Chronic Hip Pain

This guideline applies to adults over 18 years.

Introduction

Osteoarthritis can be diagnosed clinically in patients aged 45 years of older with activity related joint pain without significant joint stiffness in the absence of trauma and red flags. Out of patients presenting to primary care with chronic osteoarthritis hip pain each year, 25% will improve within 3 months and 35% at 12 months.¹

Osteoarthritis symptoms progress in 15% of patients within 3 years and 28% within 6 years¹

Red flags

Emergency conditions, requiring Emergency Department or discuss with Orthopaedic SHO on call

Severe hip pain and sudden inability to weight bear +/- history of fall: RCHT, not community hospital/minor injury clinics

Sudden severe significant deterioration of chronic hip pain

Sudden change in true leg length

Suspected/confirmed avascular necrosis

Suspected sepsis: Admit via Orthopaedic SHO

Systemically unwell

Malignancy

New malignancy

Common metastases to bone: Prostate, breast, renal, lung, thyroid

X ray suggests the possibility of Sarcoma

Appopriate specialty suspected cancer (2WW) if known primary or non site specific suspected cancer pathway (2WW NSS) if unknown primary

Myeloma work up
http://rms.kernowccg.nhs.uk/primary_care_clinical_referral_criteria/rms/primary_care_clinical_referral_criteria/haematology/mgusmyeloma

Inflammatory causes

New symptoms of inflammation suggesting systemic inflammatory joint disease, workup and refer rheumatology

Key Features of Assessment

Exclusion of trauma and red flags

Nature and location of pain

Absence of significant morning joint stiffness or mild joint stiffness lasting less than 30 minutes

How the symptoms interfere with activities of daily living, exercise, work, social activities

Presence of risk factors such as raised BMI, previous trauma or surgery to the same joint, high dose steroid use, obesity, lupus, sickle cell, high smoking and alcohol usage

Past medical history of congenital hip conditions such as Perthes disease of slipped upper femoral epiphysis (SUFE)

Frailty and other co-morbidities

Systems review to exclude red flags, referred pain and alternative conditions

Conservative measures tried, including exercise

Optimisation factors for MSK health and referral to surgery when needed

The following reduce the risk of post operative joint infection by 2-3 times

BMI less than 40

BP control less than 160/90 mmHg

Diabetes HbA1c less than 69 mmol/mol

Smoking – stop smoking, minimum 8 weeks before any planned surgery

Caution with patients on bisphosphonates

Impending or suspected atypical femoral fractures present with unilateral or bilateral thigh or groin discomfort

Investigations

Xray within 12 months

MRI is not required in Primary Care

Management

If there are features of impending or suspected atypical femoral fractures on Xray (typified by localised periosteal reactions of the lateral cortex or generalised cortical thickness of the diaphysis) organise an urgent DEXA Femur scan on ICE and urgent referral to Osteoporosis clinic.

For Osteoarthritis

Adopt a shared decision making approach with the patient

Patient Information

Osteoarthritis (OA) of the hip | Hip pain | Versus Arthritis

Osteoarthritis | Symptoms, Diagnosis and Treatment | Patient

Exercise

OVERVIEW / ESCAPE-pain Online Free NHS programme online 2 sessions/week for 6 weeks³

Let's Move with Leon | Versus Arthritis Free online 30 min videos for 12 weeks⁴

Move More - (icareimove.com)⁵GP/FCP Referral via form, contact info@icareimove.com Online 25 week programme for patients who are at risk of falls, must be medically stable especially no unstable cardiac/respiratory symptoms under investigation. Need to be able to stand up independently from a chair. Some laptops available to loan for Move More programme.

Better Health - NHS (www.nhs.uk)⁹

Weight Loss

NHS Digital Weight Management GP Referral for patients BMI > 30 (or BMI > 27.5 from Black, Asian and ethnic minority backgrounds) with Hypertension or Diabetes

Patient leaflet digital-weight-management-patient-leaflet-a4-folded.pdf (england.nhs.uk)

Better Health - NHS (www.nhs.uk)⁹

Analgesia

Analgesia at the lowest effective dose for the shortest duration of time in combination with exercise and weight loss, depending upon patient preference, co-morbidities, individual risk factors, tolerability, and contraindications:

Topical NSAIDs

Oral NSAIDs if no contraindications, consider concomitant proton pump inhibitor therapy where appropriate

Oral paracetamol or weak opioids if they are used infrequently for short term pain relief and NSAIDs are contraindicated, not tolerated or ineffective

Do not treat with glucosamine or strong opioids

Smoking Cessation

Patients are advised to stop smoking for a minimum of 8 weeks prior to surgery and ideally long term

Correct anaemia if possible

Early investigation into cause and correctable deficiencies treated

Please follow RMS Anaemia Guideline
Treat to achieve Hb 130g/L

If maximal treatment in Primary Care and Hb < 130 then refer to Blood Management Service

Additional Devices

TENS machines, appropriate footwear, foot insoles, bracing, mobility aids and assistive household devices are recommended²

Glucosamine, Chondroitin and acupuncture are not recommended²

Advice and Guidance

No formal service currently available.

