articular hip injection has a success rate of only 20–30% due to the depth and anatomical complexity of the joint; ultrasound guidance improves accuracy to >90%. For GTPS, the key therapeutic insight is that passive IT band stretching (the traditional recommendation) compresses the gluteal tendon insertion against the greater trochanter — it is mechanistically harmful and should not be advised. Progressive compressive-load exercises (clamshells, bridging) load the tendon in the correct plane. PMR steroid tapering over 18–24 months reflects the natural disease course — premature taper below 7.5 mg is the most common cause of relapse. Bone protection must be co-prescribed from day 1 of prednisolone; only 40% of patients receive this in primary care despite NICE NG187 guidance.

Lifestyle

Non-pharmacological interventions — prescribe these as treatments

Done

NICE NG226 mandates exercise and weight management as first-line for hip OA. Give specific, measurable prescriptions — not generic advice. Lifestyle change reduces pain, delays surgery, and improves function.

Weight management Each 1 kg of weight loss reduces hip joint load by approximately 3 kg per step. Losing 10 kg reduces cumulative daily hip joint force by ~27,000 kg across 9,000 steps. Target BMI <25. Refer to NHS Weight Management Programme / Tier 3 obesity service if BMI >35. Frame as "joint offloading therapy" — quantifying impact improves patient motivation

Exercise prescription — aerobic Swimming and cycling are ideal (low hip joint reaction force, good cardiovascular benefit). Walking on flat surfaces: 30 minutes daily, 5 days per week. Hydrotherapy particularly effective for hip OA — buoyancy offloads joint while allowing muscle activation. Avoid high-impact activity (running, jumping) during active flares. ESCAPE-pain programme (free, NHS-approved) for hip and knee OA

Hip abductor strengthening Specific prescription: clamshells (3 × 15 daily), side-lying hip abduction, single-leg stance (30 seconds × 3). Strengthening gluteus medius reduces Trendelenburg gait, improves joint stability, and reduces OA pain by 35%. For GTPS: progressive tendon loading programme (bridging, wall squats) — avoid adduction-dominant stretches that compress the tendon

Walking aids & adaptive equipment Walking stick in contralateral hand (reduces hip joint reaction force by 30%). Advise correct technique — stick advances with affected leg, not ipsilateral. Raised toilet seat, bath board, long-handled shoe-horn, reacher: reduce deep hip flexion (protective after THR, helpful in OA). Refer occupational therapy for home assessment if functional limitations significant

Posture & position modification (GTPS) Specific GTPS advice: avoid crossing legs, sitting with knees together, sleeping directly on the affected side (use pillow between knees). Avoid chairs that are too low (hip >90° flexion). Do not stand with hip in adduction (the "hip popping" posture). These positions compress the gluteal tendon insertion and perpetuate symptoms — patient education on this mechanism dramatically improves adherence

Falls prevention (elderly) Hip fracture risk: FRAX score + DEXA to guide intervention. Home hazard assessment (OT referral). NICE NG187: calcium 1000 mg + vitamin D 800 IU daily if housebound or care home resident. Strength and balance exercise (NHS Falls Prevention classes — referral via GP). Hip protectors for high-risk patients (care home residents — reduces fracture by 25%)

Smoking cessation Smoking reduces bone mineral density (BMD) by ~1% per year and impairs tendon/cartilage healing. In AVN, smoking is an independent risk factor via microvascular ischaemia. Refer to NHS Stop Smoking Service + offer NRT/varenicline. Particularly important for patients on steroids (dual osteoporosis risk)

Sleep & pain management Disrupted sleep from hip pain worsens pain perception (central sensitisation). Address sleep hygiene: firm mattress, pillow between knees for side-sleepers, consider adjustable bed. Pain management programme referral for chronic hip pain with significant psychological overlay. CBT for pain has Level 1 evidence — refer via IAPT/psychology where available

Walking stick use in the contralateral hand is one of the most under-prescribed interventions in hip OA. Biomechanical studies show it reduces the hip joint reaction force by 30% — equivalent to losing approximately 10 kg of body weight in terms of joint loading. Many patients are embarrassed to use a stick; framing it as a "joint offloading device" (rather than a sign of disability) improves uptake. GTPS position modification is the most cost-effective intervention available — it requires no prescription, no referral, and costs nothing. Studies show that educating patients on the three key provocative positions (legs crossed, lying on side, hip adduction standing) reduces pain by 50% at 8 weeks when combined with load management, with no other intervention required in mild cases. Hip protectors for care home residents have Level 1 evidence (Cochrane 2014) for fracture prevention — hip fracture in the elderly population is one of the highest-cost and highest-mortality events in UK healthcare.

