Hip Pain Algorithm

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.

Scope: GP assessment, initial management and referral guide. Acute septic arthritis, fracture, paediatric hip pathology, vascular emergencies and cauda equina syndrome require secondary-care assessment.

Fractured neck of femur Suspected hip fracture in an older person who cannot weight-bear, has marked pain or has a shortened/externally rotated leg → urgent ambulance transfer to ED. Use 999 if there is instability, major trauma, uncontrolled pain, neurovascular compromise or inability to transfer safely. Do not ask the patient to walk or repeatedly move the hip. Provide analgesia and immobilise/transfer safely — the prehospital/ED pathway determines the most appropriate analgesia and nerve block

Septic arthritis of hip Acute severe hip pain ± fever, unable to weight-bear (any age). Septic shock / systemic instability → 999. Clinically suspected septic arthritis in a stable patient → same-day ED/orthopaedic assessment. Delay can rapidly cause cartilage and joint destruction, permanent disability and systemic sepsis. A normal temperature, WCC or CRP does not exclude septic arthritis. Do not give antibiotics before joint aspiration unless the patient is septic or clinically unstable, or specialist advice directs otherwise. Take blood cultures if infection is suspected. Hip aspiration is specialist-led, usually with ultrasound guidance

Acute limb ischaemia Sudden severe pain + pale / cold / pulseless lower limb → 999 vascular emergency. Revascularisation is time-critical. Do not delay for imaging

Cauda equina syndrome Low back pain ± hip/buttock pain + saddle anaesthesia + bladder/bowel dysfunction ± bilateral leg weakness. Acute urinary retention/incontinence, saddle anaesthesia or progressive bilateral neurological deficit → immediate emergency referral (ED / on-call spinal team via the local pathway) — do not arrange community MRI; urgent MRI is arranged by the receiving service. 999 if severe neurological deterioration, inability to transfer or other emergency features. The urgency of decompression is determined by the spinal/orthopaedic service after urgent MRI

Avascular necrosis (acute presentation) Sudden severe constant hip pain, known risk factors (steroids, alcohol excess, sickle cell, SLE, decompression illness) → urgent imaging and orthopaedic/MSK referral. MRI is the most sensitive investigation when radiographs are normal or equivocal (plain X-ray can be normal early). Timing depends on severity, function and local access; same-day ED referral if pain is severe, weight-bearing is impossible or fracture/collapse is suspected

Bone tumour / metastasis Persistent or unexplained bone pain (particularly at rest or night), unexplained swelling, limp or fracture → examination and appropriate imaging. Adults: suspected bone sarcoma referral is triggered primarily by an X-ray suggesting possible bone sarcoma. Children and young people with unexplained bone swelling or pain → consider very urgent direct-access X-ray (NICE NG12). Do not use age >50 alone as a referral threshold; raised ALP or calcium is non-specific. Known malignancy (breast, prostate, lung, renal) with new focal hip pain → assess for metastatic disease, pathological fracture and spinal pathology; route depends on the primary cancer and local oncology pathway

Perthes disease / SUFE (children) Child with limp + hip/referred knee pain. Perthes: typically age 4–10 — a normal early X-ray does not exclude it; if suspicion remains arrange specialist assessment and further imaging. SUFE: typically adolescents but can occur outside this range; obesity is a risk factor, not a requirement; consider endocrine/renal disease in younger, older, short or atypical presentations. Suspected SUFE → no weight-bearing, same-day orthopaedic assessment. 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. Kocher criteria (fever, non-weight-bearing, raised ESR, raised WCC) may support risk stratification but do not exclude septic arthritis — clinical concern overrides the score. Non-weight-bearing, fever, severe pain, systemic illness or diagnostic uncertainty require same-day paediatric assessment

Neck of femur fracture carries significant early mortality — the perioperative period is critical and NICE CG124 recommends surgery on the day of, or the day after, admission. 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 adolescent (obese or not) with hip or knee pain and suspected SUFE needs same-day orthopaedic assessment with AP pelvis and bilateral frog-lateral views (cross-table lateral instead if an unstable slip is suspected) per local paediatric orthopaedic imaging protocol, as the slip can be missed on an AP view alone. Kocher criteria were developed for suspected septic hip in children and have limited sensitivity, particularly in atypical presentations — the commonly cited original probabilities (approximately 3%, 40%, 93% and 99% for one to four criteria) are not universally applicable.

