Hip pain: diagnosis, investigations and treatment options.

What Is Hip Pain?

Hip pain refers to discomfort located in or around the hip joint, which may originate from the joint itself or from surrounding soft tissues. Depending on the cause, pain can be felt in the groin, outer hip, thigh, or buttocks.

Hip Joint Anatomy

The hip is a ball-and-socket joint, where the femoral head represents the ball and the acetabulum is the socket. Both the ball and socket are covered with cartilage, a thick and smooth layer with permits painless and seamless movement of the hip. The labrum is a ‘rubber lining’ which deepens the socket and stabilises the joint. There are various sets of muscles surrounding the hip joint which provides movement, stability and strength around the hip as we go about our daily activities.

• Type: Ball-and-socket synovial joint,
• Bones Involved:
  • Femoral head: The "ball" at the top of the thigh bone,
  • Acetabulum: The "socket" in the pelvis,
• Articular Cartilage: Covers joint surfaces to allow smooth motion,
• Labrum: Fibrocartilaginous ring that deepens the socket and stabilises the joint,
• Ligaments: Iliofemoral, pubofemoral, and ischiofemoral ligaments stabilise the joint,
• Surrounding Muscles:
  • Flexors: Iliopsoas, rectus femoris,
  • Extensors: Gluteus maximus, hamstrings,
  • Abductors: Gluteus medius and minimus,
  • Rotators: Piriformis, obturator internus.

When patients describe hip pain, it is essential for the doctor to determine the exact location and source of the pain. It may come from within the hip joint itself or from any of the associated structures outside the hip. A thorough clinical history and examination are therefore important to help determine this.  

Typical Symptoms described by patients

• Groin pain: Suggests joint pathology (e.g., arthritis, labral tear),
• Lateral hip pain: Often from bursitis or tendinopathy,
• Posterior hip pain: May be referred from the spine or sacroiliac joint,
• Clicking, locking, or instability: Suggest intra-articular problems,
• Stiffness, limping, or reduced range of motion: difficulty putting on socks or cutting toenails.

Common Causes of Hip Pain

Intra-articular Causes

Osteoarthritis: Hip arthritis, most commonly osteoarthritis (OA), is a degenerative joint disease where the cartilage that cushions the hip joint wears down over time. This leads to:

• Pain (especially in the groin or buttocks)
• Stiffness
• Reduced range of motion
• Difficulty walking, climbing stairs, or standing up
• Femoroacetabular impingement (FAI): Abnormal bone shape causes joint damage. Impingement may happen due to bone sputs at the acetabulum or femoral head/neck junction
• Labral tear:
  Often from trauma, repetitive motion, or impingement.
  Tears of the labrum often cause pain or clicking in the hip. They may happen in patients with dysplasia or FAI.
• Avascular necrosis (AVN): Loss of blood supply to femoral head that causes secondary arthritis. 

Extra-articular Causes

• Trochanteric bursitis: Inflammation of the bursa over the greater trochanter
• Gluteus medius/minimus tendinopathy
• Hamstring or hip flexor strain
• Snapping hip syndrome: Tendons snapping over bony prominences

Referred Pain

• Lumbar spine pathology: Disc herniation, facet joint arthrosis
• Sacroiliac joint dysfunction
• Gynecological or urological conditions

Radiological Investigations

1. Plain X-ray (AP and lateral views)

This X-ray shows severe arthritis of the right hip. There is no space between the femoral head and the acetabulum, which represents worn-out cartilage.

2. MRI

This MRI shows avascular necrosis of the right hip.

3. MRI Arthrogram

Better visualisation of labral pathology.

4. CT Scan

Superior for detecting subtle bone morphology (e.g., FAI) or surgical planning

5. Ultrasound

6. Bone Scan or SPECT:

Conservative Treatments for Hip Pain

Conservative therapy is often effective for non-advanced conditions and should be tried before surgery in most cases.

