Saanichton Physical Therapy Blog

Recommendations for Hip assessment and Treatment

Recommendations for Hip assessment and Treatment

Recommendations for Hip assessment and Treatment

Major Recommendations

Definitions for the strength of evidence ratings (A, B, C, and I) and the criteria for evidence-based recommendations are presented at the end of the “Major Recommendations” field.

Summary Tables: Recommendations and Evidence

Table 1 summarizes the recommendations from the Evidence-based Practice Hip Panel for diagnostic testing for hip and groin disorders. Table 2 is a summary of recommendations for managing these disorders. Table 3 is a summary of pre-, peri-, and post-operative rehabilitation recommendations related to these disorders. Recommendations are based on critically appraised higher quality research evidence, and on expert consensus, observing First Principles when higher quality evidence was unavailable or inconsistent. The reader is cautioned to utilize the more detailed indications, specific appropriate diagnoses, temporal sequencing, prior testing or treatment, and contraindications that are elaborated in more detail for each test or treatment in the body of this Guideline in using these recommendations in clinical practice or medical management. These recommendations are not simple “yes/no” criteria, and the evidence supporting them is in nearly all circumstances developed from typical patients, not unusual situations or exceptions.

Recommendations are made under the following categories:

  • Strongly Recommended, “A” Level
  • Moderately Recommended, “B” Level
  • Recommended, “C” Level
  • Insufficient-Recommended (Consensus-based), “I” Level
  • Insufficient-No Recommendation (Consensus-based), “I” Level
  • Insufficient-Not Recommended (Consensus-based), “I” Level
  • Not Recommended, “C” Level
  • Moderately Not Recommended, “B” Level
  • Strongly Not Recommended, “A” Level

Table 1. Summary of Recommendations for Diagnostic and Other Testing for Hip and Groin Disorders

Test Recommendation(s)
Antibodies Antibody levels to evaluate and diagnose patients with hip pain if there is reasonable suspicion of a rheumatological disorder – Recommended, Insufficient Evidence (I)Antibody levels as a screen to confirm the existence of specific disorders (i.e., rheumatoid arthritis) – Strongly Recommended, Evidence (A)
Hip Arthroscopy Arthroscopy to evaluate and diagnose patients with hip pain if there is a suspicion of labral tear, intraarticular body, femoroacetabular impingement, or there are other subacute or chronic mechanical symptoms – Recommended, Insufficient Evidence (I)Arthroscopy for diagnosing acute hip pain – Not Recommended, Insufficient Evidence (I)Arthroscopy to diagnose or treat acute, subacute, or chronic hip osteoarthrosis in the absence of a remediable mechanical defect such as symptomatic labral tear – Not Recommended, Insufficient Evidence (I)Arthroscopy with chondroplasty for treatment of osteoarthrosis – Not Recommended, Insufficient Evidence (I)
Bone Scans Bone scanning for select use in patients with acute, subacute or chronic pain to assist in the diagnosis of osteonecrosis, neoplasms, or other conditions with increased polyostotic bone metabolism, particularly when more than one joint needs to be evaluated – Recommended, Insufficient Evidence (I)Bone scanning for routine use in hip joint evaluations – Not Recommended, Insufficient Evidence (I)
Computerized Tomography (CT) Routine CT for evaluating acute, subacute, or chronic hip pain – Not Recommended, Insufficient Evidence (I)CT for evaluating patients with osteonecrosis or following traumatic dislocations or arthroplasty-associated recurrent dislocations – Recommended, Insufficient Evidence (I)CT for patients who need advanced imaging, but have contraindications for MRI – Recommended, Insufficient Evidence (I)Routine helical CT for evaluating acute, subacute, or chronic hip pain – Not Recommended, Insufficient Evidence (I)Helical CT for evaluating patients with osteonecrosis who have contraindications for MRI – Recommended, Insufficient Evidence (I)

Helical CT for select patients with acute, subacute or chronic hip pain for whom advanced imaging of bony structures is thought to be potentially helpful – Recommended, Insufficient Evidence (I)