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 (typically 4–10), SUFE (typically adolescents — can occur outside this range; obesity is a risk factor, not a requirement), transient synovitis (typically 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

None or ≤30 minutes = OA (NICE NG226 clinical criterion). >30 minutes = consider 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/hip girdle stiffness + age >50 (PMR — raised ESR/CRP supportive but not required). 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) may support monitoring but does not determine referral (NICE NG226)

Groin pain is the hallmark of true hip joint pathology — groin pain strongly suggests 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 common and is a frequent reason 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 or over, 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 supports (does not establish) the diagnosis. Labral tear: catching/clicking, deep groin, often secondary to FAI or dysplasia. AVN: sudden groin pain, risk factors (steroids/alcohol/SCD), X-ray can be normal early — MRI is most sensitive when radiographs are normal or equivocal

🟠 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 (typically 3–10 yrs): self-limiting, limp, low-grade fever, recent viral URTI — a diagnosis of exclusion; a low Kocher score does not exclude septic arthritis. Perthes disease (typically 4–10 yrs): intermittent limp, groin/knee pain, AVN of femoral head — a normal early X-ray does not exclude it; specialist assessment and further imaging if suspicion remains. SUFE (typically adolescents; can occur outside this range): limp, hip/knee pain, obligate external rotation on hip flexion. Obesity is a risk factor, not a requirement; consider endocrine/renal disease in younger, older, short or atypical presentations. No weight-bearing; AP pelvis + bilateral frog-lateral views (cross-table lateral if an unstable slip is suspected) per local paediatric orthopaedic protocol; same-day orthopaedics. 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 spondyloarthritis / ankylosing spondylitis: affects men and women; chronic back pain starting before age 45, inflammatory back/buttock pain; HLA-B27 may be negative and CRP may be normal — use NICE NG65 referral criteria, not HLA-B27 alone. PMR: age >50, bilateral shoulder + hip girdle; raised ESR/CRP helpful but neither mandatory nor diagnostic; steroid response supportive only. 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 are common in primary care, yet are frequently misdiagnosed. GTPS does not respond to intra-articular hip injections (wrong target); it is managed with education, load management and physiotherapy, with corticosteroid injection giving short-term relief only in selected patients. FAI is a common cause of hip pain in young active adults — 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 structured exam supports or refutes the working diagnosis — no single test (FADIR, FABER, Trendelenburg) establishes a diagnosis in isolation.

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. A positive test supports, but does not establish, a diagnosis

Range of movement (supine)

Assess active and passive range, particularly internal rotation and flexion — reduced, painful internal rotation suggests intra-articular pathology such as OA; assess with hip and knee at 90° flexion. "Normal ranges" vary with age, habitus and technique, so compare with the other side. 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, suggesting FAI or labral pathology. Supports, but does not establish, the diagnosis

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 suggests intra-articular hip pathology (OA, septic arthritis, AVN). Use when intra-articular pathology is suspected; supports rather than establishes the diagnosis

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). Assess when trauma, fracture or structural disease is possible

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 when trauma, fracture, or a neurological or vascular cause is possible

Suggested examination structure: gait and weight-bearing · active and passive hip range of movement (especially internal rotation and flexion) · log roll if intra-articular pathology is suspected · greater trochanter and gluteal tendon palpation · spine, sacroiliac joints and knee · abdominal, inguinal and genital examination where indicated · leg length and neurovascular status when trauma, fracture or neurological/vascular disease is possible.

Reduced, painful internal rotation is a useful sign of intra-articular hip pathology such as OA — but hip OA is usually a clinical diagnosis and this sign alone does not mandate 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." A positive Trendelenburg test suggests abductor weakness (gluteal tendinopathy, OA, L5 radiculopathy) and is worth documenting to guide physiotherapy. The log roll isolates the joint by minimising soft tissue tension and is useful when intra-articular pathology is suspected. A positive FADIR, FABER or Trendelenburg test should support, not establish, a diagnosis.

Diagnose

Targeted investigations — image selectively, diagnose clinically where possible

Done

Hip OA is usually diagnosed clinically and imaging is not routinely required (NICE NG226): age 45 or over, activity-related joint pain, and morning stiffness lasting no more than 30 minutes. Image when features are atypical, an alternative diagnosis is suspected, there is trauma or suspected fracture, there is concern about AVN, malignancy, Perthes disease or SUFE, or for surgical planning.