• Activity Modification:
  • Avoid high-impact activities that worsen symptoms
• Physical Therapy:
  • Focused on strengthening gluteal muscles, improving core stability and hip mechanics
  • Also helps with waking gait, stair climbing and use of walking aids.
• Walking aid
  • Using a walking stick on the opposite side of the hip pain helps to reduce load and stress on the painful hip
• NSAID medication:
  • For short-term pain and inflammation control.
  • Helps with daily activities and functional improvements.
• Ice/Heat Therapy:
  • Ice for acute pain or inflammation; heat for chronic stiffness
• Weight Management:
  • Reduces load on the hip joint
• Injections:
  • Corticosteroids: For inflammation (e.g., bursitis, arthritis)
  • Viscosupplementation: The use of hyaluronic acid to lubricate the joint may help with pain and stiffness.
  • Platelet-rich plasma (PRP): Emerging therapy for tendinopathy or inflammation of tendons around the hip joint.

Hip injections are given either under X-ray or ultrasound guidance. This is to ensure the accuracy of the injection into the hip joint.

Surgical Options

There are several surgical procedures which orthopaedic surgeons perform for specific causes of hip pain. These are brief descriptions of the procedures. You should get more detailed information about your hip pain from your orthopaedic surgeon.

1. Hip Arthroscopy

• Indications: Labral tears, FAI, loose bodies
• Procedure: Minimally invasive surgery uses small incisions (keyhole technique) to repair or debride structures.
• Recovery: Typically faster than open procedures; rehab required

2. Core Decompression (for AVN)

• Indication: Early-stage avascular necrosis (AVN)
• Goal: Reduce excessive pressure in the femoral head and improve blood flow. This technique is used in early AVN as a form of hip preservation surgery. Once the AVN has become severe, a total hip replacement is more appropriate.
• Procedure: Small holes are drilled into the femoral head and filled with bone graft.

3. Partial hip Replacement (Hemi-arthroplasty)

These operations are frequently performed for elderly patients who have experienced a hip fracture after a fall. These patients often have brittle bones or osteoporosis. A minor fall can be enough to cause a fracture. While some fractures may be fixed with metal implants, other hip fractures, which are more severely displaced, have to be replaced. Due to the frailty of these elderly patients, a partial hip replacement is often sufficient for them to regain their mobility. This is a shorter and less risky surgery than a total hip replacement. Only the femur is replaced while the acetabulum is left alone.

4. Total Hip Replacement

Hip replacement surgery replaces the worn-out parts of the hip joint and allows patient to regain their active and healthy lifestyle. Implants are inserted, and patients are allowed to start walking the day of surgery itself.

• Indications: End-stage osteoarthritis, advanced AVN, hip fractures
• Components: Metal/plastic prosthetic socket and femoral component
• Outcomes: High success rate, excellent pain relief and function restoration
• Considerations: Implant longevity depends on the patient's body habitus, the types of physical activities involved and the implant materials used. Most hip implants (more than 95%) are problem-free even after 20 years.

Hip implants comprise the femoral stem and head as well as the acetabular cup and liner. 

Physiotherapy and rehabilitation for Hip Arthritis

1. Patient Education

• Joint protection strategies
• Importance of low-impact exercise
• Postural advice and ergonomic modifications
• Use of assistive devices if needed (e.g., cane)

 2. Exercise Therapy

The most effective, evidence-based intervention.

A. Strengthening Exercises

Target the hip abductors, gluteal muscles, core, and quadriceps:

• Bridging
• Clamshells
• Side-lying hip abduction
• Wall squats
• Step-ups

B. Stretching Exercises

Improve flexibility of the hip and surrounding muscles:

• Hip flexor stretch
• Piriformis stretch
• Hamstring and quadriceps stretches
• Gluteal stretches

C. Range of Motion (ROM) Exercises

Gentle movements to maintain joint mobility:

• Heel slides
• Hip circles
• Seated hip flexion and abduction

D. Balance and Proprioception Training

Improves stability and reduces fall risk:

• Single-leg stands
• Balance board exercises

3. Manual Therapy (Optional, by Physiotherapist)

• Joint mobilisation techniques
• Soft tissue massage to reduce muscle tension
• Myofascial release 

4. Modalities (Adjuncts)

May be used to manage symptoms during flare-ups:

• Heat therapy: Eases stiffness and improves circulation,
• Cold therapy: Reduces swelling and pain,
• Transcutaneous electrical nerve stimulation (TENS): Provides short-term pain relief.