Helical CT for patients who need advanced imaging, but have contraindications for MRI – Recommended, Insufficient Evidence (I)

C-Reactive Protein, Erythrocyte Sedimentation Rate, and Other Nonspecific Inflammatory Markers Erythrocyte sedimentation rate or other inflammatory markers for screening for inflammatory disorders or prosthetic sepsis with reasonable suspicion of inflammatory disorder in patients with subacute or chronic hip pain – Recommended, Insufficient Evidence (I)
Local Anesthetic Injections and Epidurals Local anesthetic injections to assist in the diagnosis of subacute or chronic hip pain – Recommended, Insufficient Evidence (I)
Electromyography (including Nerve Conduction Studies) Electrodiagnostic studies to assist in the diagnosis of subacute or chronic peripheral nerve entrapments including lateral cutaneous nerve to the thigh (meralgia paresthetica) – Recommended, Insufficient Evidence (I)Nerve conduction study to confirm diagnosis or in patients for whom surgery is contemplated – Recommended, Insufficient Evidence (I)
Magnetic Resonance Imaging (MRI) MRI for select patients with subacute or chronic patients with consideration of accompanying soft tissue pathology or other diagnostic concerns – Recommended, Insufficient Evidence (I)MRI for diagnosing osteonecrosis – Recommended, Insufficient Evidence (I)MRI for routine evaluation of acute, subacute, or chronic hip joint pathology, including degenerative joint disease – Not Recommended, Insufficient Evidence (I)MRI to diagnose hamstring or hip flexor strains in more severe cases – Recommended, Insufficient Evidence (I)MRI to diagnose groin strains or adductor-related groin pain in more severe cases – Recommended, Insufficient Evidence (I)
MR Arthrogram MR arthrogram to diagnose femoroacetabular impingement, labral tears, gluteus medius tendinosis or tears, or trochanteric bursitis in patients with subacute or chronic hip pain – Recommended, Insufficient Evidence (I)
Roentgenograms (X-rays) X-rays for evaluating acute, subacute or chronic hip pain or femoroacetabular impingement or dysplasia – Recommended, Insufficient Evidence (I)X-rays for diagnosing osteonecrosis – Recommended, Insufficient Evidence (I)X-rays to diagnose hamstring or hip flexor strains in more severe cases – Recommended, Insufficient Evidence (I)X-rays to diagnose groin strains or adductor-related groin pain in more severe cases – Recommended, Insufficient Evidence (I)
Single Proton Emission Computed Tomography (SPECT) and Positron Emission Tomography (PET) SPECT or PET for diagnosing acute, subacute or chronic hip pain – Not Recommended, Insufficient Evidence (I)
Ultrasound Ultrasound for evaluating patients with gluteus medius tendinopathies, greater trochanteric bursitis, greater trochanteric pain syndrome/lateral hip pain, groin strains, femoroacetabular impingement, hip instability, dislocation, ligamentum teres ruptures, labral tears, or post-arthroplasty chronic pain where peri-articular masses are suspected – Recommended, Insufficient Evidence (I)Ultrasound to diagnose other hip disorders including osteonecrosis, osteoarthritis, dysplasia, or fractures – No Recommendation, Insufficient Evidence (I)
Urine Culture Culturing urine to diagnose lower abdominal strain unless other symptoms are present – No Recommendation, Insufficient Evidence (I)Urine cultures for select patients to diagnose epididymitis or epididymo-orchitis – Recommended, Insufficient Evidence (I)

 

Table 2. Summary of Recommendations for Managing Hip and Groin Disorders

 

Hip and Groin Disorder Treatment with Evidence Rating/Recommendation Level
Recommended No Recommendation Not Recommended
Acute, Subacute, or Chronic Hip and Groin Pain Measures to prevent falls (I)Activities that do not substantially aggravate symptoms for most patients with acute, subacute, or chronic hip or groin pain (I)Bed rest for patients with clear contraindication to weight-bearing status such as an unstable fracture (I)Non-steroidal anti-inflammatory drugs (NSAIDs) for chronic hip pain especially if due to osteoarthrosis (A)NSAIDs for acute or subacute hip pain (I)

