The Hip
Take a careful history, including general health and lifestyle:
- ‘Where is the pain?’ Pain from the hip is usually felt in the groin, less often in the lateral or anterior thigh. It can also be referred to the knee. If your patient has buttock pain, the source is probably the lumbo-sacral spine.
- What makes it better or worse? Significant morning stiffness suggests inflammation. Degenerative joint disease (DJD) is usually worse on activity.
- Ask about trauma and other joint symptoms.
- Understand the impact of hip symptoms on your patient’s daily life, whether it is on work or on activities like cutting toenails.
Night pain can occur in DJD – and in malignancy. Secondary bone tumours are more common than primary.
Examination
- There may be a limp.
- Leg shortening suggests advanced DJD, but also occurs in fracture. Patients can sometimes walk on an impacted femoral neck fracture, but the leg is often externally rotated and shorter.
- Check range of movements (ROM), comparing with the other leg. Full ROM is unlikely in advanced hip disease.
- Exclude inguinal hernia too.
Investigations
- FBC, ESR, CRP, rheumatoid factor for inflammatory arthritis.
- X-ray hips or whole pelvis if you suspect Paget’s disease.
Management
If you can’t make a diagnosis, your patient is well and without a limp, and the hip moves well, you could prescribe NSAIDs and review in 2 weeks.
Mild DJD is very common. Weight loss, physiotherapy (or gentle exercise like swimming) and analgesics often help.
Severe symptomatic DJD merits surgery. Pain and loss and function are the usual reasons for hip replacement. Surgeons often use a scoring system (e.g. Oxford Hip Score) to assess symptoms pre-operatively and postoperatively.
The Knee
Knee symptoms are very common in general practice and there are many possible causes. Acute pain is often sports related. Chronic pain is more likely to be DJD.
History
- Is there pain? If so, use SOCRATES. The exact site matters: medial joint line pain suggests a meniscal problem. Pain behind the knee may be a popliteal cyst.
- Stiffness points to an inflammatory cause (rheumatoid or psoriatic arthritis, ankylosing spondylitis).
- Swelling can be synovitis, effusion or a bursa.
- ‘Does the knee give way?’ Instability suggests ligament injury.
- Locking means inability to straighten knee fully. It may mean a trapped fragment of torn meniscus, or a loose body.
- Enquire about trauma (‘What exactly happened?’), symptoms in other joints, general health, occupation, leisure and medication. Septic arthritis often causes
systemic symptoms and is more common in 
immunosuppression, including steroid therapy.
Examination
- How does the patient walk?
- Is there quads wasting? This usually suggests a knee problem, but it can be neuropathic.
- Is the knee in varus or valgus?
- What about swelling or
redness?
- Check for joint line tenderness (suggesting meniscal injury).
- Is there an effusion or synovitis?
- Check ROM. Are movements painful?
- Test the stability of the knee. Perform tests for ligament integrity.
- Remember to examine the hip too.
Investigations
Blood tests are rarely needed for chronic knee pain. X-rays show osteoarthritis in up to 70% of those with knee pain, but are unnecessary for confirming a clinical diagnosis of DJD.
Refer if there are red flags:
Significant trauma – there may be an intra-articular fracture.
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