Hip pain

The hip joint is a deep socket holding the ball at the top of the thigh bone, wrapped in thick muscle and tendon, with small cushions of fluid, the bursae, wherever a tendon runs over bone. Pain can start in any of these, or be sent from somewhere else:

• Outer-hip pain: GTPS. When the sore spot is the bony prominence you can feel on the outside of the hip, called the greater trochanter, the usual cause is greater trochanteric pain syndrome. It is also called trochanteric bursitis, after the bursa there, but the gluteal tendons anchored to that knob are usually part of it, hence its other name, gluteal tendinopathy. It is common, seldom has a single cause, turns up in one hip more often than in both, can ache down the outer thigh, often lasts months and is often missed. If a single bursa is the main problem, the picture shades into bursitis, covered separately.
• Wear in the joint. Osteoarthritis is one of the commonest reasons for a painful hip in people over 45: typically an ache in the groin or down the front of the thigh that walking makes worse, and brief stiffness after rest that passes within half an hour. Its own guide goes into it.
• Inflammation in the joint. An inflammatory arthritis such as rheumatoid arthritis behaves differently: the joint stays stiff for longer than half an hour after rest, first thing in the morning especially, and the pain eases with use rather than building with it.
• Overdoing it, or an injury. Soreness, swelling or bruising after a hard or repetitive workout is usually a sprain, a strain or an irritated tendon, and settles with care; pain after a fall or a knock goes by the lists under "When to seek help".
• Pain from the back. The lower back commonly sends pain into the buttock, the side of the hip and down the leg; pain past the knee, or pins and needles and numbness, suggests the back, the subject of our back pain guide.
• A break or an infection. A broken hip after a fall is common in older people whose bones have thinned, and an infected joint (septic arthritis), hot and swollen with or without a fever, is rarer but the other cause not to miss; their signs are in the lists under "When to seek help", which give each its route.

The place and the trigger usually point the way:

• Groin pain, or pain down the front of the thigh, brought on by walking, with stiffness after rest that passes within half an hour: the joint, most often wear
• Stiffness lasting more than half an hour first thing or after sitting, with pain that eases as you move: inflammation
• A tender spot on the bony outer hip, pain when you lie on that side at night, and pain going upstairs or balancing on one leg: GTPS
• An ache that may run down the outer thigh and may be worse with movement or lying on that side: the bursa or the tissue over the trochanter
• Pain past the knee, or with pins and needles or numbness: the back is the likelier source
• A hip that is hot and swollen, or pain that started with a fall: the lists under "When to seek help" say where to go

Most of the answer comes from talking and examining. Exactly where it hurts, what sets it off, and what the hip and the back do when they are tested usually sort the joint from the soft tissue and the spine, and GTPS in particular is recognised chiefly by examination.

Any scan is chosen to settle what is left over. Ultrasound shows, in real time, the layer where GTPS sits: the gluteal tendons, the bursae and the tissue over the greater trochanter. Point-of-care ultrasound is part of Dr Borukhson's consultation, so the scan normally takes place at the first appointment, and the ultrasound clinic page describes it. An X-ray is the test when wear in the joint is the question, and an MRI when the joint, the tendons or the spine need to be seen in more detail.

Treatment turns on what the assessment finds. For GTPS the mainstay is a physiotherapy programme that builds the gluteal muscles and tendons up step by step, often over months, with fewer of the habits that load the sore side and simple pain relief alongside. When the pain is too much to exercise, an ultrasound-guided steroid injection around the trochanter usually calms it for a while, the scan making sure it goes where it should; its effect tends to wear off and the pain can return, so the lasting gains come from the strengthening.

Wear in the joint is looked after as a condition in its own right, with exercise, weight and injections among the tools, as the osteoarthritis guide explains. An inflammatory arthritis is treated as a whole-body condition rather than hip by hip. Pain coming from the spine is dealt with as a back problem, so naming the source matters. If the hip needs a surgeon, for joint damage that has gone a long way for example, a referral is arranged. You and Dr Borukhson settle the plan together.

• Stay moving where you can, without overdoing it: resting the hip completely tends to stiffen it
• Cool a sore flare: frozen peas or an ice pack wrapped in a towel, held on for up to twenty minutes at a time, every two or three hours
• Pain relief from the pharmacy: paracetamol, or an anti-inflammatory gel such as ibuprofen gel, with tablets kept for when they are needed and safe for you. Clothing that ibuprofen gel has rubbed onto catches light more easily, so do not smoke, and keep a good distance from open flames, while you use it
• Cushioned, soft-soled shoes, and no heavy carrying or low, sinking chairs while the hip is sore
• With pain on the outer hip, lie on the good side at night, a pillow between your knees, and avoid crossing your legs
• Stretch gently and strengthen gradually: over time this protects the hip, and our arthritis and exercise guide shows how to build up
• Shedding some weight, if you carry extra, lightens the load on the hip at every step

Most hip pain starts with looking after it at home, and a GP if it lingers. A few pictures need more, and each has its route in the lists below: a hip that may be broken after a fall, an infected joint, which can become sepsis, and pain that comes on hard and fast without an injury.

Treat any of these as a 999 or A&E emergency: call 999 and do not drive yourself to A&E.

