Red flag symptoms
- Sudden onset
- A history of trauma
- Any swelling
- Any deformity
- An inability to weight bear
- Any lumps or bumps felt in the groin
- Night pain
- Any noticeable groin pulsations
- Constipation or vomiting
- Lower limb neurological symptoms - weakness, numbness or tingling
- History of steroid use
- Testicular swelling
- Night sweats, unintentional weight loss, appetite loss
- History of malignancy
- High-risk sexual activity
Hip pain is not an uncommon presentation. There are a number of aetiologies related to the hip joint and surrounding tissues per se, but other conditions may need to be considered that can present as hip pain.
This article will not cover specific hip pathology, but provides red flag symptoms to alert you to more worrying conditions arising from the hip, or possible other aetiologies that need more urgent attention and cannot be managed by physiotherapy alone.
It is important to establish where exactly the pain is. The patient’s interpretation of where the hip joint is may not be entirely accurate. Ask your patient to point to the site of the worst pain.
How long has it been present? What were they doing when it started? Did it develop suddenly or gradually? How has it changed from onset to presentation? Has it progressively worsened? Is it constant or intermittent?
Does anything make it better such as any positions or analgesics? Does anything make it particularly worse? Have they noticed any swellings or skin changes over the area?
Have they been unable to walk at all? If they are able to mobilise, how far can they walk before it gets worse? Have they noticed any lower back pain and if so, then any weakness or numbness and tingling of the legs? If the answer to these questions is yes and a more lumbar pathology is suspected, then you may wish to enquire about any bowel or bladder incontinence along with a change in perianal sensation or sensory loss.
Have there been any noticeable lumps or bumps in the area? Are they unwell in any way? Have they had this before and if so, did they require investigations?
If you suspect a more referred pain from the renal area, then enquire about urinary symptoms and in particular haematuria.
In men, you may also wish to enquire about testicular swellings, lumps or bumps.
How is the pain affecting them at home, work, college or university?
Elicit what the patient feels the problem could be and any concerns they may have about the pain that they are experiencing. This will help guide your management plan.
This will be guided by the history.
A full set of observations may be required.
Assess the patient’s gait. Are they limping (antalgic gait)? Do they look unwell?
Expose the skin and inspect the site of the pain carefully. Are there any obvious lumps, bumps or skin changes? Is there any leg shortening or obvious rotation of the affected side?
Palpate the area in question. Is there any focal tenderness? Are there any palpable masses? If so, is the mass pulsatile, or compressible? Is it worse on standing? Is the mass unilateral or bilateral?
Move the hip joint actively assessing internal rotation, external rotation, abduction and adduction. You may wish to assess passive movements also.
You may wish to examine the knee as this may be referred pain.
A rectal examination may be appropriate as well as PSA testing (see below) if you are considering the possibility of prostate cancer with secondaries.
Possible primary care investigations
These will be guided by your history, examination findings and local access to various tests.
- Blood work including full blood count, ESR, CRP, urea and electrolytes
- Blood testing for HIV with or without syphilis
- PSA testing in men
- Serum urate
- Plain hip X-ray
- Groin ultrasound scan
- MRI lumbar spine
- MRI hip joint
Consider urgent referral if there has been a history of trauma, or the patient is acutely unwell. A palpable mass may warrant an urgent referral or a scan depending on your findings. An inability to weight bear would require a same day referral to your local accident and emergency. A suspected cauda equine syndrome would also require urgent assessment.
Refer routinely if the pain persists and nothing has materialised on your investigations. The speciality you refer to will depend on the rest of your assessment.
- Septic arthritis
- Hip dislocation
- Fractured neck of femur
- Trochanteric bursitis
- Iliotibial band syndrome
- Meralgia paraesthetica
- Avascular necrosis
- Labral tears
- Referred from lumbar spine
- Referred from sacroiliac joint
Hernias, aneurysms and benign lumps
- Inguinal lymphadenopathy secondary to multiple causes
- Inguinal hernia
- Femoral hernia
- Femoral artery aneurysm
- Sebaceous cyst
- Metastatic disease such as prostate cancer or pelvic tumours
- Renal calculus (loin to groin pain)
- Iliopsoas abscess
Hip fracture (fractured neck of femur) can cause the leg to be shortened and externally rotated. If you continue to suspect a fracture despite normal X-rays, do not hesitate to refer for a CT scan via your local casualty/orthopaedic team. Patients can occasionally weight bear so do not assume a fracture has been excluded if they are weight bearing.
A fracture could indicate osteoporosis but will need to be assessed in the context of the age of the patient and the mechanism of the injury. It may be appropriate to go ahead and treat, however using FRAX +/- DEXA may also be appropriate.
Hip fractures are a significant cause of morbidity and mortality in the elderly with a 30% mortality at one year, due to complex comorbidities and difficulty with rehabilitation.
- Dr Pipin Singh is a GP in Northumberland