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Efforts are made to ensure the accuracy and agreement of these guidelines. However, we cannot guarantee this. This guidance does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer, in accordance with the mental capacity act, and informed by the summary of product characteristics of any drugs they are considering. Practitioners are required to perform their duties in accordance with the law and their regulators and nothing in this guidance should be interpreted in a way that would be inconsistent with compliance with those duties
Practice-based recommendations have been given by: .
Date of publication: 31-Oct-2011
The care map has been drafted in line with the Map of Medicine editorial methodology, current clinical practice and the following guidelines:
 Cibulka MT, White DM, Woehrle J et al. Hip pain and mobility deficits – Hip Osteoarthritis: Clinical Practice Guidelines Linked to the International Classification of Functioning, Disability, and Health from the Orthopaedic Section of the American Physical Therapy Association. J Ortho Sports PhysTher 2009; 39: A1-25.
 British Pain Society (BPS). A practical guide to the provision of Chronic Pain Services for adults in Primary Care. London: BPS; 2011.
 PRODIGY. Osteoarthritis. Version 1.6. Newcastle upon Tyne: PRODIGY; 2008.
 American College of Radiology (ACR). Chronic hip pain. Reston, VA, US: ACR; 2008.
 National Health and Medical Research Council (NHMRC). Evidence-based management of acute musculoskeletal pain. Canberra: NHMRC; 2003.
 British Pain Society (BPS). Opioids for persistent pain: good practice. London: BPS; 2010.
Further information was provided by the following references including practice-based knowledge: [2,3].
Hip pain is usually felt in the groin, buttock, or lateral or anterior thigh [2,9]. It may also be referred to the knee .
Hip disorders often also :
produce a limp and stiffness
prevent activities of daily living, eg putting on socks and shoes 
Pain assessment should include :
site − primary sites and patterns of radiation
nature − eg stabbing, burning
how long the pain has been present
what pattern it follows
factors that exacerbate or relieve the pain
impact of pain on sleep
referred pain − to the knee, back, groin
emotional impact − eg anxiety, depression etc
severity − mild, moderate, or severe or as indicated on a numerical rating scale or visual analogue scale
impact on quality of life − activities that are difficult to carry out, or the patient:
has stopped doing or avoids
manages but at a high cost to their pain
Check for a history of joint conditions or problems .
Examine joint for:
bony swellings and joint deformity 
restricted range of joint movement 
muscle wasting and weakness 
gait abnormalities 
'locking' or 'snapping' 
Examine contralateral joint for any abnormalities .
The following tests may be helpful when differentiating hip pain from other sources of pain:
tests for labral tears, eg :
FABER (Patrick's) test
flexion-adduction internal rotation test
sacroiliac joint provocation test for sacroiliac joint pain 
femoral nerve stretch test for L2-3 radiculopathy 
straight leg raise or sciatic nerve testing in posterior hip pain 
resisted hip flexion and external rotation for psoas irritation 
If hip fracture or malignancy are suspected, refer the patient urgently to specialist care .
If trauma is suspected, use clinical judgement for the urgency of referral .
Examples of trauma include :
metastases in the pelvis or proximal femur will produce hip pain 
primary bone tumours as a cause of hip pain are extremely rare li>
nocturnal or continuous pain (particularly without weight bearing) 
tenderness on direct palpation 
history of :
unexplained weight loss
cancer in the family
imaging should include:
AP pelvis ; andli>
lateral view 
treatment with local radiotherapy or biphosphonates (or both) may slow disease progression 
The most important step in management of the painful hip is to establish the underlying aetiology and to treat it as specifically as possible .
In addition to trauma/fracture and malignancy (see 'RED FLAG!' care point), the following are potential causes of hip pain :
osteoarthritis and other arthritides
avascular necrosis – suspect if patient as been on long-term corticosteroids 
painful soft-tissue conditions around the hip, eg tendonosis, greater trochanteric pain syndrome (trochanteric bursitis)
benign bone tumours (rare) 
Pain may also be referred pain:
knee – see 'Knee pain' care map 
as a result of a L2-3 radiculopathy 
It is important to recognise that one musculoskeletal problem can lead to another. For example, patients with span title="Click to view more sources"> spinal stenosis frequently develop trochanteric bursitis.. This should be considered when assessing the patient .
Consider other possible causes of pain :
from the :
knee – see 'Knee pain' care map
as a result of a L2-3 radiculopathy 
urinary tract infection
active lymph nodes
one of the most common causes of hip pain in adults
patients usually present in their 60s or 70s − may present earlier in patients with prior hip trauma or congenital abnormalities
see 'Osteoarthritis of the hip NS MOM' care map
Other arthritides include :
Avascular necrosis :
segmental avascular necrosis of the weight-bearing portion of the femoral head can occur
presents with progressive pain, limp, and late secondary osteoarthritis
most causes are idiopathic
associated conditions include:
prolonged steroid therapy
sickle cell disease 
working in a pressurised environment (eg deep sea diver)
Radiographs may be normal in avascular necrosis . If avascular necrosis is suspected, the investigation of choice is an MRI .
