Nonarthritic Hip Joint Pain

• Use culturally safe, trauma- and violence-informed care. Explain why questions matter, seek permission before sensitive topics, and adapt communication to the patient’s language, identity, culture, disability and previous health care experiences (Public Health Agency of Canada, 2018).
• Patient and contextual information: age; sex and gender when clinically relevant; language and communication needs; work or school; caregiving; sport and recreation; and activities, roles and cultural or community practices important to the patient.

Primary concerns

• Context and onset: gradual or sudden onset; trauma; recent growth or developmental change in an adolescent; prior hip, groin, pelvic or low back symptoms; childhood hip condition; surgery; and change in sport, training, work or other load.
• Location and pattern: hip, groin, thigh, buttock or referred knee pain; duration, course, severity, irritability and 24-hour pattern; and whether symptoms are improving, fluctuating, persistent or worsening.
• Aggravating and relieving factors: walking, running, cutting, pivoting, stairs, squatting, lunging, prolonged sitting, rising from a chair, getting in or out of a vehicle, sexual activity and positions involving hip flexion or rotation; response to rest, movement, position or load change.
• Associated symptoms and participation: stiffness, clicking, catching, locking, giving way, weakness, numbness or tingling; back, pelvic or abdominal symptoms; and effects on mobility, sleep, self-care, work, school, caregiving, physical activity, sport, recreation, relationships and community participation.
• Body systems review: constitutional and infectious; neurological; cardiovascular and peripheral vascular; respiratory; gastrointestinal and genitourinary; reproductive and pelvic; musculoskeletal and bone health; inflammatory or immune; endocrine or metabolic; skin; haematologic; sleep; cognition; and mood symptoms that may change safety, the differential diagnosis, care or referral.
• Health, lifestyle and history: past health conditions; hip dysplasia, instability, osteoarthritis or childhood hip disease; fractures, cancer, inflammatory disease, infection, sickle cell disease or other blood disorder; injuries, hospitalizations and surgery; current medicines and supplements, including corticosteroids and anticoagulants; physical activity, nutrition and recovery; sleep; smoking; alcohol or substance use; and family history relevant to hip, inflammatory or bone health.
• Social determinants of health: work and training demands, education, caregiving, income, housing, food security, discrimination, safety, social support, access to care and ability to modify activity when these may shape health, care or participation (Public Health Agency of Canada, 2026).
• Previous care and responses: advice, rehabilitation, medication, injection, imaging, surgery or self-management tried; what helped or did not help; adverse effects; and reasons care was difficult to use or continue.
• Patient perspective: understanding of the problem, priorities, preferences, concerns about movement or imaging, expectations and previous experiences of care.
• Flag review: check Red Flags and refer to the separate fixed Orange Flags and Yellow Flags modules when relevant.

Outcome measures

• Use a small set that matters to the patient and is practical to repeat. Record a baseline and reassess often enough to guide decisions.
• Patient-specific functioning: Patient-Specific Functional Scale (PSFS).
• Disability and participation: WHO Disability Assessment Schedule 2.0 (WHODAS 2.0).
• Hip-related quality of life and functioning: the International Hip Outcome Tool (iHOT-12 or iHOT-33) is suitable for many adolescents and adults with nonarthritic hip joint pain (Enseki et al., 2023).
• Symptoms and performance: pain rating and a small number of repeatable tasks relevant to the person’s goals, such as walking, stairs, sit-to-stand, squat, single-leg control, running or sport-specific movement, when safe.
• Individual goals: agree on patient-defined goals and how progress will be recognized. SMART wording may be used when helpful

Orange Flags are signs that a mental health or substance use concern may require emergency or timely assessment or shared care, and may change whether and how MSK care proceeds. They are not diagnoses. Ask directly and respectfully when concern arises, considering immediate safety, severity, change from usual, daily functioning and context. Psychosocial factors that may affect recovery but do not require separate mental health or medical assessment are addressed under Yellow Flags.

ACTION: Arrange emergency assessment now when there is immediate danger or an urgent medical need:

• Suicide, self-harm or harm to others: current intent or plan, a recent attempt, inability to stay safe, or behaviour suggesting an immediate risk of serious harm.
• Severe change in mental state: extreme agitation, confusion, disorganization, possible psychosis or mania with impaired judgment or unsafe behaviour, or inability to meet basic needs when this creates immediate danger.
• Substance-related or medical emergency: suspected overdose, severe intoxication, dangerous withdrawal, delirium or another sudden change requiring urgent medical care.

