Hip Pain Care Pathway

Review in progress

Disclaimer: The guidance contains helpful primary care information for management of referrals and up to date referral criteria. These guidelines are locality specific to best reflect local services. This guidance does not override or replace the individual responsibility of healthcare and social care professionals involved in the delivery of care to make informed professional judgements appropriate to the circumstances of the individual.

Scope

This guidance refers to:

  • The management of all patients presenting with hip pain

This guidance does not cover:

  • Under 18s (Wakefield) Under 16s (North Kirklees)

Commissioning Statements:

  • Referrals for Hip Replacement are subject to an eligibility criteria that must be met before a referral is made - please see Commissioning Statement for further information
  • Referrals for Hip Arthroscopy are subject to an eligibility criteria that must be met before a referral is made - please see Commissioning Statement for further information
  • Upright/Open MRI referrals are subject to an eligibility criteria that must be met before a referral is made - Please see Commissioning Statement for further information
  • For those patients who are not eligible for treatment under these policies consideration will be on an individual basis via the CCGs Prior Approval Process in accordance with NHS North Kirklees and NHS Wakefield CCG Commissioning Policy

Assessment

Signs and Symptoms

Hip Joint Related Groin Pain (Includes FAI, Dysplasia, Labrum, OA)

  • Pain in groin, inner thigh, lateral hip or buttock.
  • Pain after hip flexion/internal rotation activities e.g. shoes/socks, crossing legs, prolonged sitting.
  • May report stiffness < 30mins in the hip upon waking (OA)
  • May report clicking/clunking/catching (FAI/Labrum)

Greater Trochanteric Pain Syndrome (Gluteal Tendinopathy)

  • Reports predominantly lateral hip pain; can refer lateral thigh and even below the knee but rarely into the foot.
  • No neurological symptoms.
  • Pain with single leg standing, crossing legs, side lying (can be both sides).
  • No issues with putting on shoes/socks.

Proximal Hamstring Tendinopathy

  • Pain in the buttock, localised to the ischial tuberosity +/- radiation into posterior thigh.
  • Does not report back pain, symptoms below the knee or neurology.
  • Pain with prolonged sitting, especially on hard surfaces.
  • Pain with activities that combine hip and knee flexion e.g. cycling, uphill walking

Adductor Related Groin Pain

  • Pain in the groin, localised to pubic bone +/- radiation into the inner thigh.
  • Pain with changing direction, often at speed.
  • Usually perform a sport that involved kicking or frequent changes of direction e.g. football

Iliopsoas Related Groin Pain

  • Pain in the anterior groin with hip flexion activities; often no pain with sitting.
  • May report pain when walking up hill, cycling or with fast walking.
  • Pain usually follows a period of unaccustomed activity that involves repetitive hip flexion, often under load e.g. increased cycling/sprinting.

History and Examination

  • Clinical history should include:
  • History of trauma (fracture, labral tear)
For additional information on signs and symptoms please click here - Signs and Symptoms

Examinations should include:

  • Pain in hip and/or groin on movement
  • Reduction of hip flexion and/or internal and external rotation (OA)
  • Leg shortening/rotation (consider fracture)
  • Lateral tenderness (trochanteric)
  • Consider referred pain from the spine.

Red Flags

Seek immediate or urgent specialist advice/treatment if:

  • If suspected fracture
  • Consider urgent referral if rapid onset or functional deterioration

Investigations

Please note:

  • Plain AP and lateral hip x-rays should only be considered if referring for a further opinion
  • No further imaging (e.g. MRI or bone scan) is appropriate before referral

Management

Clinical Management

  • Lifestyle advice: weight loss, exercise, cushioned footwear
  • Patient education: OA is an active process, it is not wear and tear. Exercise does not increase damage
  • Simple analgesia - paracetamol
  • Oral NSAIDs with PPI cover - ibuprofen or naproxen. Aim for short term or intermittent use
  • Consider opioids only if pain is not controlled. Avoid potent opioids, especially in the elderly
  • Consider injection for bursitis
  • Consider injection for hip osteoarthritis under fluoroscopic guidance (by secondary care radiology)

Consider referral if:

  • Pain is persistent
  • Primary care management tried and pain or disability not acceptable
  • Confirmed osteoarthritis on x-ray
  • Unclear diagnosis e.g. mixture of hip and back pain
  • Consideration of steroid injection eg for bursitis

Referral

Referral Criteria

  • Red Flags
  • North Kirklees (MSK, Trauma and Orthopaedics and Physiotherapy)
    • All MSK referrals (excluding red flags) should be made to Connect Community MSK who will undertake clinical assessment and triage and refer on as appropriate (including to physiotherapy). Choice of provider will be offered following triage
    • Please click here to open the Clinical Decision Making Aid for further guidance on which part of Connect's pathway to refer into i.e. Physioline, Physio or CATs
  • Wakefield – MSK
    • Those not presenting with red flag symptoms or where diagnosis or treatment is unclear should be referred to Connect Community MSK who will undertake clinical assessment and treatment and/or refer on to physiotherapy or secondary care as appropriate. Choice of provider will be offered for onward referrals.
  • Wakefield - Physiotherapy
  • Wakefield – Trauma and Orthopaedics
    • Patients should be offered choice of provider for trauma and orthopaedics.

Referral Requirements

  • For Hip Relacement, Hip Arthorscopy and Upright/open MRI referrals documented evidence is required to demonstrate that the patient meets the commissioning statement criteria
  • For those patients who do not meet the eligibility criteria evidence of prior approval authorisation is required

Commissioning Statements:

  • Referrals for Hip Replacement are subject to an eligibility criteria that must be met before a referral is made - please see Commissioning Statement for further information
  • Referrals for Hip Arthroscopy are subject to an eligibility criteria that must be met before a referral is made - please see Commissioning Statement for further information
  • Upright/Open MRI referrals are subject to an eligibility criteria that must be met before a referral is made - Please see Commissioning Statement for further information
  • For those patients who are not eligible for treatment under these policies consideration will be on an individual basis via the CCGs Prior Approval Process in accordance with NHS North Kirklees and NHS Wakefield CCG Commissioning Policy

Referral Instructions

  • e-Consultation is not currently available for this specialty
  • Referrals should be made via ICG to TRISH (if training has been undertaken) - See user guides (EMIS & S1) for further information.
  • For those Practices who have not received ICG training referrals should be made via eRS
  • Please identify speciality and clinic type

Supporting Information

Shared Decision Making

  • Patients have a right to make decisions about their care and should be fully informed about the options they face. They should be provided with reliable evidence-based information on the likely benefits and harms of interventions or actions, including any uncertainties and risks, eliciting their preferences and supporting implementation. Prior to referral for surgery the patient should understand their options and the benefits and risks and the likelihood of these occurring. If relevant patients should be signposted to decision aids for Decision Aid for Arthritis of the Hip or SDM Hip Osteoarthritis

Patient information/Public Health/Self Care

Evidence/additional information

Assurance & Governance

  • This guidance was developed on: 03.2017
  • This guidance was ratified by: The OSCAR Assurance Group
  • Date ratified: 05.2017
  • Publication Date: 05.2017
  • Updated: 06:2018
  • Review Date: 04.2019
  • Ref No: MSK2 - 03.2017
Any feedback or suggestions to improve this guidance should be sent to: oscaradmin@this.nhs.uk
Only the electronic version is maintained, once printed this is no longer a controlled document

 

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