An MRI gives a diagnosis in the early stages, but if radiological evidence is established, surgical treatment to arrest the disease is less successful .
Hip replacement may ultimately be required .
primary septic arthritis is rare in adults
risk factors include:
prior hip joint disease
should be obtained first in most cases
however, plain X-ray may miss signs of infection
whether radiographs are normal or not, results are useful for selecting further investigations and for comparison with other studies (eg MRI, radionucleotide bone scans)
joint aspirationu under fluoroscopic guidance is generally necessary to establish the diagnosis
Surgical drainage is usually necessary, along with prolonged intravenous antibiotics . Where antibiotics therapy is deemed necessary, Consultant Microbiologist advice should be sought to guide antibiotic treatment choices, doses and duration of treatment.
Painful soft-tissue conditions around the hip include :
The standard RSS referral form is available as an EMIS Template
Paget's disease :
pelvis is often involved − can cause hip pain, usually during the active phase
Treatment of the disease with biphosphonates can reduce pain, but coexistent osteoarthritis of the hip can also occur .
MSK Interface provide assessment, diagnostic and treatment of a wide variety of musculoskeletal conditions. This includes both simple and complex problems that may traditionally have been referred direct to orthopaedics.
Primarily the role is assessment of non-surgical cases or assessing and triaging those patients where the need for surgery is not obvious.
Treatments include an injection service, exercise therapy, self management programs and referral on for physiotherapy, podiatry and surgical appliances as required.
Diagnostics includes access to MRI and ultrasound when deemed clinically relevant by the clinician
Open or Arthroscopic Femoro-Acetabular Surgery for Hip Pain including Impingement
Criteria Based Access Policy
Date Adopted: 1st June 2016
In addition to the condition specific criteria below, funding approval for surgical treatment will only be provided by the CCG for patients meeting these general criteria set:
1. The patient has been assessed (including paper based triage where appropriate) by Musculoskeletal Services and diagnosed as suffering from end-stage osteoarthritis suitable for referral for consideration of surgery,
2. The clinician has ensured that the patient understands what is involved, is aware of the serious known complications outlined in NICE patient information and agrees to the treatment knowing that there is only evidence of symptom relief in the short and medium term,
3. The patient has fully engaged with conservative therapy for at least 3 months including activity modifications, restriction of exercise and avoidance of symptomatic motion (clearly detailed throughout the patient’s primary care record or via Musculoskeletal Services’ letters or other clinic letters), has failed to improve the patient’s or the symptoms of the patient
4. Diagnosis has been confirmed by appropriate investigations including X-Rays, MRI and/or CT scans.
5. The patient’s significant functional impairment which is likely to be corrected or significantly improved by surgery.
Significant functional impairment is defined by the BNSSG Health Community as:
- Symptoms preventing the patient fulfilling routine work or educational responsibilities
- Symptoms preventing the patient carrying out routine domestic or carer activities
Condition Specific Criteria Policy - CRITERIA BASED ACCESS
Labral Tears and/or Loose Body Treatment
The CCG will fund open or arthroscopic hip surgery ONLY when patients fulfil all of the criteria numbered 1 to 5 above and the following criterion:
1. The patient is experiencing moderate-to-severe hip pain that is worsening by flexion activities (e.g., squatting or prolonged sitting or climbing stairs)
Condition Specific Criteria Policy - CRITERIA BASED ACCESS
Femoro-acetabular or Hip Impingement
The CCG will fund open or arthroscopic hip surgery for the treatment of femoro-acetabular impingement (FAI) ONLY when patients fulfil all of the criteria numbered 1 to 4 above and the following criterion:
1. Patients should be skeletally mature (i.e. they should be 19 and have completed puberty).
2. Have severe symptoms typical of FAI with:
2.1. The symptoms lasting for a period of least six months (clearly detailed throughout the patient’s primary care record or via Musculoskeletal Services’ letters or other clinic letters).
2.2. Compromised function, which requires urgent treatment within a 6-8 months time frame,
2.3. Where failure to treat early is likely to significantly compromise surgical options at a future date.
Note: In order to comply with NICE recommendations:
the surgeon must have completed specialist training and have experience of providing arthroscopic hip surgery and for each case should include discussion of each case with a specialist musculoskeletal radiologist; and
the provider must seek patient consent and, where agreed, provide full data on100% patients undergoing this procedure to the British Hip Society register (British Hip Society, 2016) to support assessment of long term outcomes as well as undertake local review of cases to monitor safety and short term outcomes.
The CCG will not routinely fund hip arthroscopy in patients with femoro-acetabular impingement where any of the following criteria apply:
Patients with advanced Osteo-Arthritic change on preoperative X-ray or severe cartilage injury.
Patients with a joint space on plain radiograph of the pelvis that is less than 2mm wide anywhere along the sourcil.
Patients who are a candidate for hip replacement.
Any patient with severe hip dysplasia or with a Crowe grading classification of 4.