When immediate safety is uncertain, do not leave the person alone while help is arranged. Follow local emergency procedures and call 9-1-1 for immediate danger or urgent medical need. If the person is thinking about suicide, call or text 9-8-8: Suicide Crisis Helpline with them or support them to do so.

If violence, abuse or exploitation is disclosed or suspected, support immediate safety and follow applicable safety and reporting requirements.

ACTION: Arrange prompt medical or mental health assessment when there is:

• Suicide or self-harm thoughts: thoughts without immediate danger.
• Substantial symptoms or effects: severe, persistent or worsening symptoms of depression, anxiety, trauma, possible psychosis or mania, eating problems or substance use that substantially affect daily life, decision-making or safe participation in care.
• Other reasons for assessment: a marked change from usual behaviour or functioning; concern about medication or substance effects; a presentation outside the clinician’s competence; or a request for help.

Agree with the patient on who will be contacted, how soon and what to do if the situation worsens. Confirm that the person has connected with the service when clinically important.

ACTION: Adapt and coordinate MSK care:

• Safe care: care may continue when it is safe and acceptable and does not delay needed assessment. Adapt communication, examination and care; obtain ongoing consent; and coordinate with other providers with the patient’s permission.
• Continue the MSK assessment: do not assume that a mental health or substance use concern explains the MSK presentation. Continue to consider physical causes and the patient’s account.
• Questionnaires: they may support conversation and monitoring, but do not establish a diagnosis or replace direct questions, clinical judgment or action.
• Acceptable support: ask what type of help is acceptable and whether language, cultural, family, community or other supports are important to the patient.

ACTION: Document and follow up:

Record the concern; relevant questions and the patient’s responses; the safety decision and reasons; actions, advice and referrals; communication and consent; follow-up; and any unresolved concern. Follow applicable privacy, safety and reporting requirements.

For provincial, territorial and national services, see Mental health support: Get help (Public Health Agency of Canada 2026).

Yellow Flags are personal, social, work, school, healthcare, environmental or structural factors that may influence symptoms, functioning, participation or response to care. They are contextual, not diagnoses or certain predictions, and do not mean that symptoms are psychological. They guide how care is tailored and do not by themselves require urgent referral. Explore them through conversation and ongoing outcome review, with attention to the patient’s priorities, strengths and circumstances. A separate Yellow Flag score is not required. New or worsening signs of serious physical illness follow the Red Flag process. Mental health or substance use concerns that need separate assessment, or any immediate safety concern, follow the Orange Flag process and applicable emergency or safeguarding procedures.

Explore relevant factors:

• Understanding, expectations and healthcare experiences: concerns about injury or damage, uncertainty, recovery expectations, confidence, conflicting advice, previous dismissal or harm, and trust in care.
• Responses to symptoms and activity: worry, fear, avoidance, cycles of doing too much and then needing prolonged rest, difficulty pacing, coping, sleep, confidence in self-management, and return to meaningful activities.
• Emotional and life context: distress, low mood, anxiety, grief, trauma, caregiving, relationship change, job loss or other major events. Ask permission before sensitive questions and limit discussion to what is relevant and acceptable to the patient.
• Relationships, culture and strengths: supportive relationships, isolation, family and community roles, cultural or spiritual practices, identity, preferences, language and other sources of resilience.
• Work, school and administrative context: physical and psychosocial demands, control, satisfaction, job security, accommodations, return concerns, and compensation, insurance or legal processes. Explore these neutrally and in context.
• Social and structural conditions: consider social and structural determinants of health (Public Health Agency of Canada 2026), including income, housing, food security, transportation, childcare, access and cost of care, discrimination, racism, colonialism, neighbourhood and workplace conditions, and physical or digital accessibility.

ACTION: Respond with the patient:

• Ask, do not assume: use open questions to understand what helps, what gets in the way, what matters and what feels feasible. Ask about strengths and protective factors, not only difficulties. Do not treat a person’s circumstances, culture or choices as a deficit.
• Plan together: integrate relevant findings into shared goals, education, self-management, physical activity or exercise, and participation in meaningful activities. Adapt communication, setting, pace, cost and access where possible.
• Connect and coordinate: with the patient’s consent, consider appropriate clinical, social, workplace, school, community, Indigenous or culturally specific supports. Clarify who will do what and follow up when the connection is important to the plan.
• Review response to care: reassess the patient’s account and the pathway’s selected outcomes at clinically relevant points. If progress differs from expected, review the clinical impression, care plan, access and other barriers; do not automatically attribute the outcome to Yellow Flags.
• Document: record relevant factors and strengths, the patient’s priorities and preferences, agreed actions, consent, referrals or coordination, follow-up, and any change requiring the Orange Flag process.