NSAIDs for acute flares (C)

Proton pump inhibitors or misoprostol for patients at substantially increased risk for gastrointestinal bleeding (A)

Sucralfate for patients at substantially increased risk for gastrointestinal bleeding (B)

H2 blockers for patients at substantially increased risk for gastrointestinal bleeding (C)

NSAIDs for patients with known cardiovascular disease or multiple risk factors for cardiovascular disease if the risks and benefits of NSAID therapy for pain are discussed (I)

Acetaminophen (or the analog, paracetamol) for acute or subacute hip pain particularly in patients who have contraindications for NSAIDs (I)

Acetaminophen (or the analog, paracetamol) for chronic hip pain particularly in patients who have contraindications for NSAIDs (C)

Acetaminophen or aspirin as a 1st-line therapy for patients with cardiovascular disease risk factors (A)

Judicious use of opioids for acute severe hip pain (I)

Opioids for select patients with subacute or chronic hip pain (I)

Muscle relaxants for acute and subacute, moderate to severe hip pain from muscle spasm that is unrelieved by NSAIDs, avoidance of exacerbating exposures or other conservative measures (I)

Capsicum for short-term treatment of acute or subacute hip pain as well as for acute exacerbations of chronic hip pain as a counter-irritant (I)

Canes and crutches for moderate to severe acute hip or groin pain or subacute and chronic hip or groin pain where the device is used to advance the activity level (I)

Orthotics, shoe insoles, or shoe lifts for patients with significant leg length discrepancy with hip pain felt to be a consequence of that discrepancy (I)

Cryotherapies for home use if efficacious for temporary relief of acute, subacute, or chronic hip pain (I)

Self-application of low-tech heat therapy for acute, subacute, or chronic hip pain (I)

Manipulation or mobilization for subacute or chronic hip pain (C)

A psychological evaluation as part of the evaluation and management of patients with chronic hip pain (see indications) in order to assess whether psychological factors will need to be considered and treated as part of the overall treatment plan (I)

Cognitive-behavioral therapy as an adjunct to an interdisciplinary program for subacute or chronic hip pain (I)

Work conditioning, work hardening, and early intervention programs for chronic hip pain syndromes (I)

Multidisciplinary or interdisciplinary program (IPRP) with a focus on behavioral or cognitive-behavioral approaches combined with conditioning exercise for patients who due to chronic hip pain, demonstrate partial/total work incapacity (I)

Ergonomic interventions to prevent or facilitate recovery (I)Yoga for chronic persistent hip pain (I)Norepinephrine reuptake inhibiting anti-depressants for subacute or chronic hip pain (I)Topiramate for subacute or chronic hip pain (I)Gabapentin for subacute or chronic hip pain (I)

Willow bark (Salix), ginger extract, rose hips, Camphora molmol, Maleluca alternifolia, Angelica sinensis, Aloe vera, Thymus officinalis, Mentha piperita, Arnica montana, Tancaetum parthenium, and zingiber officinalis, avocado soybean unsaponifiables, oral enzymes, topical copper salicylate, S-Adenosylmethionine, and diacerein harpagoside for acute, subacute, or chronic hip pain (I)

Acupuncture for acute or subacute hip pain (I)

Diathermy for acute, subacute, or chronic hip pain (I)

Infrared therapy for acute, subacute, or chronic hip pain (I)

Ultrasound for acute, subacute, or chronic hip pain (I)

Low-level laser therapy for acute, subacute, or chronic hip pain (I)

Manipulation or mobilization for acute hip pain (I)

Massage for acute, subacute, or chronic hip pain (I)

Electrical therapies outside of research settings for acute, subacute, or chronic hip pain (I)

Transcutaneous electrical nerve stimulation (TENS) for acute, subacute, or chronic hip pain (I)

Botulinum injections (I)