X-ray pelvis + hip When indicated

Not routinely required for uncomplicated clinical OA. Indications: atypical features or alternative diagnosis suspected, trauma/fracture, SUFE, Perthes, Paget's, AVN, suspected malignancy, surgical planning. Views (AP pelvis, lateral hip, weight-bearing films) according to local radiology/orthopaedic protocol; suspected SUFE: AP pelvis + bilateral frog-lateral per local paediatric orthopaedic protocol. Normal X-ray does NOT exclude early OA, AVN (early), Perthes (early) or stress fracture

Bloods — inflammatory Targeted

FBC, CRP/ESR where infection, inflammatory disease or malignancy is suspected. RF and anti-CCP when persistent synovitis is present and RA is suspected. HLA-B27 only in the specific NICE NG65 referral context for suspected axial spondyloarthritis — avoid indiscriminate testing. Serum urate may support gout assessment but does not confirm or exclude acute crystal arthritis during a flare. ALP, calcium and myeloma tests guided by the clinical picture. PSA not routine for every male with hip pain — only where prostate cancer is clinically suspected or there is unexplained bone pain/raised ALP in an appropriate patient. Blood cultures if septic arthritis or osteomyelitis is suspected

PMR screen

Age >50, bilateral shoulder + hip girdle aching, morning stiffness >45 min: ESR + CRP + FBC. ESR and CRP are helpful but neither is mandatory or diagnostic; an ESR >40 is not required and normal inflammatory markers are uncommon but possible. Exclude alternatives (elderly-onset RA, infection, malignancy, myopathy, hypothyroidism, drug-related myalgia). Steroid response is supportive, not diagnostic in isolation

MRI hip 2nd line

Indicated for: suspected AVN (plain X-ray can be normal early — MRI is the most sensitive investigation), occult NOF fracture (X-ray normal but high clinical suspicion — offer MRI; CT if MRI not available within 24 hours or contraindicated — NICE CG124), suspected labral tear (young adult with groin catching), stress fracture (runner with groin pain + normal X-ray), bone tumour characterisation, persistent unexplained hip pain with normal X-ray in an active patient

Ultrasound hip

Effusion detection (specialist-led 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) — per NOGG/local pathway after fragility or NOF fracture, or when the FRAX result falls in the NOGG assessment band; DXA is not always required before starting treatment. 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; indiscriminate HLA-B27 or PSA testing

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), offer MRI; if MRI is not available within 24 hours or is contraindicated, consider CT (NICE CG124). Do not discharge simply to repeat an X-ray in 10 days if clinical suspicion remains high.

Some 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. NICE CG124 recommends MRI, with CT if MRI is unavailable within 24 hours or contraindicated. 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: normal inflammatory markers are uncommon but possible and do not exclude the diagnosis. PMR requires a compatible clinical syndrome and exclusion of alternatives; response to prednisolone 15 mg OD is supportive, not diagnostic in isolation.

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 hip fracture with inability to transfer safely, neurovascular compromise, major trauma or uncontrolled pain. Suspected acute limb ischaemia. Cauda equina features with acute retention/incontinence, saddle anaesthesia or progressive neurological deficit. Open fracture. Septic arthritis with sepsis, shock or rapid deterioration

Same-day urgent

Same-day Suspected septic arthritis hip → ED / orthopaedics (specialist-led aspiration ± washout). Suspected hip fracture → urgent ambulance transfer to ED (NICE CG124: surgery on the day of, or the day after, admission; the NHFD benchmark is within 36 hours). Child with fever and acute limp or inability to weight-bear → same-day paediatric assessment regardless of Kocher score. Suspected SUFE (restricted hip movement, hip/knee pain; obesity not required) → no weight-bearing, same-day orthopaedics with imaging per local paediatric protocol. Suspected pathological fracture. Acute severe hip pain in a patient at high risk of AVN where fracture/collapse or other emergency pathology is possible. Suspected cauda equina → immediate emergency referral (ED / on-call spinal team via the local pathway); MRI arranged by the receiving service

Suspected cancer

NICE NG12 Persistent unexplained bone pain or swelling → examination and X-ray. Adults: consider a suspected cancer pathway referral for bone sarcoma when an X-ray suggests possible bone sarcoma. Children and young people with unexplained bone swelling or pain → consider very urgent direct-access X-ray. Age alone and raised ALP/calcium are not referral criteria. Known malignancy with new focal hip pain → assess for metastatic disease, pathological fracture and spinal pathology; route depends on the primary cancer and local oncology pathway