Select examination elements that answer a clinical question or may change care. Adapt the examination to the patient’s presentation, comfort, consent and abilities.

• Consent and comfort: explain what you propose, provide choices about positioning, draping, pace and support, and confirm ongoing consent, especially before examining the groin, pelvis or another sensitive area.
• Condition-specific safety: defer provocative hip testing and arrange appropriate assessment when fracture, stress fracture, infection, slipped capital femoral epiphysis or another serious condition is suspected.
• Observation and gait: standing and sitting posture, gait, weight-bearing tolerance, stride, foot progression, pelvic and lower-limb movement, guarding, asymmetry and use of supports.
• Movement and range of motion: active and passive hip flexion, extension, abduction, adduction and rotation as relevant, noting range, quality, end feel and familiar symptom response rather than treating a restriction as diagnostic.
• Strength and muscle performance: hip flexion, extension, abduction, adduction and rotation, with trunk and lower-limb testing guided by the presentation; record pain, force, endurance, control and tolerance to load.
• Functional assessment: select safe tasks linked to the person’s goals, such as walking, stairs, sit-to-stand, squat, step-down, single-leg stance, running, cutting or sport-specific movement. Note symptom response, strategy, confidence and capacity.
• Lumbar, pelvic and neurological examination: assess the lumbar spine, pelvis, lower-limb strength, sensation and reflexes when referred pain, coexisting symptoms or neurological involvement is plausible.
• Palpation: examine relevant bony and soft-tissue structures when this helps assess a competing extra-articular condition or local symptom response.
• Hip provocation tests: flexion-adduction-internal rotation and flexion-abduction-external rotation can help assess hip-related pain. A negative result can reduce the likelihood of femoroacetabular impingement syndrome, but a positive test reproduces symptoms and does not confirm a tissue diagnosis (Enseki et al., 2023; Reiman et al., 2020).
• Imaging: not routine for every person. It can support a diagnosis that requires imaging criteria, clarify suspected dysplasia or instability, investigate serious pathology, or inform specialist or surgical planning when the result is likely to change care. Interpret morphology and soft-tissue findings with the symptoms and clinical signs (Reiman et al., 2020; Griffin et al., 2016).
• Repeat and adapt the examination when needed to review progress, revisit the working diagnosis or decide whether further assessment or referral is appropriate.

Working clinical presentations

• Presentations can overlap or change. Use the history, examination and imaging when relevant, and do not force the person into a tissue diagnosis from pain location, a provocative test or an imaging finding alone (Reiman et al., 2020).
• Femoroacetabular impingement syndrome: motion- or position-related hip or groin symptoms, relevant clinical signs and imaging findings of cam or pincer morphology are all required. Morphology without symptoms and clinical signs is not the syndrome (Griffin et al., 2016).
• Acetabular dysplasia or hip instability: hip or groin pain may occur with loading, impact, end-range movement, apprehension or giving way. Clinical examination and imaging have limited diagnostic utility in isolation, so suspected instability or undercoverage may need specialist assessment (Reiman et al., 2020).
• Other intra-articular hip-related pain: labral, chondral or ligamentum teres involvement may be suspected when hip or groin pain occurs with loading or movement and may include clicking, catching or locking. These features and imaging findings are not diagnostic on their own (Enseki et al., 2023; Reiman et al., 2020).
• Hip-related pain without a confirmed specific condition: the presentation appears to arise from the hip joint after serious, extra-articular and referred causes have been assessed, but available findings do not support a more specific diagnosis. Record the working impression and revisit it as the course and response to care become clearer.

Develop care with the patient. Choices reflect the working presentation, safety, goals, preferences, culture, access, other health conditions, previous responses and the burden of care. Respect the patient’s right to accept, decline, limit or stop any part of care.

