Hip pain in adults

Pathophysiology

• Microtrauma occurs with repetitive stress such as running or prolonged standing

• Traumatic injuries can result from falls or high-impact collisions

• Abnormal anatomy may lead to femoroacetabular impingement (FAI) or leg length discrepancy contributing to chronic hip irritation

Common Causes

• Osteoarthritis, rheumatoid arthritis, iliotibial band (ITB) syndrome, trochanteric bursitisFemoroacetabular impingement (FAI), gluteus medius tear

Differentials

Bone

• Avascular necrosis (AVN), osteoarthritis, osteitis pubis, tumours or metastases

• Slipped upper femoral epiphysis (SUFE) in late adolescence

Cartilage and Tendons

• FAI, labral tear, ITB syndrome, chronic tendinopathies

Attachments

• Greater trochanteric pain syndrome (GTPS)

• Gluteus medius or minimus tendon tears

Nerves

• Sciatica, piriformis syndrome, obturator nerve entrapment, meralgia paraesthetica

Bursa

• Trochanteric bursitis presenting with lateral hip pain and tenderness

Muscles

• Gluteus medius tear leading to Trendelenburg gait

• Iliopsoas issues causing anterior hip or groin discomfort

Referred Pain

• Spine pathology (e.g. L2–L4 radiculopathy)

• Knee pathology (e.g. medial compartment OA)

Inflammatory

• Rheumatoid arthritis, ankylosing spondylitis, and other spondyloarthritides

Investigations

Imaging

• Plain X-ray (AP view in GP) to assess for OA, fractures, or AVN. Judicious use of frog-leg lateral views if FAI is suspected

• MRI for labral tears, occult fractures (including stress fractures), or suspected AVN if X-rays are inconclusive

• Ultrasound to detect bursitis, effusions, or tendon pathology (gluteus medius tear)

Bloods

• CRP/ESR if inflammatory conditions or infection are suspected

• Full blood count if malignancy or systemic infection is in the differential

• Other tests (e.g. rheumatoid factor, HLA-B27) if indicated by clinical suspicion

Management

Non-Pharm

• Weight reduction of at least 5–10% of body weight or aiming for a BMI <25 to decrease mechanical load

• Physiotherapy to strengthen stabilisers (gluteus medius and core), improve hip flexibility, and address leg length discrepancy if present

• Activity modification to reduce high-impact or repetitive stress. Low-impact exercises such as swimming or cycling can maintain fitness

• Ice application post-activity, especially in bursitis, tendinopathy, or acute flare-ups

Pharm

• NSAIDs (e.g. ibuprofen) for pain and inflammation

• Corticosteroid injections targeting sites such as the greater trochanteric bursa in cases of severe bursitis or GTPS

• Analgesics like paracetamol or tramadol for severe or persistent pain, considering patient comorbidities

Key Conditions

Osteoarthritis

• Morning stiffness improving after activity, pain on weight bearing, positive FABER test

• Joint space narrowing, osteophytes on X-ray

Avascular Necrosis (AVN)

• Gradual onset groin pain, risk factors include steroid use, excessive alcohol intake

• MRI more sensitive than X-ray in early disease

Osteitis Pubis

• Groin pain exacerbated by running or kicking, often with a widened pubic symphysis on X-ray

• Common in athletes, managed with rest and gradual rehabilitation

Femoroacetabular Impingement (FAI)

• Pain or clicking with hip flexion, internal rotation, and adduction, positive FADIR test

• Arthroscopic evaluation may be needed for persistent cases

Labral Tear

• Catching, clicking, or giving way, worse with rotation or prolonged sitting

• MRI arthrogram can detect labral pathology more accurately than standard MRI

Iliotibial Band (ITB) Syndrome

• Lateral hip pain or snapping, often in runners

• Improves with stretching, foam rolling, and strengthening

Greater Trochanteric Pain Syndrome (GTPS)

• Lateral hip pain and tenderness at the greater trochanter

• Positive FABER test if pain is reproduced laterally

• May involve trochanteric bursitis or gluteus medius tendinopathy

Piriformis Syndrome

• Deep buttock pain, possibly radiating down the sciatic distribution

• Triggered by prolonged sitting or activities like cycling

Meralgia Paraesthetica

• Burning or numbness in the lateral thigh from lateral femoral cutaneous nerve compression

• Aggravated by tight belts or clothing

Red Flags

• Significant trauma suggesting fracture or dislocation

• Systemic signs such as fever or unexplained weight loss raising concern for infection or malignancy

• Persistent groin pain suggesting AVN or an intra-abdominal source

• Mechanical locking or instability indicating possible labral tear or advanced OA

Other Interventions

• Platelet-rich plasma (PRP) injections for chronic tendinopathies if refractory to standard care

• Hydrodilatation or image-guided injections for adhesive capsulitis or recalcitrant bursitis

• Surgical referral for labral tears, FAI correction, advanced AVN, or severe OA requiring joint replacement

• Podiatry referral for orthotics if leg length discrepancy or foot biomechanics contribute to hip stress

Additional Points

• Trendelenburg sign can indicate gluteus medius weakness, commonly seen in GTPS or advanced OA

• Early intervention with physiotherapy can minimise progression of chronic conditions such as FAI or gluteus medius tears

• In adolescents or young adults with persistent hip or groin pain, consider SUFE or early AVN and arrange timely imaging

• Ensuring adequate vitamin D, calcium, and addressing any underlying metabolic bone disease can aid long-term joint health