Urgent outpatient

Suspected AVN without acute instability → urgent orthopaedic/MSK referral. Suspected persistent synovitis → urgent rheumatology referral, particularly if more than one joint, small joints of hands/feet, or delay of 3 months or more — do not delay referral for RF, anti-CCP, CRP or ESR results (NICE NG100). Suspected axial SpA → rheumatology per NICE NG65 criteria. Persistent unexplained bone pain or swelling. Suspected Perthes despite normal initial X-ray → paediatric orthopaedics. PMR with atypical features → rheumatology before or soon after starting prednisolone (typical PMR is managed in primary care). Perthes confirmed → paediatric orthopaedics

Routine orthopaedics

Hip OA: symptoms substantially affect quality of life and non-surgical management is ineffective or unsuitable (no fixed treatment period required), Oxford Hip Score to describe severity only — NICE NG226 says not to use scoring tools as a referral threshold. Suspected FAI/labral pathology with persistent symptoms despite physiotherapy → MSK/orthopaedics (arthroscopic assessment). Recurrent hip dislocation. Acetabular dysplasia causing symptoms

Physiotherapy First-line

Hip OA — therapeutic exercise is core first-line treatment (NICE NG226); consider a supervised programme or physiotherapy. 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 with atypical features, relapse or steroid-sparing need. Recurrent crystal arthropathy. Suspected vasculitis or connective tissue disease with hip involvement

Osteoporosis / falls

Hip fracture → local Fracture Liaison Service (FLS); assess falls risk and secondary fracture prevention; bone health assessment and treatment per NOGG/local pathway (DXA not always required before treatment); calcium and vitamin D based on dietary intake, deficiency and clinical risk rather than automatically for everyone. Falls assessment → community falls prevention service. FRAX result above the NOGG assessment or intervention thresholds → DEXA ± treatment per NOGG guidelines

NICE CG124 (Hip Fracture) recommends surgery on the day of, or the day after, admission (the National Hip Fracture Database benchmark is within 36 hours) — delay beyond this is associated with higher 30-day mortality. The fracture liaison service referral after any hip fracture is part of the bone-health and falls liaison described in NICE QS16 (Hip fracture in adults, 2012, updated January 2023) — secondary fracture prevention is a key opportunity after any hip fracture. For AVN, femoral head-preserving options are mainly considered before collapse, so suspected AVN warrants urgent imaging and orthopaedic/MSK referral. NICE NG226 (Osteoarthritis, 2022) says to use clinical assessment rather than scoring tools such as the Oxford Hip Score to decide on referral for joint replacement: refer when symptoms substantially affect quality of life and non-surgical management is ineffective or unsuitable — a score can describe severity but must not act as a referral threshold.

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): Exercise and weight management are core treatments (NICE NG226) — tailor to preference, function and comorbidity: aerobic exercise (walking, swimming, cycling, aquatic exercise) + hip-specific strengthening. Advise that exercise does not accelerate OA. Provide a Versus Arthritis OA patient information leaflet

Step 2Analgesia — topical then oral: Consider a topical NSAID (NICE NG226 — joints other than the knee); check preparation and frequency against the current product SPC and local formulary, and explain it may have limited value for deep hip joint pain. Paracetamol: NICE NG226 advises against routine use — only infrequently, for short-term relief, when other drug options are contraindicated, not tolerated or ineffective. Avoid strong opioids (no long-term evidence, significant harm — NICE NG226)

Step 3Oral NSAIDs: Consider if topical treatment is ineffective or unsuitable — choose per local formulary, with PPI gastroprotection (NICE NG226); assess overall GI risk rather than applying a fixed age rule. 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: Consider for short-term relief or to facilitate exercise (NICE NG226). Performed by a suitably trained clinician, often image-guided because the joint is deep. Frequency per local procedural policy. Do not use hyaluronan injections

Step 5Total hip replacement referral: symptoms substantially affecting quality of life with non-surgical management ineffective or unsuitable (NICE NG226 — a score such as the Oxford Hip Score describes severity but is not a referral threshold), no fixed period of failed treatment is required before referral. Discuss: implant lifespan, risks (VTE, infection, dislocation) and realistic recovery

NICE NG226 explicitly states: Do not routinely offer opioids, particularly strong opioids. Do not routinely offer paracetamol. Do NOT offer glucosamine or chondroitin. Do NOT offer hyaluronan injections. 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 ± short NSAID course if suitable (lowest effective dose, shortest duration; consider renal, cardiovascular and GI risk). 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). Progressive loading improves pain and function for many patients and should be continued over time — avoid passive stretching of the IT band which compresses the tendon and worsens symptoms

