One-liner#
Adult/geriatric approach to hip pain: localize pain (groin vs lateral vs buttock), separate intra-articular hip disease from referred lumbar pathology, and screen for fracture/infection.
Quick nav#
- Red flags / send to ED
- Key history
- Focused exam
- Differential (quick pattern recognition)
- Workup
- Initial management
- Management by diagnosis
- Follow-up
- Patient instructions
Red flags / send to ED#
- Inability to bear weight after fall/trauma (occult hip fracture until proven otherwise in older adults)
- Hot, swollen, painful hip with fever/systemic illness (suspected septic arthritis)
- Acute severe atraumatic pain with systemic symptoms or rapidly progressive functional decline
- New objective neuro deficits (consider lumbar spine pathology)
Key history#
- Location: groin/deep anterior (often intra-articular hip), lateral (greater trochanteric pain), buttock/back (lumbar/SI)
- Trauma vs atraumatic; ability to bear weight; onset (sudden vs gradual)
- Mechanical symptoms: catching/clicking; stiffness; night pain
- Radiation: down leg (radicular) vs localized
- Risk factors: age/osteoporosis, chronic steroids/alcohol (AVN risk), diabetes/immunosuppression (infection risk)
- Functional impact: walking tolerance, stairs, putting on socks/shoes, getting in/out of car
Focused exam#
- Gait (antalgic, Trendelenburg); ability to single-leg stand
- Palpation: greater trochanter, groin/anterior hip flexors, SI region
- ROM: especially internal rotation (often reduced/painful in hip OA); log roll
- FABER/FADIR (context-dependent); pain location with maneuvers matters
- Strength: hip abductors; neuro screen if radicular symptoms (strength/sensation/reflexes)
Differential (quick pattern recognition)#
Common/likely (outpatient)#
| Diagnosis | Keywords patients use | Key clues | Focused exam clues | Initial next step |
|---|---|---|---|---|
| Hip osteoarthritis | “Groin pain,” “stiff,” “hard to put on socks” | Gradual; worse with weight-bearing | Decreased/painful internal rotation; crepitus | PT/strengthening, activity pacing, topicals/analgesics; consider x-ray if changes management |
| Greater trochanteric pain syndrome | “Side of hip,” “hurts to sleep on it” | Lateral pain; worse with stairs/lying on side | Tender greater trochanter; pain with resisted abduction | PT (glute med strengthening), avoid compressive positions, topicals |
| Lumbar radiculopathy referred to hip | “Burning/shooting,” numbness | Back pain + leg symptoms | +SLR/femoral stretch; neuro changes | Treat spine pattern; consider imaging if deficits |
| Hip flexor/adductor strain | “Pulled,” anterior pain with lifting knee | Overuse; sports; acute strain | Pain with resisted flexion/adduction | Relative rest, gradual rehab |
| SI joint pain | “Pain near one dimple,” buttock pain | Worse with transitions/standing | Tender SI; provocative tests may reproduce | PT/core/hip stabilization |
Can’t-miss / urgent#
| Diagnosis | Keywords patients use | Key clues | Focused exam clues | Initial next step |
|---|---|---|---|---|
| Hip fracture (including occult) | “Can’t bear weight,” after fall | Older/osteoporosis; even minor fall | Pain with log roll; shortened/externally rotated leg (may be absent) | ED/same-day imaging; consider MRI if x-ray negative but suspicion high |
| Septic arthritis | “Hot,” “throbbing,” feels sick | Fever/risk factors; severe pain with any motion | Pain with passive ROM; inability to bear weight | ED now; aspiration/labs/IV antibiotics |
| Avascular necrosis | “Deep groin pain,” progressive | Steroids/alcohol; gradual but progressive | Painful ROM; x-ray may be normal early | Non-urgent MRI if suspected; referral |
Workup#
- X-ray (AP pelvis + hip; weight-bearing if possible) for trauma, inability to bear weight, suspected OA when it changes management, or persistent symptoms.
- MRI (urgent) when fracture is suspected but x-ray is negative (occult fracture pathway).
- MRI (non-urgent) for suspected AVN or atypical persistent groin pain with normal x-ray when results would change management/referral.
- Labs (CBC, ESR/CRP) when infection/inflammatory arthritis suspected (do not delay ED pathway if septic arthritis suspected).
Initial management#
- Localize and treat the likely pain generator (hip vs trochanteric vs spine).
- Analgesics/topicals as appropriate—see medication tables below.
- Offload when needed: cane in contralateral hand, shorten stride, avoid painful hills/stairs during acute flare.
- Early PT for OA/GTPS and many overuse syndromes; prioritize hip abductor strength and gait mechanics.
