Hip pain- Adult Leeds

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1.  Background Information / Scope of Pathway

Quick info:
These pathways were developed to guide clinicians when managing adults with common musculoskeletal problems. The pathways are not provider specific and so the guidance and forms apply to all providers.

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2.  Information Resources for Patients and Carers

Quick info:
Patient information:

MSK TAS Patient Information Leaflet

See attached patient information leaflet for groin strain.

See attached patient information leaflet for lateral hip pain.

See attached patient information leaflet for trochanteric bursitis

Patient Information Leaflet Surgery BMI over 35

Hip Replacement Patient Information Leaflet

See attached patient information leaflet for osteoarthritis of the hip.

It is good practice to give patients written material to read whilst they decide whether to go ahead with hip replacement. Please use the attached abridged patient information leaflet or the comprehensive patient information leaflet available from Arthritis Research UK.

A decision aid can also be accessed online: Decision Aid for Hip Replacement

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3.  Development and Updates to this Pathway

Quick info:
Development

The pathway redesign was a clinicaly lead city wide process. It was conducted through the Musculoskeletal Steering Group which had representation from the 3 CCGs, Patients, NHS Leeds, Leeds Teaching Hospitals Trust and the Leeds Musculoskeletal Services.

The individual pathways were authored by the appropriate clinical staff involved in delivering the pathway, but chiefly comprised of GPs, Consultants and Therapists.

The pathways went live on the 2/7/2012

Updates

Referrals Forms Updated October 2012. Major Review and Update June 2013
This involved reformating of the pathway and referral forms.

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4.  Referral Forms

Quick info:
Referral Forms

Mail Merged
The forms below are provided as a repository. They can be downloaded to your computer and be imported to your clinical system. This is so all practices have access to the most up to date forms.

EMIS - merged
MSK 1 Hip Form V3
MSK 2 Hip Replacement Form V3
MSK 3 Hip Pain Post Replacement V3
MSK14 Problem Not on Pathway Form V3

SystmOne - merged
MSK 1 Hip Form V3
MSK 2 Hip Replacement Form V3
MSK 3 Hip Pain Post Replacement V3
MSK14 Problem Not on Pathway Form V3

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6.  Red Flags

Quick info:
GP information
Remember the red flags and manage accordingly:

  • fever
  • malaise
  • night sweats/night pain
  • weight loss
  • IV drug use
  • excess alcohol
  • steroid use
  • cancer history
  • immunocompromised

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7.  Suspected Groin Strain

Quick info:
Patient Information
See attached patient information leaflet containing information for patients explaining causes, nature, treatment, and management of groin strain.

GP information
Groin strain:

  • this umbrella term has been utilised to describe pain in the groin/hip region which is suspected to originate from a soft tissue injury
  • the area is notoriously complicated and difficult to diagnose accurately
  • these conditions are most likely to occur in active/sporty individuals

Diagnoses may include (but not limited to):

  • adductor-related pain:
    • adductor strain (classical groin strain, acute onset, symptoms reproduced on resisted hip adduction)
    • similar signs but insidious onset pain medial groin may be adductor tendinopathy/enthesopathy (active/sporty individuals)
  • iliopsoas pathology:
    • chronic groin and hip pain, may cause contracture and tightness (pain on resisted flexion of affected hip from Thomas Test position useful sign)
  • sports hernia:
    • this is another umbrella term for various possible diagnoses, seen in active athletic populations
    • associated with overuse and repetitive twisting and turning at speed
    • there is no true inguinal hernia, but may involve weakness of the posterior inguinal wall, tear of the conjoint tendon, or external oblique aponeurosis tear
    • a suspected classical inguinal hernia should not be managed on this pathway
  • Management:
    • treatment for suspected acute simple adductor strain would involve simple advice such as:
      • rest
      • ice
      • compression; and
      • elevation

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8.  Lateral Hip Pain

Quick info:

Patient Information

See attached patient information leaflet containing information for patients explaining nature of condition, ways in which symptoms can be best managed, exercise, and lifestyle which may assist, etc.

