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Hip Osteoarthritis Care Pathway

Date of last update: October, 2024

4. Differential Diagnosis Requiring Medical Attention

 

Note: Musculoskeletal peripheral neuropathies or hip pathologies do not necessarily require referral to a medical provider, unlike other conditions in this section.

 

Red Flags: Immediate Referral to Emergency Care:

1. Cauda Equina Syndrome

  • Pain Location: Severe low back pain.

  • Signs/Symptoms/Red Flags: Saddle anesthesia, bowel overflow incontinence, bladder retention or overflow incontinence, bilateral progressive radicular signs.

  • Physical and Neurological Examination: Decreased perianal sensation, decreased anal sphincter tone, progressive lower extremity weakness.

  • Action: Immediate referral to emergency care.

 

2. Hip Infection (e.g., septic arthritis)

  • Pain Location: Localized severe hip pain.

  • Signs/Symptoms/Red Flags: Systemic (fever, chills, fatigue), localized pain, swelling, redness, immunosuppression, recent infection or surgery, TB (tuberculosis) history, IV drug use, poor living conditions.

  • Physical and Neurological Examination: Tenderness over the affected area, possible erythema and warmth, possible neurological deficits.

  • Action: Immediate referral to emergency care.

 

3. Traumatic Hip Fracture (e.g., avulsion, compression, etc.)

  • Pain Location: Localized pain in the hip or upper leg.

  • Signs/Symptoms/Red Flags: Sudden onset of severe pain following severe trauma, swelling and bruising around hip and/or upper leg, inability to stand or put weight on the affected hip.

  • Physical and Neurological Examination: Point tenderness, erythema, edema, and/or bruising.

  • Action: Immediate referral to emergency care.

 

Refer to Medical Provider:

 

1. Non-traumatic Stress Hip Fracture

  • Pain Location: Localized pain in the hip or thigh.

  • Signs/Symptoms: Sudden onset of severe pain following minor trauma or spontaneous in osteoporotic patients, corticosteroid use, female sex, older age (>60), history of spinal fracture or cancer.

  • Physical and Neurological Examination: Point tenderness over the hip, antalgic gait.

  • Action: Referral to appropriate medical provider.

 

2. Hip Malignancy (e.g., Chondrosarcoma, Multiple Myeloma, etc.)

  • Pain Location: Severe, progressive, localized hip pain, with possible referral to the thigh.

  • Signs/Symptoms: History of cancer; persistent pain, worse at night, not relieved by rest, constitutional symptoms (night sweats, unexplained weight loss, fatigue, fever).

  • Physical and Neurological Examination: Localized tenderness, but pain not reproducible with range of motion and orthopedic tests.

  • Action: Referral to appropriate medical provider.

 

3. Inflammatory Arthritides

1. Spondyloarthropathies (e.g., Ankylosing Spondylitis, Psoriatic Arthritis, Reactive Arthritis):

  • Pain Location: Hip pain. May radiate to buttocks and thighs.

  • Signs/Symptoms: Morning stiffness > 1 hour, pain improves with activity, pain worse at night or at rest, presence of other inflammatory signs (e.g., uveitis, psoriasis), systematic symptoms (fatigue, weight loss, fever).

  • Physical Examination: Possible reduced spinal mobility, positive Schober’s test, tenderness over joints.

  • Action: Referral to appropriate medical provider.

2. Polymyalgia Rheumatica

  • Pain Location: Bilateral hip pain, may also include bilateral shoulder pain.

  • Signs/Symptoms: Symmetrical joint pain and stiffness, morning stiffness > 1 hour, systemic symptoms (fatigue, weight loss, fever, loss of appetite, unexplained weight loss).

  • Physical Examination: Joint swelling, tenderness. No weakness.

  • Action: Referral to appropriate medical provider.

3. Systematic Lupus Erythematosus (SLE)

  • Pain Location: May include lower back and other joints.

  • Signs/Symptoms: Joint pain and swelling, fatigue, butterfly-shaped rash on the face, photosensitivity, systemic symptoms (fatigue, weight loss, fever).

  • Physical Examination: Joint tenderness and swelling, skin rashes, signs of organ involvement such as kidney issues or pleuritis.

  • Action: Referral to appropriate medical provider.

4. Referred Pain (from abdominal/pelvic visceral conditions)

 (e.g., aortic aneurysm, testicular pain, endometriosis, ovarian cysts, kidney stones, appendicitis)

  • Pain Location: Varies depending on the condition, often referring to the back or hip.

  • Signs/Symptoms: Specific to the underlying condition, may include abdominal pain, gastrointestinal symptoms, urinary symptoms, systemic symptoms (e.g., fever, chills, weight loss).

  • Physical Examination: Abdominal or pelvic tenderness, palpable mass, and other specific signs related to the condition (e.g., Murphy's sign for kidney stones, Cullen's sign for pancreatitis, rebound tenderness of McBurney’s point for appendicitis).