Biofeedback for chronic hip pain (I)

Bed rest for patients with acute, subacute, or chronic hip pain (I)Norepinephrine reuptake inhibiting anti-depressants for acute hip pain (I)Selective serotonin reuptake inhibitors (SSRIs) for acute, subacute, or chronic hip pain (I)Skeletal muscle relaxants (I)Topiramate (I)

Gabapentin for acute hip pain (I)

Routine use of opioids for acute, subacute, or chronic non-malignant pain conditions (C)

Topical NSAIDs (I)

Wheatgrass cream (I)

Lidocaine patches (I)

Eutectic mixture of local anesthetics (EMLA) (I)

Other creams/ointments (I)

Tumor necrosis factor-alpha blockers for acute, subacute, or chronic hip pain (I)

Complementary or alternative treatments or dietary supplements, etc. for acute, subacute, or chronic hip pain (I)

Magnets and magnetic stimulation for acute, subacute, or chronic hip pain (I)

Reflexology for acute, subacute, or chronic hip pain (I)

Prolotherapy injections for acute, subacute, or chronic hip pain (I)

Osteonecrosis Measures to prevent falls (I)Reduction or elimination of activities that significantly provoke osteonecrotic symptoms, including avoidance of dysbaric exposures, or control of diabetes mellitus, elimination or reductions in glucocorticosteroid use, and/or elimination of alcohol and tobacco products (I)Aggressive targeting of all coronary artery disease risk factors (I)Bisphosphonates particularly for mild to moderate cases of osteonecrosis (C)NSAIDs (I)

Core decompression surgery (I)

Hip arthroplasty for osteonecrosis with collapse or unresponsive to nonoperative treatment (A)

Total hip arthroplasty as an effective operation to speed improvements in patient’s symptoms and functional status in those with moderate to severe hip disease (A)

Metal-on-metal hip resurfacing arthroplasty for select patients (C)

Ergonomic interventions to prevent or facilitate recovery (I)Institution of non-weight-bearing activities (I)Hyperbaric oxygen (I) Glucocorticosteroids, including by injection, in early disease stages (I)
Bilateral Osteoarthrosis or Hip Joint Disease Measures to prevent falls (I)For bilateral disease, carefully selected patients may safely undergo simultaneous bilateral hip replacement (C)Total hip arthroplasty as an effective operation to speed improvements in patient’s symptoms and functional status in those with moderate to severe hip disease (A)Metal-on-metal hip resurfacing arthroplasty for select patients (C) Ergonomic interventions to prevent or facilitate recovery (I)Botulinum injections (I)
Epididymo-Orchitis Measures to prevent falls (I)NSAIDs (I)Age-appropriate antibiotics (I)Physical or occupational therapy (I) Ergonomic interventions to prevent or facilitate recovery (I)Needle aspiration for epididymito-orchitis (I)Work limitations for patients with epididymitis or epididymo-orchitis, although limitations may be necessary depending on the severity of the condition and the physical job demands (I)Ice (I)Intermittent elevation (I) Bed rest (I)
Gluteus Medius Tendinosis and Tears Measures to prevent falls (I)Trochanteric glucocorticosteroid injections for gluteus medius tears with accompanying clinical bursitis (C)NSAIDs or acetaminophen for gluteus medius tears with accompanying clinical bursitis (I)Progressive, eccentric exercise for gluteus medius tendinosis and tears, particularly to strengthen the lateral hip musculature (I)Surgical repair for gluteus medius tears that are non-responsive to medical management (I) Ergonomic interventions to prevent or facilitate recovery (I)
Greater Trochanteric Bursitis/Greater Trochanteric Pain Syndrome Measures to prevent falls (I)Limitations may be helpful in the acute phase (I)Trochanteric glucocorticosteroid injections for acute, subacute, or chronic trochanteric bursitis or greater trochanteric pain syndrome (C)NSAIDs or acetaminophen for acute, subacute, or chronic trochanteric bursitis or greater trochanteric pain syndrome (I) Ergonomic interventions to prevent or facilitate recovery (I)Topical NSAIDs (I)Lidocaine patches (I)Eutectic mixture of local anesthetics (EMLA) (I)Other creams/ointments (I)
Groin Strains and Adductor-Related Groin Pain Measures to prevent falls (I)NSAIDs (I)Work limitations for patients with groin strains or adductor-related groin pain who perform high-physical jobs or cannot avoid job tasks thought to have resulted in the strain (I)Ice (I)Heat (I)