GP information
Lateral hip pain is often attributable to conditions variously described as trochanteric bursitis, gluteus medius tendinopathy, or ‘greater trochanteric pain syndrome’. Whilst the former two conditions overlap, differences exist, and the latter umbrella term may be most helpful.

Clinical indicators of a trochanteric bursitis include:

  • females > males
  • overweight
  • exacerbated by lying on affected side, prolonged standing, transitioning to standing position

Gluteus medius tendinopathy has similar features and difficult to distinguish clinically.

Weakness during the walking/running stance phase, and climbing stairs, with a positive trendelenburg test is suggestive. Possible differentials are numerous, but include osteoarthritis, meralgia paraesthetica, and referred pain, eg from lumbar spine. Management:

  • A three-week trial of appropriate analgesia is suggested for first presentations, to distinguish between persistent significant pathology and transient symptoms.
  • Persistent symptoms warrant a Tier 1 referral to consider appropriate physiotherapy and possible corticosteroid injection in cases of greater trochanteric pain syndrome.
  • Furthermore, consideration can be given to the possibility of less common diagnoses through onward referral to MSK-MDT from Tier 1 if atypical features exist, or symptoms fail to respond to appropriate treatment.
  • An MSK-MDT referral can be initiated at any stage if the symptoms are severe and/or atypical.
  • If a patient is discharged from Tier 1 following apparently successful treatment, and re-presents with recurrence, it would be appropriate to refer straight to MSK-MDT.

NB: If expertise exists within the practice it may be appropriate to consider corticosteroid injection for clinical trochanteric bursitis prior to Tier 1 referral.

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9.  Suspected Hip Osteoarthritis

Quick info:
Patient Information
See attached patient information leaflet containing information on definition, causes, symptoms, and management of osteoarthritis of the hip.

GP information
Presentation:

  • patient will usually be age 50 years and older
  • pain described as worse with walking
  • the pain will start usually in the groin but can refer down the anterior thigh to the knee
  • often patients will also complain of buttock pain
  • morning stiffness lasting up to 30 minutes common

Examination of the patient supine with the hip flexed to 90 degrees. Pain and limitation of movement on internal rotation of the hip compared to the pain free side. Often with a block to internal rotation.

Other causes to think about are patients with pain originating in the spine from a compressed L3 nerve root, these patients will have normal examination of the hip joint (ie, it will rotate fully).

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10. Diagnosis Unclear Clear

Quick info:
Pathway information
Following the Musculoskeletal Pathway review, it was decided that we needed to adopt a system of early diagnosis.

If after assessing the patient on one or two occasions (supported by an X-ray if appropriate) the diagnosis is not clear, then referral to the MSK-MDT is appropriate.

The aim is to avoid delay of diagnosis leading to chronicity and also to avoid wasting NHS resources on inappropriate treatment.

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12. Problem Not on Pathway

Quick info:
There are 2 broad groups of patients who fall into this category:

Those who have a clear problem but there is no Leeds pathway and so you are ensure of where to refer the patient.

Those with a clear problem and course of action but you are unable to make the referral because of referral restrictions caused by some pathways still not allowing GPs to directly refer to the appropriate surgeon. Pathways where these restrictions still occur are the Shoulder / Elbow, Spine, Knee and Foot / Ankle.

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14. Refer Tier 1 Physiotherapy Referral Form (MSK1)

Quick info:
Referral Form:
MSK 1 Hip Form V3

Choose and Book
You can find this clinic on Choose and Book under:

Speciality: Physiotherapy
Clinic Type: Musculoskeletal

Provider information
The only provider of Tier 1 physiotherapy in the city is the Leeds Musculoskeletal Service. This service is directly bookable via Choose and Book. Please complete the appropriate form and send via Choose and Book.

If symptoms persist, referral to Tier 1 physiotherapy is appropriate, who will refer onward to MSK-MDT if symptoms persist or there is diagnostic doubt.

