Hip Pain Due to Osteoarthritis

Scope

This is the commissioned pathway for hip pain due to osteoarthritis

450 patients per 100 000 population present to Primary Care annually with hip pain

25% resolve in 3 months – 35% at 12 months

Pain felt around and attributed to the hip can also be due to spinal or abdominal disorders which should be excluded.

Hip pathology may cause pain felt only at the knee.

Degenerative hip disease is the most common diagnosis in the adult and is the long-term consequence of predisposing conditions.

Osteoarthritis (OA) may not be progressive and most patients will not need surgery, with their symptoms adequately controlled by nonsurgical measures. Symptoms progress in 15% of patients within 3 years and 28% within 6 years.

Unless red flags are present all patients referred for consideration of arthroplasty due to osteoarthritis will be assessed by a community assesment service which provide a holistic assessment of their symptoms and disabilities before being helped to make a decision on the possible treatment options. This assessment will include Oxford hip scoring and patient decision making aids. Treatment options will include lifestyle modifications, physiotherapy, improved general health and well being or surgery.

Please note pre-referral criteria are applicable in this referral and referrals may be returned if this information is not contained within the referral

Please note primary care is requested to follow In Shape for Surgery best practice which can be seen here.

Out of Scope

Hip pain for reasons other than osteoarthritis.

Assessment

History

Please include detail such as:

  • Pain
    • In the groin, medial thigh or greater trochanter radiating to thigh or knee at rest and/or after activity
    • isolated knee pain
  • Impact on occupation, daily activity or sports (e.g. decrease in walking distance, difficulty in negotiating stairs or performing pedicure)
  • Duration and onset
  • Aggravating and relieving factors
  • Details of previous surgery

Red Flags

Red Flags which will bypass the Community Assesment Service (should be referred urgently to secondary care)

  • Fracture or trauma
  • Suspicion of tumour or evidence of any destructive lesion on radiograph
  • Unexplained, increasing or sudden onset severe pain in a previously replaced joint
  • Any features suspicious of infection, including:
    • Cellulitis over the joint
    • Large effusion and erythema
    • Inflamed scar/wound over a previously replaced joint
  • Inability to walk or weight bear
  • Evidence of new inflammatory arthropathy
  • Avascular necrosis/osteonecrosis
  • The following hip condition:
    • Protrusio acetabula

Investigations

  • A plain A-P radiograph of the pelvis may be requested to confirm the diagnosis after history and examination if the patient is over 50 years of age OR is younger than this if OA is suspected
  • No further imaging (e.g. MRI or bone scan) is appropriate before referral

Management

Mild Symptoms

  • see MyHealth Devon Hip Pain (Osteoarthritis)
  • Offer verbal and written information about condition
  • Offer information to support weight loss if people are overweight or obese (BMI greater than 30) as a core treatment
  • Advise on local muscle strengthening and general aerobic exercise as a core treatment
  • Use of shared decision making tools
  • Suggest oral simple analgesia and anti-inflammatory medication
  • Assess need for aids and devices (refer to occupational therapy or physiotherapy) including instruction in using a walking aid
  • Prescribe supervised and evidence based physical therapies - refer to Local Physiotherapy Service

Moderate Symptoms:

Surgery

  • Primary Hip Replacement
  • Hip Resurfacing is commissioned in line with NICE TA 304 (Total Hip Replacement and resurfacing arthroplasty for end-stage arthritis of the hip). Other forms of arthroscopic or open hip surgery are low priority procedures and will only be funded through exceptional cases panel approval

Referral

Referral Criteria

Please note pre-referral criteria are applicable in this referral and referrals may be returned if this information is not contained within the referral.

Consider referral for persistent pain and disability that has not responded to up to 12 weeks of evidence based nonsurgical treatments. This time to include any manual therapy (including physiotherapy) received in primary care (British Association orthopaedics commissioning guide 2016 ).

Unless red flags are present all patients referred for consideration of hip arthroplasty due to osteoarthritis will be assessed by a community assessment service which provide a holistic assessment of their symptoms and disabilities before being helped to make a decision on the possible treatment options. This assessment will include Oxford hip scoring and patient decision making aids. Treatment options will include lifestyle modifications, physiotherapy, improved general health and well being or surgery.

Where conservative treatment with lifestyle measures and analgesia has failed – patient to be referred via the MSK "Physio First" Single Point of Access Pathway. This applies even when physiotherapy has recently been undertaken (NHS or private) or is not clinically indicated.

  • GPs will either need to provide the patient with the Patient Knows Best website to self-refer

or

  • the physio self-referral number: 0300 456 9987

If no clinical improvement with physiotherapy – physios are able to refer onto Extended Scope Practitioners (ESPs):

Any referral made to secondary care that is not for a red flag condition will be re-directed by DRSS to the relevant community physio team and a letter sent to the GP practice informing them of the correct pathway.

Please note primary care is requested to follow In Shape for Surgery best practice which can be seen here.

Referral Instructions

GPs will either need to provide the patient with the Patient Knows Best website to self-refer

or

the physio self-referral number: 0300 456 9987

Any referral made to secondary care that is not for a red flag condition will be re-directed by DRSS to the relevant community physio team and a letter sent to the GP practice informing them of the correct pathway.

Where the circumstances of treatment for an individual patient do not meet the criteria described above exceptional funding can be sought. Individual cases will be reviewed by the appropriate panel of the CCG upon receipt of a completed application from the patient's GP, consultant or clinician. Applications cannot be considered from patients personally.

Referral Forms

DRSS referral form

Supporting Information

GP Information

NICE OA Guideline

Patient Information

Patient Information for pain arising from the hip in adults

MyHealth patient information - Hip pain

Hip joint replacements

Hip replacement

Pathway Group

This guideline has been signed off on behalf of the NHS Devon Clinical Commissioning Group.

Publication date: April 2019

 

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