Ace wraps (I)

Physical or occupational therapy (I)

Ergonomic interventions to prevent or facilitate recovery (I)Work limitations for most groin strains or adductor-related groin pain (I) Bed rest (I)
Hamstring and Hip Flexor Strains Measures to prevent falls (I)NSAIDs (I)Work limitations for patients with hamstring or hip flexor strains who perform high-physical jobs or cannot avoid job tasks thought to have resulted in the strain (I)Ice (I)Heat (I)

Ace wraps (I)

Physical or occupational therapy (I)

Progressive agility, trunk stabilization and icing (PATS) (I)

Ergonomic interventions to prevent or facilitate recovery (I)Work limitations for most hamstring or hip flexor strains (I) Bed rest (I)
Hip Fracture Measures to prevent falls (I)Bisphosphonates for select patients with osteopenia-related hip fractures (A)Calcitonin for patients with hip fracture, particularly those who are intolerant to or have other contraindications for bisphosphonates (I)Transcutaneous electrical nerve stimulation (TENS) for emergency transport of patients with hip fracture (B)Acupressure for transporting patients with hip fracture to the hospital (B)

Surgical treatment (C)

Surgical intervention as soon as the patient is medically stable (I)

Arthroplasty for older patients with displaced femoral neck and subcapital fractures (A)

Ergonomic interventions to prevent or facilitate recovery (I)Manipulation or mobilization (I)
Femoroacetabular Impingement, “Hip Impingement,” and Labral Tears Measures to prevent falls (I)NSAIDs (I)Local glucocorticosteroid injections (I)Physical or occupational therapy (I)Arthroscopic surgery or open repair for “hip impingement” or labral tear cases that fail conservative management (I) Ergonomic interventions to prevent or facilitate recovery (I)
Hip Osteoarthrosis Measures to prevent falls (I)Aerobic exercise (B)Stretching exercises for select patients with significant reductions in range of motion that are not thought to be fixed deficits (I)Strengthening exercises (B)A trial of aquatic therapy for patients with hip osteoarthrosis who meet the referral criteria for supervised exercise therapy and have co-morbidities (e.g., extreme obesity, significant degenerative joint disease, etc.) that preclude effective participation in a weight-bearing physical activity and who will either transition to a land-based program or a self-administered water-based program (I)

NSAIDs for chronic hip pain especially if due to osteoarthrosis (A)

Acupuncture for select use for chronic osteoarthrosis of the hip as an adjunct to more efficacious treatments (B)

Cryotherapies for home use if efficacious for temporary relief of osteoarthrosis (I)

Self-application of low-tech heat therapy (I)

Intraarticular glucocorticosteroid injections (B)

Intraarticular hip viscosupplementation injections (I)

Hip arthroplasty for severe arthritides (A)

Ergonomic interventions to prevent or facilitate recovery (I)Norepinephrine reuptake inhibiting anti-depressants (I)Topiramate (I)Gabapentin (I)Glucosamine sulfate 1,500mg daily (single or divided dose), chondroitin sulfate, or methylsulfonylmethane for treatment hip osteoarthrosis (I)

Glucosamine sulfate intramuscular injections (I)

Glucosamine sulfate intraarticular injections (I)

Glucosamine sulfate, chondroitin sulfate, or methylsulfonylmethane for prevention of osteoarthrosis (I)

Diacerein (I)

Diathermy (I)

Infrared therapy (I)

Ultrasound (I)

Low-level laser therapy (I)

Manipulation or mobilization (I)

Massage (I)

Electrical therapies outside of research settings (I)