Who should be referred to Tier 1 Physiotherapy:

  • patients presenting with:
    • adductor strain/tendonitis
    • hamstring strain
    • pubic symphysis pain
    • ischial bursitis
    • differential diagnosis with sacroiliac joint dysfunction

What can be provided:

  • assessment and diagnosis
  • treatment to include advice on strengthening and stretching exercises
  • manual therapy
  • activity modification and advice on returning to normal activity
  • onward referral to the MSK-MDT if required

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16. Refer MSK-MDT Referral Form (MSK1)

Quick info:
Referral Form:
MSK 1 Hip Form V3

Choose and Book
You can find this clinic on Choose and Book under:
Speciality: Orthopaedics
Clinic Type: Hip Pain

Provider Information
The only provider of the MSK-MDT clinic in the city is the Leeds Musculoskeletal Service. This is a multiprofessional clinic including senior physiotherapists and musculoskeletal physicians.

This clinic provides diagnosis, investigation, treatment and onward referral if needed.

This service is directly bookable via Choose and Book. Please complete the appropriate form and send via Choose and Book.

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17. Refer to MSK-TAS (Telephone Assessment Service) (Form MSK14)

Quick info:
MSK TAS Patient Information Leaflet

Referral Form:
MSK14 Problem Not on Pathway Form V3

Choose & Book
You can find this clinic on Choose & Book under:
Speciality: Orthopaedics

Clinic Type: Hip

The MSK Telephone Assessment Service (MSK-TAS) is offered as a way of ensuring patients get into the right clinic when it is not clear from the pathways what the right course of action is.

This is distinct from the Diagnosis Unclear Pathway which is there to offer quick access to diagnostic assessment when patients present with symptoms that don't immediately fall into a diagnostic group.

Patients who are appropriate for the MSK-TAS fall into two categories:

Those who have a clear problem but there is no Leeds pathway and so you are ensure of where to refer the patient. Those with a clear problem and course of action but you are unable to make the referral because of referral restrictions caused by some pathways still not allowing GPs to directly refer to the appropriate surgeon. Pathways where these restrictions still occur are the Shoulder / Elbow, Spine, Knee and Foot / Ankle.

When you book the patient into the MSK-TAS via Choose & Book you are booking them a telephone appointment.

Once the referral form has been completed and sent via Choose & Book a senior Physiotherapist will review the referral form within 48 hours. They will then decide the appropriate course of action and the patient will be contacted by phone at the allotted time in order to make the necessary arrangements for onward referral.

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18. Refer Tier 1 Physiotherapy Referral Form (MSK1)

Quick info:
Referral Form:
MSK 1 Hip Form V3

Choose and Book
You can find this clinic on Choose and Book under:

Speciality: Physiotherapy
Clinic Type: Musculoskeletal

Provider information
The only provider of Tier 1 physiotherapy in the city is the Leeds Musculoskeletal Service. This service is directly bookable via Choose and Book. Please complete the appropriate form and send via Choose and Book.

If symptoms persist, referral to Tier 1 physiotherapy is appropriate, who will refer onward to MSK-MDT if symptoms persist or there is diagnostic doubt.

Who should be referred to Tier 1 Physiotherapy:

Patients presenting with:

  • trochanteric bursitis
  • iliotibial band friction syndrome
  • gluteus medius tendinopathy
  • mild OA hip flare up
  • sacroiliac joint dysfunction

What can be provided:

  • assessment and diagnosis
  • treatment to include advice on strengthening and stretching exercises
  • manual therapy
  • activity modification and advice on returning to normal activity
  • onward referral to the MSK-MDT if required

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22. Refer MSK-MDT Referral Form (MSK1)

Quick info:
Referral Form:
MSK 1 Hip Form V3

Choose and Book

You can find this clinic on Choose and Book under:

Speciality: Orthopaedics
Clinic Type: Hip Pain

Provider information

The only provider of the MSK-MDT clinic in the city is the Leeds Musculoskeletal Service. This is a multiprofessional clinic including senior physiotherapists and musculoskeletal physicians.