Referral

Urgent Orthopaedic Referral Criteria

Evidence of Avascular Necrosis or bone collapse on X ray

Newly strong opioid (morphine and morphine equivalent opiates) dependent pain in the joint requiring specialist opinion

Significant and evidenced functional impairment such as severely restricted mobility such as house or bed bound or recurrent falls due to the joint requiring specialist opinion

If the diagnosis is unclear, the patient requires further optimisation, medically unfit or declining surgery but requires onward management, refer to MSK Interface

MSK Interface Referral Criteria

Patients with shoulder, hip, knee problems including sports medicine problems of these joints whereby:

Conservative measures have failed including a course of tailored physiotherapy

Diagnostic uncertainty (including if not sure whether surgery is indicated)

Patient is medically unfit or declining surgery

Exclusion Criteria

· Red flag pathology

· Severe symptoms with functional limitations and willingness for surgery

· Previous joint replacement or significant major surgery to the same joint

· Patients under 16 years

· Hand and foot problems

· Spinal problems (see Spinal Interface)

· Multiple/inflammatory arthropathy

· Lumps, bumps, ganglia

An X ray within 12 months is required for the referral

Routine Orthopaedic Referral Criteria

Adults with persistent hip pain with:

Severe pain and/or persistent functional limitation of activities of daily living, work and/or leisure with X ray evidence of moderate to severe Osteoarthritis not responsive to at least 3 months conservative measures including consistent exercise. Please note Physiotherapy is no longer a pre-requisite for referral.

For young adults under 40 years please follow Young Adult Hip Pain (kernowccg.nhs.uk) guidelines

ANY pain after metal-on-metal THR requires investigation & referral to hip surgeon May start with trochanteric pain. There is a risk of ALVAL (aseptic lymphocytic vasculitis associated lesions)

In very elderly patients and those assessed as unsuitable for surgery consider Orthopaedic referral for image guided intra-articular steroids. These can be beneficial for between 3 weeks and 3 months. Refer as usual on eRS, documenting the counselling had with the patient on the theoretical risks with Covid. Coronavirus counselling information

If there are ongoing symptoms of concern within 6 months of surgery to the same joint refer back to original consultant depending upon clinical judgement

Routine Referral Checklist

Meets referral criteria

Specified conservative measures tried including exercise

Have up to date X Ray within 12 months

BMI less than 40 desirable or actively engaging with weight loss

BP controlled less than 160/90mmHg desirable or at maximal tolerated therapy

Up to date HbA1c less than 69 mmol/mol desirable or at maximal tolerated therapy

Smoking cessation, or planning to stop smoking 8 weeks prior to surgery desirable

If the patient declines or is on maximum tolerated therapy please specify on the referral.

Please note an up to date X ray within 12 months is required for all referrals.

No other imaging including MRI is required prior to referral

Supporting Information

For professionals:

Cochrane Musculoskeletal – What are My Options for Managing Hip or Knee Osteoarthritis?

Versus Arthritis – Osteoarthritis (OA) of the Hip

For patients:

OVERVIEW / ESCAPE-pain Online Free NHS programme online 2 sessions/week for 6 weeks³

Let's Move with Leon | Versus Arthritis Free online 30 min videos for 12 weeks⁴

Move More - (icareimove.com)⁵

Better Health - NHS (www.nhs.uk)⁹

Hip replacement - NHS (www.nhs.uk)

References

Pain arising from the hip in adults. British Orthopaedic Association, British Hip Society and Royal College of Surgeons Commissioning Guide, 2017

Osteoarthritis In Over 16s: Diagnosis and Management. National Institute Of Clinical Excellence, 2022

Orthopaedic Research UK. Escape Pain Online, 15 August 2021 OVERVIEW / ESCAPE-pain Online]

Versus Arthritis. Let’s Move With Leon, 2021 Let's Move with Leon | Versus Arthritis

iCareiMove. Move More Programme, Move More - (icareimove.com)

Lengeurran E et al. Risk Factors Associated With Revision For Prosthetic Joint Infection Following Knee Replacement: An Observational Cohort Study From England And Wales. The Lancet 01 2019 Jun; 19, 6, 589-600

Alamanda VK, Springer BD. The Prevention Of Infection: 12 Modifiable Risk Factors. Bone Joint J 2019 Jan; 101-B1 (1 Supple A):3-9

NHS England. NHS Digital Weight Management Programme, 2021.

NHS. Better Health Better Health - NHS (www.nhs.uk)

Cornwall Council. Health Cornwall, 2019 Contact us - Healthy Cornwall

Joint British Diabetes Societies For Inpatient Care. Management Of Adults With Diabetes Undergoing Surgery And Elective Procedures. Improving Standards; March 2016.

Munoz M et al. International Consensus Statement On The Peri-operative Management Of Anaemia And Iron Deficiency. Anaesthesia; 2017, 72, 233-247

Centre For Peri-Operative Care. Impact Of Peri-operative Care On Healthcare Resource Use; June 2020

Royal Cornwall Hospitals NHS Trust. Pre Assessment Clinical Guidelines v6.0; Nov 2018.

Page Review Information

Review date	21 March 2024
Next review date	21 March 2026
Clinical editor	Dr Rebecca Hopkins
Contributors	Dr Rebecca Hopkins, General Practitioner and Kernow Referral Management Service Orthopaedics Guidelines Lead Dr Janine Glazier, General Practitioner and Kernow Referral Management Service Clinical Lead Dr Will Jewell, Consultant Anaesthetist, Royal Cornwall Hospitals Trust Mr Gavin Bartlett, Consultant Orthopaedic Surgeon, Royal Cornwall Hospitals Trust Mr Tim Powell, Extended Scope Physiotherapist, Royal Cornwall Hospitals Trust