Recurrent Hip Area Pain in an Adult

Hip area pain is a common presentation in the middle-aged and elderly, and the patient will often attribute it to osteoarthritis. This diagnosis may well be correct, although the differential is wide – besides, the patient’s view of what actually constitutes the ‘hip’ may be at odds with the anatomical truth. The differential for the child with hip pain is very different – see the 'Limp in a child' section.

Published: 2nd August 2022 | Updated: 15th August 2022

Differential diagnosis

Common Diagnoses

  • Muscular/Ligamentous Strain
  • Osteoarthritis
  • Trochanteric Bursitis
  • Referred from Back
  • Meralgia Paraesthetica

Occasional Diagnoses

  • Inflammatory Arthritis
  • Avascular Necrosis
  • Hernia
  • Complications of a Total Hip Replacement (e.g. Loosening, Infection)
  • Spinal Stenosis
  • Iliotibial Band Syndrome
  • Acetabular Labral Tear

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

Likely: X-ray.

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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Website disclaimer

Pulse Reference is based on the best-selling book Symptom Sorter.

The experts behind Pulse Reference are Dr Keith Hopcroft who is the co-author of Symptom Sorter, a GP in Essex and Pulse’s editorial advisor and Dr Poppy Freeman, a GP in Camden and also a clinical advisor to Pulse.

This website is for clinical guidance only and cannot give definitive diagnostic information. Practitioners should work within the limits of their individual professional practice, seek guidance when necessary and refer appropriately.