Analgesic options for hip pain#
| Drug | Dose | Contraindications | Monitoring | Cost | Notes |
|---|---|---|---|---|---|
| Acetaminophen | 650–1000 mg q6–8h; max 3 g/day | Severe hepatic impairment | LFTs if prolonged use | $ | Safe first-line; limited efficacy alone for OA |
| Ibuprofen | 400–600 mg q6–8h with food; max 2400 mg/day | CKD, GI bleed, HF, anticoagulation | Cr, BP if prolonged | $ | Effective; limit to 7–10 days if possible |
| Naproxen | 250–500 mg q12h; max 1000 mg/day | Same as ibuprofen | Same as ibuprofen | $ | Convenient BID dosing |
| Meloxicam | 7.5–15 mg daily | Same as ibuprofen | Same as ibuprofen | $ | Once-daily; COX-2 preferential |
| Diclofenac gel 1% | Apply 4 g to lateral hip QID | Avoid on broken skin | Minimal systemic absorption | $$ | Useful for GTPS (superficial); less effective for deep hip OA |
| Duloxetine | 30 mg daily × 1 week, then 60 mg daily | Hepatic impairment; MAOIs | BP, mood | $$ | FDA-approved for chronic MSK pain; consider if NSAIDs contraindicated |
Hip injection options (verify local protocol)#
| Injection site | Agent/Dose | Indications | Contraindications | Notes |
|---|---|---|---|---|
| Intra-articular hip (GH joint) | Triamcinolone 40–80 mg + lidocaine | Hip OA not responding to conservative care | Infection, overlying cellulitis | Usually done with fluoroscopy or ultrasound guidance; provides weeks–months relief |
| Greater trochanteric bursa | Triamcinolone 40 mg + 3–5 mL lidocaine | GTPS not responding to PT | Infection, overlying cellulitis | Can be done landmark-guided or with ultrasound; good response rates |
When NOT to inject:
- Suspected septic joint (aspirate first)
- Overlying cellulitis or skin breakdown
- More than 3 injections per site per year
- Uncontrolled diabetes without glucose monitoring plan
Management by diagnosis#
Hip osteoarthritis#
- Education: imaging correlates imperfectly with pain; strengthening and pacing drive function.
- Treatment:
- PT (hip/core; hip abductor and posterior chain strengthening), activity pacing, and graded walking plan.
- Topical NSAID first-line; consider oral NSAID if needed and safe.
- Consider injection pathway when pain blocks rehab and diagnosis is consistent (verify local protocol).
- Consider ortho referral when function remains poor despite optimized conservative care.
- Follow-up: 6–12 weeks.
Greater trochanteric pain syndrome#
- Education: avoid prolonged side-lying on the painful side and sustained hip adduction (e.g., crossing legs) early on.
- Treatment:
- Gluteal strengthening and gradual loading; address biomechanics (Trendelenburg gait, hip drop).
- Avoid compressive positions early (side-lying on painful side, legs crossed); consider pillow between knees when sleeping.
- Consider injection pathway if persistent and rehab-limited (verify local protocol).
- Follow-up: 4–6 weeks.
Hip flexor/adductor strain#
- Education: overuse/strain improves with gradual loading; sharp worsening should prompt reassessment.
- Treatment: relative rest, avoid high-knee loading initially, gradual rehab and flexibility/strength work via PT as needed; analgesics/topicals as appropriate.
- Follow-up: 2–4 weeks (earlier if worsening or inability to bear weight).
Lumbar radiculopathy referred to hip#
- Education: leg symptoms can persist for weeks; monitor strength and function.
- Treatment: treat as spine pattern (activity as tolerated, PT/nerve mobility as indicated); consider imaging/referral if objective deficits or persistent disabling symptoms.
- Follow-up: 1–2 weeks if significant symptoms; urgent re-eval for new/worsening weakness, bowel/bladder changes.
Avascular necrosis (suspected)#
- Education: early x-rays can be normal; persistent deep groin pain with risk factors warrants further evaluation.
- Treatment: activity modification and analgesia while arranging MRI and referral pathway.
- Follow-up: within 2–4 weeks (sooner if rapid decline).
Suspected occult fracture / inability to bear weight#
- Education: fractures can be missed on initial x-ray.
- Treatment: urgent imaging and protected weight-bearing until clarified.
- Follow-up: same-day/ED pathway.
Follow-up#
- Reassess in 4–6 weeks for OA/GTPS once rehab plan started.
- Reassess sooner (days–1 week) for severe pain, inability to bear weight, or uncertain diagnosis.
- Urgent return for fever with worsening hip pain, new inability to bear weight, or new neurologic deficits.
- If not improving after 6–12 weeks of appropriate conservative care, escalate (repeat imaging if indicated, injection pathway, or referral) based on the working diagnosis.
Patient instructions#
- Keep walking/moving as tolerated; avoid activities that sharply worsen pain.
- Use ice/heat and over-the-counter pain options if safe for you.
- Seek urgent care for fever with a hot/painful hip, or if you cannot bear weight after a fall.
Smartphrase snippets#
Hip OA, conservative management:
Hip pain consistent with osteoarthritis; groin pain with decreased internal rotation. Plan: PT referral for hip/core strengthening, activity pacing, topical NSAID. Will consider injection if conservative measures fail. Return precautions reviewed.
Greater trochanteric pain syndrome:
Lateral hip pain consistent with greater trochanteric pain syndrome; tender over greater trochanter. Plan: PT for gluteal strengthening, avoid compressive positions, topical NSAID. Will consider injection if persistent. Return precautions reviewed.
Hip pain, uncertain etiology:
Hip pain with [groin/lateral/buttock] localization; exam notable for [findings]. Differential includes [OA/GTPS/referred lumbar]. Plan: [PT/imaging/analgesics]. Will reassess in [timeframe]; return precautions reviewed.
Related pages#
Complaint pages#
- Back pain — lumbar pathology that may refer to hip/buttock
- Knee pain — hip pathology may refer to knee; evaluate both
- Falls/Injury evaluation — trauma assessment and fracture risk
- Monoarticular swelling — acute joint swelling differential
Problem pages#
- Osteoarthritis — comprehensive OA management including hip-specific considerations
- Osteoporosis — fracture risk assessment and bone health (hip fracture prevention)
- Gout — crystal arthropathy can affect hip (less common)
Coding/billing notes (optional)#
- Document pain location (groin vs lateral vs buttock), weight-bearing status, ROM findings (esp. internal rotation), and red-flag screening.