Hip pain in adults over 50 is one of the most commonly mismanaged conditions in primary care. The hip is a complex joint with multiple pain generators in close proximity, and the correct treatment depends entirely on an accurate diagnosis. A dull ache in the groin with restricted range of movement suggests different pathology than lateral hip pain that worsens lying on the affected side.
The Main Clinical Presentations
- True hip joint pain: typically felt in the groin, can refer to the anterior thigh, worsens with internal rotation of the hip, most commonly caused by osteoarthritis or femoroacetabular impingement
- Greater trochanteric pain syndrome: lateral hip pain that worsens with lying on the side, crossing the legs, and prolonged walking, caused by gluteal tendinopathy rather than bursitis as historically thought
- Lumbar referred pain: pain felt in the hip that originates from the lumbar spine, typically L3 or L4 referral patterns, often diagnosed as hip pathology and treated incorrectly
- Piriformis syndrome: deep buttock pain that can radiate down the leg, driven by piriformis muscle tension compressing the sciatic nerve
Greater Trochanteric Pain Syndrome: The Most Commonly Mismanaged
This condition, previously known as trochanteric bursitis, is now understood to be primarily a gluteal tendinopathy rather than a bursitis. Anti-inflammatory injections produce short-term relief but do not address the underlying tendon degeneration. The evidence-based approach is a progressive loading programme targeting the gluteal tendons, with specific education about postures that compress the tendons, including crossing the legs and sitting with significant hip adduction.
When Imaging Is and Is Not Useful
Hip X-ray is appropriate when true joint pathology is suspected. MRI provides more detail on soft tissue and bone marrow pathology. Ultrasound is the most useful for identifying tendon and bursal pathology. None of these investigations replaces a thorough clinical examination to identify the pain source and the mechanical factors driving it.