TENS (I)

Botulinum injections (I)

Tumor necrosis factor-alpha blockers (I)Magnets and magnetic stimulation (I)Reflexology (I)
Lower Abdominal Strains Measures to prevent falls (I)NSAIDs (I)Work limitations for patients with lower abdominal strains who perform high-physical jobs or cannot avoid job tasks thought to have resulted in the strain (I)Ice (I)Heat (I)

Physical or occupational therapy (I)

Ergonomic interventions to prevent or facilitate recovery (I)Work limitations for most lower abdominal strains (I) Bed rest (I)
Meralgia Paresthetica Measures to prevent falls (I)Weight loss for patients who are overweight or obese, avoidance of aggravating exposures, and the wearing of loose clothing (I)Glucocorticosteroid injections for meralgia paresthetica if more conservative treatments are not efficacious (I)Surgical release for select patients (I) Ergonomic interventions to prevent or facilitate recovery (I)NSAIDs (I)Topical lidocaine patches (I)Spinal cord stimulators for select patients (I)

Table 3. Summary of Recommendations for Pre-, Peri-, and Post-operative Issues Related to Hip and Groin Disorders

Recommended No Recommendation Not Recommended
Gabapentin for peri-operative management of hip pain to reduce need for opioids, particularly in patients with adverse effects from opioids (A)NSAIDs for post-operative hip pain (I)NSAIDs for prevention of heterotopic bone formation after arthroplasty (B)Acetaminophen (or the analog, paracetamol) for post-operative hip pain particularly in patients who have contraindications for NSAIDs (I)Judicious use of opioids for post-operative hip pain (I)

Cryotherapy for hip arthroplasty and surgery patients (C)

Acupuncture for hip arthroplasty procedures (B)

One-day use of systemic antibiotics for patients undergoing surgical hip procedures (B)

Pre-operative education program prior to hip arthroplasty (B)

Prevention of venous thromboembolic disease for post-operative hip patients, particularly arthroplasty patients or other post-operative patients with prolonged reductions in activity (early ambulation is recommended) (A)

Use of post-operative graded compression stockings for prevention of venous thromboembolic disease (B)

Use of lower extremity pump devices for prevention of venous thromboembolic disease (B)

Low-molecular weight heparin for prevention of venous thromboembolic disease (A)

Factor Xa inhibitors for prevention of venous thromboembolic disease (A)

Warfarin and heparin for prevention of venous thromboembolic disease (B)

Aspirin for prevention of venous thromboembolic disease (B)

A pre-operative exercise program particularly emphasizing cardiovascular fitness and strengthening especially for patients who exhibit evidence of weakness or unsteady gait. Flexibility components may be reasonable in those without fixed deficits. (B)

Post-operative exercise program and rehabilitation program for hip arthroplasty surgery patients (B)

For at least the first 6 weeks post-operatively, use walking aid as long needed (C)

For at least the first 6 weeks post-operatively, add other recommendations only if needed (e.g., elevated toilet seats, prohibiting driving) (C)

For at least the first 6 weeks post-operatively, activity of daily living (ADL) adaptive equipment as needed (e.g., long-handled reacher, long-handled shoe horn or sock aid) (I)

Post-operative exercise program and rehabilitation program for hip fracture patients (B)

Geriatric unit treatment for patients with multiple health care issues, particularly if there is moderate dementia (C)

A late post-operative exercise program after either arthroplasty or hip fracture emphasizing cardiovascular fitness and strengthening or resistance for patients who exhibit significant evidence of weakness or unsteady gait. A home exercise program among motivated patients may be sufficient. (C)

Manipulation or mobilization for surgical patients (I)Pre-operative autologous blood donation (I)Routine peri-operative use of bisphosphonates (I)Routine post-operative use of calcitonin (I)Use of treatment in a geriatric unit or using interdisciplinary rehabilitation (I)

Use of a late post-operative program for patients with mild reductions of questionable significance in the late post-operative period (I)

Specific vocational or avocational pursuits post-operatively.