Hip osteoarthritis assessment and treatment — Rapid

Synopsis

Diagnose typical hip osteoarthritis clinically, recognise diagnoses that should not enter a routine degenerative pathway, quantify function and goals, deliver evidence-based non-operative care, and refer for replacement without inappropriate barriers.

NICE supports a clinical diagnosis in people aged 45 or over with activity-related joint pain and no morning stiffness or stiffness lasting no longer than 30 minutes; routine imaging is unnecessary in a typical presentation.
Localise groin, buttock and referred knee pain, test gait, flexion and internal rotation, examine both hips and distinguish spine, trochanteric and knee sources.
Image when the presentation is atypical, rapidly progressive, traumatic, inflammatory or uncertain, or when radiographs are needed for surgical planning; severity on film does not equal symptom severity.
Core treatment is tailored therapeutic exercise plus support for weight loss when overweight or obese, delivered with education and sustained behaviour change rather than rest.
Consider a topical NSAID and, if ineffective or unsuitable, an oral NSAID at the lowest effective dose for the shortest time with gastrointestinal, renal, liver and cardiovascular risk review and gastroprotection.
Do not routinely offer paracetamol or weak opioids except infrequently for short-term relief when other medicines are contraindicated, not tolerated or ineffective; do not offer strong opioids.
An intra-articular corticosteroid injection may offer short-term relief for about 2 to 10 weeks when other pharmacological options are unsuitable or to support exercise; do not offer hyaluronan injections.
Refer for joint replacement when pain, stiffness or reduced function substantially affects quality of life and non-surgical care is ineffective or unsuitable; use clinical judgement, not a numerical severity score or arbitrary BMI barrier.

Key red flags

Fever, systemic illness, intense passive-movement pain or a recent bacteraemic source raises concern for septic arthritis and requires urgent aspiration and source-control assessment.

Inability to bear weight after a fall, shortened or externally rotated limb, or focal bony tenderness requires urgent fracture imaging even if previous radiographs showed osteoarthritis.

Night pain unrelated to movement, weight loss, mass, previous cancer or destructive radiographic change requires malignancy investigation rather than escalation of analgesia alone.

Rapid onset in a younger adult, steroid or alcohol exposure, sickle-cell disease or transplant history raises concern for femoral-head osteonecrosis and supports early MRI when radiographs are non-diagnostic.

Investigation priorities

First-line clinical assessmentFirst stepFirst line

Diagnose a typical presentation and measure functional impact.

Management branches

TypicalDiagnose clinically and begin core care

The person is 45 or older with activity-related pain and absent or brief morning stiffness and no red flags.

Explain the diagnosis and variable relationship between symptoms and structural change without ordering routine imaging.
Prescribe tailored strengthening, aerobic and range exercise and address weight, gait aids and functional barriers.
Use medication only to enable activity, beginning with the safest suitable local or short systemic option.
Set a review against walking, sleep and personal goals rather than pain score alone.

AtypicalInvestigate the alternative

Age, tempo, stiffness, examination or systemic findings do not fit routine osteoarthritis.

Use urgent fracture or infection pathways when weight bearing, physiology or passive movement is severely abnormal.
Obtain targeted radiographs, blood tests or MRI for the specific competing diagnosis.
Refer inflammatory, oncological or osteonecrosis patterns to the appropriate specialist pathway.
Do not let pre-existing osteoarthritis on imaging explain a new red-flag syndrome.

Key medicines

Oral NSAID with gastroprotection when appropriateIf a topical NSAID is ineffective or unsuitable, prescribe one oral NSAID at the lowest effective licensed adult dose for the shortest necessary period and co-prescribe a proton-pump inhibitor such as omeprazole 20 mg orally once daily while NSAID treatment continues when appropriate.Review ulcer or bleed history, renal and liver function, cardiovascular disease, blood pressure, frailty, pregnancy, anticoagulants, antiplatelets and other nephrotoxins; avoid combining NSAIDs and stop during significant dehydration or acute kidney injury.

Intra-articular corticosteroidUse one image-guided intra-articular corticosteroid injection under the local hip-injection protocol when other pharmacological treatment is ineffective or unsuitable or a short analgesic window will support exercise; explain that benefit is usually short term, around 2 to 10 weeks.Exclude infection, discuss transient hyperglycaemia, bleeding and rare joint infection, check anticoagulation and timing relative to planned arthroplasty, and avoid serial automatic injections without reassessing diagnosis and goals.

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