Step 3Corticosteroid injection (selected patients): may provide short-term symptom relief but does not treat the underlying tendinopathy. Landmark- or image-guided according to local expertise and the target pathology (e.g. methylprednisolone 40 mg + 1% lidocaine). Combine with physiotherapy. No fixed lifetime number — consider previous response, diagnostic certainty, diabetes and infection risk, tendon pathology, potential local tissue effects and alternative physiotherapy/MSK options

Step 4Not improving despite load management and physiotherapy → physiotherapy referral intensification or MSK/orthopaedic review: ESWT (extracorporeal shockwave therapy) — NICE HTG248 (formerly IPG376, 2011): evidence limited, use only with special arrangements for governance, consent and audit or research. 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. GTPS is primarily a clinical diagnosis; initial management is education, load modification and progressive hip abductor strengthening.

③ Polymyalgia Rheumatica (PMR)

Diagnosis

Compatible clinical syndrome (age >50, bilateral shoulder + hip girdle aching, morning stiffness >45 min) with exclusion of alternatives. ESR/CRP helpful but neither mandatory nor diagnostic; ESR >40 not required. Exclude elderly-onset RA, infection, malignancy, myopathy, hypothyroidism and drug-related myalgia. GCA: any new headache, scalp tenderness, jaw/tongue claudication, visual symptoms, constitutional symptoms or limb claudication → same-day specialist discussion (rheumatology/acute medicine per GCA pathway, not ophthalmology alone). If visual or neurological features are present, commence urgent high-dose glucocorticoid per the GCA pathway and do not wait for ophthalmology

First-line treatment

Prednisolone 15 mg OD orally — a rapid response is supportive, not diagnostic in isolation. If no response at 1 week, reconsider diagnosis. Bone protection: assess rather than prescribing automatically — age and sex, fragility-fracture history, dose and expected duration, FRAX/NOGG risk, renal function, calcium and vitamin D status, pregnancy potential. For people aged ≥50 on prednisolone ≥7.5 mg/day for ≥3 months, NOGG recommends starting bone protection at the same time in appropriate risk groups, without waiting for DXA

Tapering schedule

Reduce to 12.5 mg after approximately 3 weeks (if symptoms controlled). Then 10 mg after a further 3 weeks, held for 4–6 weeks. Then reduce by 1 mg every 4–8 weeks. Individualise according to symptoms, inflammatory markers, relapse and toxicity. 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). Repeat DXA guided by fracture risk and treatment decisions (NOGG/local guidance) — not routinely annual. Adrenal insufficiency risk if abrupt stop — never stop suddenly

④ Inflammatory Arthritis — New Presentation

Acute management

NSAID while awaiting rheumatology only after considering age, renal function, hypertension, cardiovascular disease, ulcer risk, anticoagulants and pregnancy — lowest effective dose, shortest duration, PPI gastroprotection where indicated, per local formulary. Do not initiate DMARD without specialist confirmation. Do not routinely start bridging prednisolone — discuss with rheumatology first

Axial SpA / AS

Affects men and women; HLA-B27 may be negative and CRP may be normal — do not diagnose on HLA-B27 alone. Refer per NICE NG65: chronic back pain starting before age 45 plus at least four additional features; if exactly three are present, HLA-B27 testing may help decide referral. NSAIDs improve symptoms. MRI uses an inflammatory back-pain protocol and is usually arranged through the specialist pathway. Physiotherapy essential — daily extension exercises

Refer urgently

Suspected persistent synovitis → urgent rheumatology referral (NICE NG100), particularly if more than one joint, small joints of hands or feet, or delay of 3 months or more. Do not delay referral for RF, anti-CCP, CRP or ESR results. Early DMARD (methotrexate ± hydroxychloroquine for RA) reduces irreversible joint damage

Next steps: see Osteoarthritis · Greater trochanteric pain syndrome · Polymyalgia rheumatica · Osteoporosis · Axial spondyloarthritis

Intra-articular hip injection should be performed by a suitably trained clinician and is often image-guided because the joint is deep. 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 should be assessed from the start of prednisolone and started at the same time in appropriate risk groups per NOGG. The taper is individualised according to symptoms, inflammatory markers, relapse and toxicity.

