Recurrent Hip Area Pain in an Adult

Differential Diagnosis

Common Diagnoses

Occasional Diagnoses

Rare Diagnoses

  • Impacted Fracture
  • Dislocation
  • Bony Pathology (e.g. Secondaries, Paget’s)

Ready Reckoner

Key distinguishing features of the most common diagnoses

Muscular/ ligamentOsteoarthritisTrochanteric BursitisReferred from BackMeralgia Paraesthetica
Pain Lying on Affected SidePossibleNoYesNoNo
Leg NumbnessNoNoNoPossibleYes
Painful Hip MovementYesYesPossibleNoNo
Pain Mainly in GroinPossibleYesNoPossibleNo
Coexisting Back PainNoPossibleNoYesNo

Possible Investigations

Likely:X-ray.

Possible:FBC, CRP, autoantibodies, HLA-B27, alkaline phosphatase, urinalysis.

Small Print:Arthroscopy, bone scan, lumbar spine MRI (all in hospital).

  • X-ray: May show evidence of osteoarthritis, avascular necrosis, fracture, dislocation, hip replacement loosening and bony pathology. Spinal X-ray may reveal spinal pathology as a cause.
  • FBC, CRP: CRP may be elevated and Hb reduced in inflammatory arthritis. CRP and WCC raised in infection of joint prosthesis.
  • Autoantibodies: For clues about the aetiology of inflammatory arthritis.
  • HLA-B27: A high prevalence in spondoarthritides.
  • Alkaline phosphatase: Raised in Paget’s disease.
  • Urinalysis: May reveal proteinuria or haematuria if there is renal involvement in inflammatory arthritis.
  • Arthroscopy: Diagnostic and potentially therapeutic in labral tear.
  • Bone scan: May reveal bony secondaries.
  • Lumbar spine MRI: For evidence of spinal stenosis; might reveal other causes of pain referred from spine.

Top Tips

  • Check what the patient means by ‘hip’. Most don’t realise that the hip joint is actually in the groin.
  • An X-ray may not be necessary, even if the clinical picture suggests hip arthritis – but the patient may well expect one, so ensure it is at least discussed.
  • Examine the patient standing up – this may reveal a hernia as the cause.
  • Localised lateral pain aggravated by lying on the affected side is likely to be caused by trochanteric bursitis.

Red Flags

  • Remember the possibility of loosening or infection in joint replacements.
  • Consider avascular necrosis if a patient on long-term steroids develops severe hip pain.
  • Beware that the elderly can sometimes remain weight bearing – albeit with pain and a limp – after an impacted hip fracture.
  • Significant depression may aggravate or result from hip arthritis pain – consider a trial of antidepressants.

Published: 2nd August 2022 Updated: 10th April 2024

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Based on the best-selling book Symptom Sorter, Nursing in Practice Reference is designed to help nurses working in primary and community care make sense of patient presentations. Written by GPs and adapted by nurses, it covers the vast majority of symptoms seen in primary care to inform different nursing disciplines with a range of responsibilities. Each symptom is organised into common, occasional or rare differentials, with distinguishing features, possible investigations and key points. It also provides guides on managing more than 350 conditions. The perspective is very much grass roots primary care, informed by the latest evidence and guidance.

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Disclaimer

Nursing in Practice Reference is based on the best-selling book Symptom Sorter. The experts behind Nursing in Practice Reference are Marilyn Eveleigh who is Nursing in Practice’s editorial advisor and a primary care nurse in East Sussex, Dr Keith Hopcroft who is the co-author of Symptom Sorter, a GP in Essex and Pulse editorial advisor and Dr Poppy Freeman, a GP in Camden and also a clinical advisor to Pulse.