• Severe illness with suspected sepsis: a high fever with shaking, confusion, rapid breathing, or feeling dramatically worse over hours
• With a fever or feeling unwell, a rash that does not fade when you press it, a stiff neck with eyes that cannot bear bright light, or skin, lips or tongue turning blue, grey, pale or blotchy, since these can be signs of meningitis or sepsis, as can a very bad headache, confusion or a first seizure with a fever or feeling unwell; on black or brown skin the rash and the change of colour may be easier to see on the palms of the hands or the soles of the feet
• A joint you cannot put weight on or move, or that has moved out of place, or, after a fall or injury, very bad pain or any tingling or numbness
• After an injury, a crack heard as it happened, or skin around it that has turned blue, grey or cold, since these can be signs of a broken bone
• Lips, mouth, throat or tongue that suddenly swell, a throat that feels tight, very fast breathing or a struggle to breathe or to swallow, skin, tongue or lips turning blue, grey or pale (on black or brown skin this may be easier to see on the palms of the hands or the soles of the feet), becoming suddenly very confused, drowsy or dizzy, or fainting and not being able to be woken, since this can be a severe allergic reaction, anaphylaxis, which can follow a dose of any medicine

Any of these needs an assessment that is urgent, on the same day, from your GP or NHS 111:

• A joint that is hot and swollen, with a fever or feeling unwell, since an infected joint has to be ruled out at once, at A&E or through NHS 111
• A joint that has become hot and very swollen suddenly, or is worsening quickly, even without a fever, since an infected joint does not always announce itself with one
• Joint pain with a fever, or feeling hot, cold or shivery, or generally unwell, since an infection in or around a joint has to be found the same day
• Severe hip pain that came on suddenly with no fall or injury behind it, a hip that is swollen and feels hot even without a fever, or skin around the hip that has changed colour, since the cause has to be found the same day; a hip you cannot put weight on or move belongs to the first list instead
• Hip pain after a fall or an injury, short of the signs in the first list, or a swelling or bruise there that is large or still growing, since a break has to be ruled out; NHS 111 can say where to go, and an urgent treatment centre can sometimes X-ray it

See a GP within days if your hip is stiff for more than half an hour after you wake, since that can mean inflammation in the joint, as our joint pain without swelling guide explains, and if you are losing weight without trying alongside the hip pain, since that needs a closer look. See a GP if the pain stops you doing your usual activities or disturbs your sleep, if it is worsening or keeps returning, or if a fortnight of looking after it at home has not helped. After a fall or an injury, a hip or leg left at an odd angle, looking shorter than the other, or out of shape is a 999 or A&E emergency. No referral is needed to be seen here; next-working-day appointments can almost always be arranged, and same-day appointments are sometimes possible. If you cannot tell how urgent something is, asking is never a mistake.

A painful hip asks three things at once: is it the joint, the tissue around it, or the back? The three overlap and can coexist, and each needs different treatment, so getting the source right is worth the visit. One specialist appointment can look at all three, with ultrasound on the day for the tendons and bursae of the outer hip, and a guided injection can often be given at the same sitting where it is the right step. If your hip pain lingers or returns, an assessment can find out why and set out a plan that holds.

Why does the side of my hip hurt?

Soreness on the bony knob at the side of the hip is most often greater trochanteric pain syndrome, GTPS, a condition also known as trochanteric bursitis that takes in gluteal tendinopathy. The bursa there was once thought to be the whole story; the gluteal tendons that fix onto that knob are usually involved as well. It is very common, usually starts for no clear reason, turns up in one hip more often than in both, and can ache down the outer thigh or feel as though it comes from the joint. Because it is often missed, simply naming it helps.

What helps GTPS?

Exercise comes first: a physiotherapy programme that builds up the gluteal muscles and their tendons, often over several months, with pain relief and fewer of the habits that press on the sore side, such as lying on it or sitting with the legs crossed. When the pain is too fierce to exercise, or painkillers are not controlling it, a steroid injection guided by ultrasound usually quietens it for a while, but the effect tends to wear off: it is the strengthening that keeps the improvement.

When does hip pain need help straight away?

A leg you cannot walk on or put weight on, a hip you cannot move, or a hip that has moved out of place is a 999 or A&E emergency, fall or no fall; so, after a fall or an injury, are a hip that hurts badly, pins and needles or numbness in the hip or the leg, and a hip or leg left at an odd angle or looking shorter than the other, because the hip may be broken. Call 999 and do not drive yourself to A&E. A hip that is hot and swollen with a fever or feeling unwell needs the same day, at A&E or through NHS 111, so that an infected joint can be ruled out; severe pain that has come on suddenly without a fall, a hip that is swollen and feels hot even without a fever, or hip pain with a high temperature needs your GP or NHS 111 the same day, though a leg that will not take weight belongs with the first sentence. Hip pain after a fall, short of those signs, needs NHS 111 the same day too. The lists under when to seek help hold them all.

How is the cause worked out?

Mostly from where it hurts, what sets it off and what the hip and the back do when they are examined, which between them usually tell the joint from the soft tissue and the spine. Point-of-care ultrasound is part of the consultation with Dr Borukhson, so the tendons and bursae on the outer hip can be scanned at the same appointment. If the joint or the spine still needs looking into, an X-ray or an MRI comes next.

Can pain in my hip come from my back?

Yes, often. Trouble in the lower back can be felt in the buttock, over the side of the hip and along the leg, and it can sit alongside a true hip problem, which is why any hip examination includes the back. Pain that reaches below the knee, or comes with pins and needles or numbness, makes the back the more likely source, the subject of our back pain guide.