Red flags for hip conditions

Prior to referral consider / screen to exclude:

  • Traumatic injury / fracture  e.g. osteoporotic fracture in elderly (pubic rami fracture an example), AVN (consider lifestyle of younger patient) and pathological fracture
  • Diabetes :- risk of neurovascular complications and infection
  • HIV risks:- sero-negative arthropathy, infective arthritis,  peripheral neuropathy
  • Inflammatory Arthropathy e.g. Rheumatoid Arthritis, Psoriatic Arthritis
  • Peripheral arterial disease and occlusion risks:-Ischaemic heart disease , claudication, smoker, sedentary, Type II Diabetes
  • Septic Arthritis / Infection :-  risks e.g. recent infection,  surgery or injection, immunosuppressive disorders
  • Past medical history of cancer (possible malignant fracture proximal femur).

Key Clinical Observations of concern:

  • Hot / red / swollen joint with raised body temperature  (raised inflammatory markers)
  • Septic/Unwell
  • Rapidly worsening deformity
  • Neuro-vascular compromise
  • Weight loss
  • Continuous pain, including at night and when not weight bearing.
  • Unable to walk or move hip.
Urgent hip referral

Patients with any of the following suspected should be sent to A&E

  • Fracture or dislocation
  • Suspected infection


Urgent appointments can be made for patients at Fracture/ Trauma Clinic.

  • On- going infection
  • Trauma/stress fracture
  • Slipped capital femoral epiphysis
  • Apophyseal injury
  • Avascular necrosis


Urgent appointments can be made in elective Orthopaedic/ Rheumatology/Pain Clinics for patients with:

  • Rapidly worsening symptoms
  • Confirmed presence of cancer on imaging.
  • Constant unrelenting pain / especially unrelenting night pain in presence of cancer
  • Progressive or significant neurological loss suggestive of acute peripheral nerve compression
GP / Primary Clinician
Exclude red flags: e.g. infection, trauma-femoral neck fracture, AVN.

Consider diagnosis (discuss within peer review).

Differential diagnoses:

  • Lumbosacral referred pain, facet OA, sciatica/nerve root pain.
  • OA Hip, Inferior or Superior Gluteal nerve injury, Gluteus medius tear.

Regional Pain Syndrome combinations of bursitis, gluteal tendinopathy, myofascial pain:

  • Prevalence 1.8/1000 (10-25% population).
  • Higher in women, patients with coexisting low back pain, osteoarthritis, iliotibial band tightness, leg length discrepancy or obesity.
  • Overuse injury often associated with sporting activities.


  • Exquisite tenderness over the lateral hip/ greater trochanter. Pain may radiate to the knee.
  • Pain worse lying on the affected side, with prolonged standing or transitioning to a standing position, sitting with the affected leg crossed and with climbing stairs, walking, running or other high impact activities.
  • Painful single leg stand.
  • Pain made worse on palpation with active contraction of gluteus medius (resisted hip abduction in side-lying).


Most cases can successfully be treated with self management:

  • Optimal analgesia/ NSAIDS
  • Avoid aggravating activities
  • Ice packs - 10 minutes 3-4 times a day.
  • Weight loss, if appropriate.
  • Consider temporary use of walking stick.
  • Consider self referral or refer to Physiotherapy .

If not resolving in 4 weeks steroid injection +/- local anaesthetic (small volume injection adequate) with an exercise programme to confirm the diagnosis. If not able to offer this treatment refer to Interface Team.

If steroid injection does not work reconsider diagnosis.


  • Consider X-ray if trauma or suspected tumour or infection or arthritis, AVN or inflammation.
  • Not routinely indicated if firm diagnosis.
  • Consider guidelines in previous section.
  • Assessment / Diagnosis/ Detailed advice.
  • Appropriate multi –modal package of care i.e. combinations of stretching, strengthening and joint mobilisation as part of functional restoration and adherence to exercise.
  • Consider corticosteroid injection (if available within service) as part of a package of care with exercise and stretches

If not responding consider onward referral to Interface Team.

Interface Team
  • Review/Consider previous assessment , diagnosis and management
  • Consider corticosteroid injection if not already undertaken or in recurrence.
  • If not responding, despite steroid injection consider referral to surgeon (if fits criteria).

If patient does not fit surgical criteria or patient does not want to consider surgery refer back to GP or consider referral to Pain Clinic.


  • Consider X-ray if trauma or suspected tumour or infection or arthritis, AVN or inflammation.
  • Not indicated routinely.
  • MRI scan if recalcitrant (for diagnosis if x-ray inconclusive).
  • GTPS consider MRI pre surgical referral.


Surgical Criteria

Patients with lateral hip pain are highly unlikely to require a referral to secondary care. Therefore, no referrals should be made to secondary care orthopaedics unless the following criteria are met:

  • Patient has intrusive pain affecting lifestyle despite 6-12 months of comprehensive conservative management including physiotherapy.


  • Corticosteroid injection has been considered and undertaken (if appropriate) with limited response up to a maximum of 3 injections per year


  • Review by MSK interface suggests that patient is likely to benefit from further management/surgery by a secondary care consultant.


  • The patient has shown commitment to weight reduction through active participation in a weight management programme if the patient’s BMI is >30


  • General Health including fitness for anaesthesia has been considered and believed adequate to proceed to potential surgical intervention and it is believed that the patient is likely to derive quality of life benefits from surgery


  • Health Care Professional has discussed surgery with the patient who has confirmed they want explore surgery


Note that patients with lateral hip pain are unlikely to benefit from surgery.

  • Patients with Bursitis rarely require referral to secondary care and surgery for this condition is extremely rare.
  • Decompression surgery (70% success rate) - recovery period 4-6 weeks.