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 (eg. Septic arthritis or ostemyelitis)


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 Cancer ie not previously documented metastases
  • 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

Consider diagnosis (discuss within peer review).

  • Screen for red flags.
  • Consider avascular necrosis (AVN).
  • Consider rapid deterioration in symptoms.

Common Presentation:

  • Pain in groin, buttock and thigh - worse on weight bearing, walking, crossed leg sitting and putting on shoes and socks.
  • Night pain is common.
  • Relieved by  non weight bearing or stiffness after rest.
  • Sometimes pain referred to anterior aspect of the knee (knee X-ray likely NAD).
  • Loss of hip flexion and internal rotation.
  • Useful blood test FBC.
  • Undertake Oxford score PROM to ascertain pre treatment score in accordance with commissioned referral.


Early stages:

  • Optimal analgesia/ NSAIDS/Ice.
  • Avoid aggravating activities.
  • Discuss weight management and smoking cessation if appropriate
  • Advice on walking stick (held in opposite hand from affected joint).
  • Consider self referral or referral to Physiotherapy.
  • Refer for Falls Assessment if appropriate.

Later Stages:


  • Recommend X-ray AP Pelvis centred on pubic symphysis for OA diagnosis or where rapid deterioration of symptoms present.
  • X-ray AP Pelvis where suspicious of trauma, infection, tumour, inflammatory arthritis (AVN maybe X-ray negative until established 6-9 months).
  • X-ray AP Pelvis prior to onward referral.
  • Consider guidelines in previous section.
  • Assessment / Diagnosis/ Detailed advice.
  • Motivational interview for physical activity and weight management.
  • Lifestyle management / General exercises for aerobic fitness.
  • Safe supply of aids and appliances e.g. walking stick if not already supplied.
  • Specific exercise for strengthening and mobilising/stretching.
  • Manual therapy/ mobilisations where indicated.
  • Mobility/ balance assessment (consider falls risk and management).

If not responding consider referral to Interface Team.

Interface Team
  • Consider/ review previous assessment, diagnosis and management .
  • Consider referral criteria for weight management services.
  • Motivational interview for physical activity and reinforce weight management.
  • Discuss shared decision making grid (if not already undertaken).                                              
  • If complies with surgical criteria refer for orthopaedic appointment.
  • If patient does not choose surgical option; consider referral to Occupational Therapist for aids to daily living or consider referral to Pain Clinic.
  • Where patient has intrusive pain but is not fit (or willing) for surgery consider referral to Pain clinic for consideration of intra-articular steroid (although limited benefit).


  • Recommend X-ray if not previously undertaken.
  • X-ray AP Pelvis centred on pubic symphysis for OA diagnosis or where rapid deterioration of symptoms present.
  • X-ray where suspicious of trauma, infection, tumour, inflammatory arthritis (AVN maybe X-ray negative until established 6-9 months).
  • X-ray A-P pelvis essential prior to onward referral.
Referral Criteria

In addition to Osteoarthritis being clinically considered as the likely diagnosis, the additional criteria must be met prior to a referral to secondary care:

  • Patient has intrusive pain affecting lifestyle that is not improving despite 6 months of comprehensive conservative management and lifestyle changes in line with NICE Guidance


  • X-ray undertaken prior to referral confirms OA diagnosis


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


  • Review by health care professional suggests that patient is likely to benefit from surgery.


  • A healthcare professional has discussed surgery with the patient who has confirmed they want to explore surgery


  • 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.


Individual Funding Requests

Hip resurfacing and hip replacement is listed on Gloucestershire CCG's Effective Clinical Commissioning Policy.  Please the links below for details of access criteria and funding arrangements:

  • Total Hip replacement- time to drive 6 weeks, time to recovery 3-9 months. Understanding implications for life changes critical.
  • Hip re-surfacing - time to drive 3-4 weeks, time to recovery 3-9 months.