Education, self-management and participation

• Explanation and shared understanding: explain the working diagnosis, what is known and uncertain, and why symptoms, examination and imaging are considered together. Use imaging terms without implying that morphology or a labral finding is damage that needs correction (Reiman et al., 2020; Griffin et al., 2016).
• Load and position management: temporary changes to deep hip flexion, pivoting, prolonged sitting, training volume, work tasks or another aggravating load can reduce repeated provocation while maintaining feasible movement and participation. Progress the activity as tolerance and confidence improve (Enseki et al., 2023).
• Participation planning: build return to work, school, caregiving, recreation or sport around symptoms, repeated outcomes, strength, movement control, confidence and the demands of the task rather than a fixed calendar.

Physical activity and exercise

• Multimodal rehabilitation: options include progressive hip, trunk and lower-limb strengthening; mobility work for relevant restrictions; balance; and functional practice. Type, amount and progression reflect the presentation, goals, current capacity and response (Enseki et al., 2023; Probst et al., 2023).
• Movement pattern and task training: individualized practice can modify a painful strategy during daily, work or sport tasks without presenting one movement pattern as universally correct (Enseki et al., 2023).
• Condition-specific precautions: reduce repeated symptom-provoking impingement positions for femoroacetabular impingement syndrome and excessive end-range capsuloligament stress when instability is suspected. Revisit the diagnosis or coordinate specialist care if loading cannot be progressed (Enseki et al., 2023).

Hands-on and symptom-relieving care

• Joint and soft-tissue techniques: mobilization or soft-tissue techniques can accompany exercise and task practice when a short-term change in comfort or mobility helps the person participate. Review the response against the agreed goal (Enseki et al., 2023).
• Culturally grounded and personal strategies: traditional, Indigenous, spiritual, community-based or other symptom-relieving approaches identified by the patient can be integrated when safe, acceptable and within scope.

Psychological, social and interdisciplinary support

• Psychologically informed care: supportive communication, graded exposure and coping strategies can form part of care when fear, distress, low confidence, mood or anxiety affects activity or recovery. Coordinate mental-health care when needs extend beyond the clinician’s competence or scope (Enseki et al., 2023).
• Social and practical support: workplace, school or sport accommodations, coaching or team communication, community services and help with access barriers can support participation when they match the patient’s priorities.

Medication and procedural shared care

• Medication or injection questions: review current use, intended benefit, adverse effects, interactions and how symptom relief relates to the person’s goals with an authorized prescriber or pharmacist. Prescribing, dosing and procedural decisions remain with the appropriate medical provider.
• Hip specialist opinion: can form part of shared care when suspected dysplasia or instability needs clarification, the diagnosis remains uncertain, or symptoms continue to limit valued activity despite an appropriate trial of nonoperative care. Do not base referral or procedural decisions on imaging alone (Enseki et al., 2023; Reiman et al., 2020).

Monitoring and reassessment

• Agree on a reassessment point based on the presentation, safety, goals, care being tried, patient needs and access rather than a fixed visit schedule.
• Repeat the small outcome set recorded at baseline and review symptoms, weight-bearing and movement tolerance, strength, task performance, functioning, participation, confidence, benefits, adverse effects, treatment burden and progress toward patient-defined goals.
• Continue what is useful and acceptable; adapt or stop what is not; and revisit Red Flags, the working presentation, differential diagnosis, imaging, referral or shared care when progress differs from expectations or new safety concerns emerge.

• Expected course: prognosis is individual. Many people in nonoperative studies report meaningful improvement or a satisfactory response, but results vary widely and do not establish one expected timeline or predict whether a particular person will later choose procedural care (Probst et al., 2023; Cheng et al., 2026).
• Factors associated with a less favourable course: more severe symptoms at baseline may be linked to a lower likelihood of a satisfactory nonoperative response in adolescents and young adults seen in tertiary care. Persistent high demands, limited ability to modify aggravating loads, coexisting health concerns, distress and barriers to care may also affect the course, but none determines an individual’s outcome (Cheng et al., 2026; Enseki et al., 2023).
• Potential supports for recovery: a clear explanation, feasible load changes, progressive exercise and task practice, confidence in movement, supportive relationships and teams, suitable accommodations, access to care and timely shared care may support functioning and participation.
• Discussing prognosis: describe uncertainty in plain language, ask what the patient wants to know, and update the outlook using goals, repeated outcomes and the observed response over time. Do not use morphology, a single test or one outcome score as a fixed prediction.