Lifestyle

Non-pharmacological interventions — prescribe these as treatments

Done

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

Weight management Any weight loss is likely to be beneficial; losing 10% is likely to be better than 5% (NICE NG226). Provide personalised support rather than setting BMI <25 as a mandatory target. Refer to an NHS weight management programme or Tier 3 obesity service where eligible under local criteria. Frame as "joint offloading therapy"

Exercise prescription — aerobic Swimming, cycling, walking and aquatic exercise are reasonable options — tailor to preference, function and comorbidity rather than a fixed universal protocol. Avoid high-impact activity (running, jumping) during active flares. ESCAPE-pain programme (free, NHS-approved) for hip and knee OA

Hip abductor strengthening Options include clamshells, side-lying hip abduction and single-leg stance, individualised by the physiotherapist. Strengthening gluteus medius may reduce Trendelenburg gait and improve joint stability and pain. 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 (offloads the hip). 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). Calcium and vitamin D based on dietary intake, deficiency and clinical risk (e.g. housebound or care home residents). Strength and balance exercise (NHS Falls Prevention classes — referral via GP). Consider hip protectors for high-risk patients (e.g. care home residents)

Smoking cessation Smoking reduces bone mineral density (BMD) 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 NHS Talking Therapies/psychology where available

Walking stick use in the contralateral hand is one of the most under-prescribed interventions in hip OA. Used in the contralateral hand it offloads the hip joint. 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. Educating patients on the three key provocative positions (legs crossed, lying on side, hip adduction standing), combined with load management, may be sufficient in mild cases. Hip protectors can be considered for high-risk care home residents — 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.

1–3 weeks

PMR started on prednisolone: review at 1–3 weeks, then after dose reductions and at clinically appropriate intervals — symptoms and function, GCA symptoms, ESR/CRP where useful, BP, glucose/HbA1c and weight, steroid adverse effects, bone protection and fracture risk. Response is supportive, not diagnostic. Inflammatory arthritis: confirm rheumatology referral sent and accepted. Acute soft tissue injury: weight-bearing status, analgesia adequacy. NSAID started: check eGFR + BP early in older people, CKD, hypertension, heart failure or higher-risk prescribing; ongoing review based on risk and duration

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 approximately 3 weeks

3 months

Hip OA: clinical review of symptoms and function (Oxford Hip Score may support monitoring but does not replace clinical assessment); weight review; if inadequate response on steps 1–3, consider intra-articular injection or expedite physiotherapy. PMR: CRP/ESR; on 10 mg from about 6 weeks, then reduce by 1 mg every 4–8 weeks if controlled. Gout on allopurinol: serum urate, eGFR, LFT — dose-titrate to target <360 μmol/L (<300 μmol/L if tophi, chronic gouty arthritis or continuing flares — NICE NG219)

6 months

Failed conservative hip OA (substantial impact on quality of life despite non-surgical care — NICE NG226): 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: clinical review of symptoms and function, weight, NSAID safety check (eGFR, BP), analgesic review. PMR ongoing: ESR/CRP, BP, weight, HbA1c (steroid-induced DM), bone protection and fracture-risk review, vertebral fracture assessment. Post-THR: annual review for implant longevity signs (pain, instability), infection surveillance. Osteoporosis: repeat DXA interval individualised per fracture risk and NOGG/local guidance. Denosumab: do not delay or stop without a planned alternative antiresorptive strategy because of the risk of rebound vertebral fractures (MHRA)

Safety-net → 999

999 Fall + unable to weight-bear or shortened/externally rotated leg (suspected hip fracture) — do not try to walk. 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 Hot, very painful hip with fever, or new inability to weight-bear (any age) — same-day assessment (999 if systemically unwell). Older person with new hip or groin pain after a fall, even if able to walk — same-day assessment and X-ray (impacted fracture). 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

Risk-based: check eGFR + BP early when prescribing for older people or those with CKD, hypertension or heart failure; ongoing monitoring according to risk and duration. Review indication at every consultation. Target: stop or use topical preparation if possible. NSAIDs can raise BP and reduce renal function — stop if eGFR falls significantly

Patient resources

Versus Arthritis hip OA leaflet. NHS website hip pain information. ESCAPE-pain programme (free, NHS-approved online/group exercise). Oxford Hip Score (patient-completed — may support monitoring, not a substitute for clinical assessment). 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 can develop silently, so monitor glucose/HbA1c, BP and weight.