This clinic provides diagnosis, investigation, treatment and onward referral if needed.

This service is directly bookable via Choose and Book. Please complete the appropriate form and send via Choose and Book. Groin strain patients who should be referred to MSK-MDT:

  • not responding to Tier 1 physiotherapy with the following conditions:
    • adductor strain/tendonitis
    • hamstring strain
    • pubic symphysis pain
    • ischial bursitis
  • patients requiring:
    • differential diagnosis with sacroiliac joint dysfunction
    • investigation/diagnosis
    • injection therapy +/- ultrasound guidance
  • diagnosis not clear following GP assessment and referral
  • patients also presenting with:
    • pubic symphysis pain
    • sportsman’s hernia
  • patients requiring specialist treatment planning
  • onward referral to secondary care

The majority of patients will be managed by conservative measures but a small number may require surgical input, eg sportsman’s hernia, labral pathology.

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24. Refer MSK-MDT Referral Form (MSK1)

Quick info:
Referral Form:
MSK 1 Hip Form V3

Choose and Book
You can find this clinic on Choose and Book under:
Speciality: Orthopaedics
Clinic Type: Hip Pain

Provider information
The only provider of the MSK-MDT clinic in the city is the Leeds Musculoskeletal Service. This is a multiprofessional clinic including senior physiotherapists and musculoskeletal physicians.

This clinic provides diagnosis, investigation, treatment and onward referral if needed.

This service is directly bookable via Choose and Book. Please complete the appropriate form and send via Choose and Book. Who should be referred to MSK-MDT (Tier 2) with lateral hip pain:

  • not responding to Tier 1 physiotherapy for lateral hip pain
  • conditions including:
    • trochanteric bursitis
    • iliotibial band friction syndrome
    • gluteus medius tendinopathy
    • mild OA hip flare up
    • sacroiliac joint dysfunction
  • patients requiring specialist assessment and treatment planning/rehabilitation
  • patients requiring investigation/diagnosis
  • injection therapy for trochanteric bursitis
  • diagnosis not clear following GP assessment and referral
  • onward referral to secondary care

Key Dates
Published: 09-Oct-2015, by Leeds
Valid until: 17-Jun-2016

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References

This is a list of all the references that have passed critical appraisal for use in the care map MSK - Hip pain

Reference

  1. Cibulka MT, White DM, Woehrle J et al. Hip pain and mobility deficits - Hip Osteoarthritis: . Clinical Practice Guidelines Linked to the International Classification of Functioning, Disability, and Health from the Orthopaedic Section of the American Physical Therapy Association. J Orthop Sports Phys Ther 2009; 39: A1-25.

  2. Adebajo A. ABC of rheumatology: Fourth edition. Chichester: John Wiley and Sons Ltd; 2010.

  3. Map of Medicine (MoM) Clinical Editorial Team and Fellows. London: MoM; 2011.

  4. British Pain Society (BPS). A practical guide to the provision of Chronic Pain Services for adults in Primary Care. British Pain Society 2011; http://www.britishpainsociety.org/NAPP_RESOURCEPACK.pdf

  5. PRODIGY. Osteoarthritis. Version 1.6. Newcastle upon Tyne: PRODIGY; 2008. http://prodigy.clarity.co.uk/osteoarthritis

  6. American College of Radiology (ACR). Chronic hip pain. American College of Radiology 2008; http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/ExpertPanelonMu sculoskeletalImaging/ChronicHipPainDoc8.aspx

  7. National Health and Medical Research Council (NHMRC). Evidence-based management of acute musculoskeletal pain. National Health and Medical Research Council 2003; http://www.nhmrc.gov.au/_files_nhmrc/publications/attachments/cp94.pdf

  8. British Pain Society (BPS). Opioids for persistent pain: good practice. British Pain Society 2010; http://www.britishpainsociety.org/book_opioid_main.pdf

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