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


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.
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