5. Functional Training

Helps improve daily activities:

• Sit-to-stand practice
• Gait training
• Stairs navigation
• Strategies to improve transitions (e.g., in/out of bed or car)

6. Aquatic Therapy (Hydrotherapy)

Exercising in water reduces joint loading while allowing movement:

• Water walking
• Pool-based strengthening
• Excellent for overweight or mobility-limited individuals

Rehab after a total hip replacement (THR)

There are several methods surgeons use to perform a THR. Just like there are many ways to enter a house (front or back door, side window), the surgeon may choose to enter the hip through the front, back or side. This detail is crucial as each surgical approach is associated with specific pros and cons. Rehabilitation begins within 24 hours after surgery and progresses through several phases over 3–6 months (or longer, depending on individual factors).

Phase 1: Immediate Postoperative Phase (Day 0–7)

Goals:

• Prevent complications (blood clots, pneumonia)
• Begin safe mobility
• Protect the surgical site

Key Components:

• Pain management: Medications, ice therapy
• Circulatory exercises: Ankle pumps, deep breathing
• Weight-bearing: As per surgeon's instructions (usually WBAT—weight-bearing as tolerated)
• Mobility training:
  • Get in/out of bed with support
  • Walk with a walker or crutches
  • Sit-to-stand transfers
• Hip precautions (only for posterior approach): This is due to the risk of implant dislocation. These precautions are not applicable for anterior approach total hip replacement.
  • No bending hips >90°
  • No internal rotation
  • No crossing legs

Phase 2: Early Recovery (Weeks 2–6)

Goals:

• Restore basic function
• Reduce swelling and pain
• Improve mobility and independence

Exercises:

• Isometric strengthening: Gluteal squeezes, quadriceps sets
• Active ROM: Hip abduction, heel slides, straight leg raises (as tolerated)
• Gait training: Progress from walker to cane
• Balance training
• Stair climbing: Begin with handrail support

Phase 3: Strengthening & Conditioning (Weeks 6–12)

Goals:

• Regain strength and endurance
• Normalise walking pattern
• Begin return to low-impact activity

Exercise Progression:

• Standing hip abduction and extension with resistance bands
• Step-ups
• Stationary cycling (with proper seat height)
• Aquatic therapy (if incision healed)

Functional Goals:

• Walk without an assistive device
• Return to light household chores
• Improve balance and coordination

Phase 4: Advanced Strengthening & Return to Activities (3–6+ Months)

Goals:

• Return to recreational and occupational activities
• Improve overall fitness and endurance
• Prevent re-injury

Activities Allowed:

• Walking, swimming, cycling
• Golf, doubles tennis, low-impact aerobics
• Light resistance training

Activities to Avoid (Long-term):

• High-impact sports: Long-distance running, basketball, football, singles tennis
• Deep squats or lunges
• Twisting or pivoting on the operated leg, no bungee jumping or forceful massage

Long-Term Tips for THR Success

• Maintain a healthy body weight
• Keep active with low-impact activities
• Follow up with your surgeon as scheduled
• Inform healthcare providers about your prosthetic joint before procedures (e.g., dental work, due to infection risk)
• Consider yearly X-rays to monitor implant condition

Conclusion

 There are many reasons patients experience pain in the hip. It is important for the orthopaedic surgeon to come to an accurate diagnosis through thorough history taking, clinical examination as well as through the appropriate imaging modality e.g. MRI scan. Once the diagnosis is obtained, the surgeon will then be able to advise which conservative or surgical treatment option is appropriate for you. The details of the procedure and post-procedure rehabilitation should be explained so that patients understand what to expect.