Hip Pain - Adults

Comment

It might be useful to note that patients call posterior pelvic pain 'hip pain'. Hip pain usually causes pain in the groin and upper thigh -or occasionally referred to the lower thigh or knee. Hip pain in children has some specific causes which often require active intervention. See Hip Pain - Children

When to refer

1. When unsure of diagnosis. The differential diagnosis includes:
   1. hip arthritis usually osteoarthritis rarely rheumatoid disease also avascular necrosis and secondary to osteomalacia.
   2. referred spinal pain
   3. sacroiliac joint strain or inflammation
   4. vascular insufficiency
   5. polymylagia rheumatica
   6. hernias including inguinal, femoral or adductor
   7. psoas abcess
   8. soft tissue syndomes e.g. trochanteric / ischial bursitis
   9. meralagia parasthetica
   10. metastatic bone disease especially from breast/prostate
2. In osteoarthritis of the hip - refer to orthopaedics
   When pain is not controlled by simple analgesia, walking distance is not acceptible to the patient and there is nocturnal pain preventing sleep and not controlled by bed time analgesia.
   Refer to rheumatology: if the above criteria are not met or patient does not want or is not fit for surgery. Aim to access multidisciplinary team to ensure patients quality of life is as good as possible
3. Pagets disease - refer rheumatology
   This should be treated if there is pain not controlled by simple analgesia, alkaline phospatase > 2x normal upper limit or if hip replacement surgery is contemplated.
4. Impacted fracture of the hip - refer to orthopaedics
   May occur without obvious injury and therefore may not present acutely. It is not uncommon.
   Consider osteoporosis.
   In a patient with rheumatoid arthritis, suspect hip fracture if there is a sudden loss of mobility.

Investigations

• FBC
• ESR/PV
• Profile
• Radiograph of pelvis (ask for pelvis for hips as radiograph is centred lower)
• Rheumatology referral

First line management

This is dependant on the diagnosis.

1. see Osteoarthritis
2. see Inflammatory Arthritis
3. Soft tissues diseases may be treated with local steroid injection and or physiotherapy.
4. Sacroiliac joint disease should be treated initially with physiotherapy

Special points

1. Hip radiographs may show changes late and should not be used to reassure patients if clinical examination reveals likely pathology.
2. Isotope bone scan and ulrasound are useful techniques to assist diagnosis.
3. Hip pain often arises from the spine.
4. Hip disease often presents as knee pain causing little pain in the hip.

Document Information
Expiry Date: 11/04/04
Author: Kennedy Tom Dr and Smith Mr D
Organisation: Arrowe Park Hospital