  • Action: Referral to appropriate medical provider.

 

5. Avascular Necrosis (e.g., Chandler’s Disease)

  • Pain Location: Pain in the hip, groin or buttock, unilateral or bilateral.

  • Signs/Symptoms: Vague non-specific pain in the hip, pain and decreased range of motion progressively worsening over time, limp. Worse with standing or walking. Relieved with rest. May present with knee pain. Predisposing factors include middle or older age, trauma, hemoglobinopathies, corticosteroid use, collagen disease, radiation, alcoholism, smoking, gout, or metabolic syndrome.

  • Physical Examination: Pain with range of motion and limited motion. Antalgic gait. Muscle atrophy around the hip joint.

  • Action: Referral to appropriate medical provider.

 

6. Hernia (e.g., femoral or inguinal hernia)

  • Pain Location: Groin pain.

  • Signs/Symptoms: Swelling or bulge/lump in groin. Bulge can be pushed back in or disappears with lying down. Coughing and straining recreates the pain and makes the lump appear. More common with aging.

  • Physical Examination: Visible bulge with abdominal flexion.

  • Action: Referral to appropriate medical provider, unless sudden severe pain and/or the hernia becomes firm or tender, which requires immediate referral to emergency care. 

7. Meralgia Paresthetica

  • Pain Location: Hip pain with anterior-lateral thigh pain.

  • Signs/Symptoms: Leg pain, burning, or numbness that can be unilateral or bilateral. History of recent weight gain or pregnancy.

  • Physical Examination: Pain, burning, numbness, or tingling  reproduced with compression of the lateral femoral cutaneous nerve of the thigh, tenderness medial to the anterior superior iliac spine.

  • Action: Does not necessarily require referral to a medical provider.

8. Lumbar Radiculopathy or Radicular Pain

  • Pain Location: Unilateral upper thigh pain with or without low back pain.

  • Signs/Symptoms: Leg pain, paresthesia, or weakness a dermatomal or myotomal distribution of a lumbar nerve root. Leg pain aggravated with flexion or all movements. Relieved with extension or standing.

  • Physical Examination: Possible sensory deficits, weakness, or reflex loss. Provocation tests such as Straight Leg Raise or Ely’s are positive.

  • Action: Does not necessarily require referral to a medical provider unless there are significant or progressive neurological deficits, severe unresponsive pain, or other complicating factors that may require further medical intervention or surgical consultation. Possible causes of radiculopathy are lumbar disc herniation or facet joint arthritis leading to IVF stenosis. 

9. Neurogenic Claudication (Lumbar Spinal Stenosis)

  • Pain Location: Unilateral or bilateral buttock, with or without leg pain.

  • Signs/Symptoms: “Searing” or burning pain; aggravated by prolonged standing, walking, or sitting reclined.

  • Physical Examination: Pain may or may not be reproduced by in-clinic tests; no neurological deficits.

  • Action: Does not necessarily require referral to a medical provider.

10. Common Low Back Pain

(e.g., non-specific, lumbar or lumbo-sacral strain/sprain, sacroiliac joint dysfunction, myofascial pain syndrome, facet joint irritation, osteoarthritis)

  • Pain Location: Below costal margin and above inferior gluteal folds, with or without leg pain.

  • Signs/Symptoms: Sharp, dull, shooting, or aching pain; aggravated by specific movements; associated muscle stiffness or spasms; may refer into legs but not below knees.

  • Physical Examination: Pain reproduced by tests; no neurological deficits.

  • Action: Does not necessarily require referral to a medical provider.

11. Deep Gluteal Syndrome

(e.g., piriformis syndrome)

  • Pain Location: Buttock and posterior leg, with or without pain radiating to foot.

  • Signs/Symptoms: Pain exacerbated by sitting, climbing stairs, or performing squats; tenderness in deep gluteal region.

  • Physical Examination: Signs of sciatic nerve irritation, but not following a radicular pattern associated with nerve roots.

  • Action: Does not necessarily require referral to a medical provider.

12. Soft Tissue Disorders of the Hip

(e.g., greater trochanteric pain syndrome, bursitis, hip flexor strain or sprain, tendinopathy, femoroacetabular impingement, labral tear, IT band syndrome, snapping hip syndrome, adductor strain)

  • Pain Location: Hip (trochanteric area) and/or buttock pain

  • Signs/Symptoms: Hip or buttock pain that may refer into the anterior or posterior thigh or groin. Aching or sharp pain. May include popping, snapping, or locking. Possible history of traumatic injury in sport or recreational activity.

  • Physical Examination: Pain is reproduced during hip examination, limping gait, possible Trendelenburg sign.

  • Action: Does not necessarily require referral to a medical provider.

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