Safety

Follow-up, monitoring & safety-netting

Done

Close every consultation with explicit, specific safety-netting. Hip pain has several time-critical diagnoses where delayed re-presentation causes permanent harm.

1–2 weeks

PMR started on prednisolone: confirm dramatic response (diagnostic) and bone protection prescribed. Inflammatory arthritis: confirm rheumatology referral sent and accepted. Acute soft tissue injury: weight-bearing status, analgesia adequacy. NSAID started: check eGFR + BP at 1–2 weeks if new in elderly patient

4–6 weeks

Hip OA: physiotherapy attendance confirmed; if not improving, step up analgesia or arrange injection. GTPS: position modification adherence review; physiotherapy progress. PMR: ESR/CRP recheck; prednisolone at 12.5 mg if symptoms controlled at 3–4 weeks

3 months

Hip OA: Oxford Hip Score reassessment; BMI review; if inadequate response on steps 1–3, consider intra-articular injection or expedite physiotherapy. PMR: CRP/ESR; slow taper to 10 mg if controlled. Gout on allopurinol: serum urate, eGFR, LFT — dose-titrate to target <300 μmol/L

6 months

Failed conservative hip OA (Oxford Hip Score ≤26): refer orthopaedics for THR discussion. GTPS failed conservative: consider ESWT referral or MSK specialist. PMR: review steroid dose — aim ≤7.5 mg by 6 months if possible; consider methotrexate if steroid-sparing needed

Annual review

Hip OA: Oxford Hip Score, BMI, NSAID safety check (eGFR, BP), analgesic ladder review. PMR ongoing: ESR/CRP, BP, weight, HbA1c (steroid-induced DM), DEXA (if not done), vertebral fracture assessment. Post-THR: annual review for implant longevity signs (pain, instability), infection surveillance. Osteoporosis: DEXA every 2 years on bisphosphonate

Safety-net → 999

999 Fall + unable to weight-bear + shortened/externally rotated leg (NOF fracture). Sudden severe hip pain + pale/cold leg (acute ischaemia). Bilateral leg weakness + urinary retention/saddle anaesthesia (cauda equina). Rapid fever + severe hip pain + systemically unwell (septic arthritis / sepsis)

Safety-net → same-day

Same-day Child with acute limp + fever — never wait and watch (septic arthritis vs transient synovitis requires same-day specialist assessment). Worsening hip pain in a known cancer patient (metastatic fracture risk). New sudden severe groin pain in patient on long-term steroids (AVN). Post-THR: sudden new pain, swelling, or fever (prosthetic joint infection)

Safety-net → return if

Pain significantly worsens despite treatment. New mechanical symptoms develop (locking, giving way, catching). Bilateral symptoms develop. New systemic symptoms: fever, night sweats, weight loss. Steroid side effects: weight gain, bruising, mood change, hyperglycaemia, hypertension

NSAID monitoring

eGFR + BP at 4–6 weeks when new prescription in elderly/CKD. 6-monthly for chronic use. Review indication at every consultation. Target: stop or use topical preparation if possible. BP monitoring 6-monthly (NSAIDs raise BP ~3–5 mmHg). Stop if eGFR falls >25% from baseline

Patient resources

Versus Arthritis hip OA leaflet. NHS Choices hip pain information. ESCAPE-pain programme (free, NHS-approved online/group exercise). Oxford Hip Score (patient-completed — give at each review). FRAX calculator referral if fracture risk identified

The child with a limp is the highest-stakes hip presentation in primary care. Transient synovitis and septic arthritis of the hip are clinically indistinguishable without aspiration — the Kocher criteria stratify risk but do not exclude septic arthritis even at low scores. The consequence of missing septic arthritis is AVN of the femoral head and permanent disability. Every child with acute limp and fever must be assessed same-day by a specialist. Post-THR patients require explicit safety-netting about prosthetic joint infection — a devastating complication that requires immediate aspiration (never empirical antibiotics first) and often two-stage revision. Patients frequently attend their GP with post-THR symptoms before orthopaedics, and delays in recognition lead to irreversible implant failure. Prednisolone side effects must be proactively monitored — steroid-induced diabetes develops in up to 15% of PMR patients on prednisolone, often silently, and requires HbA1c monitoring every 3 months in the first year.