Reviewed on : 22 Oct 2025

Reviewed by : Gateway Editor

Expires : 22 Oct 2027

Referral to Adult Physiotherapy Service

If patients have ongoing musculoskeletal hip pain and have not improved with relative rest or analgesic advice consider referral to the Adult Physiotherapy Service for assessment & treatment with:

• Advice
• Specific exercises
• Mobilisations/ soft tissue techniques
• Acupuncture
• Injection – for lateral hip/ GTPS only – No hip joint injections provided
• Appropriate walking aids
• Investigations or secondary care referral if appropriate

Primary Hip Replacement

Please note that CWICB have classified Primary Hip Replacement as requiring prior approval before the procedure is commissioned (please see below)

Prior approval should be sought by Secondary Care before scheduling any planned procedure

Please note Hip Pain referral guidelines

Hip Pain Referral Guidelines

These guidelines are divided into three categories:

Non Arthritic Hip

Moderate/ Severe Hip Arthritis

Previous Hip Replacement with pain or reduced function

 

Hip Pain Pathway (Adult Native Hip)

 

Hip Pain Pathway (Previous Hip Arthroplasty)

Previous Hip Replacement with pain or reduced function

Previous Hip Replacement	With pain or reduced function
Clinical Examination	Concern if pain on standing from a sitting position or on weight bearing Note: Hip joints should not be painful after a joint replacement, however trochanteric pain is common
Radiology	X-Ray within 6 months: AP Hips + Lateral Hip
Management plan	Referral to Revision Hip Surgeon if specific hip joint concerns Referral to Physiotherapy and encourage Weight Loss if specific trochanteric pain

Referral for Primary Hip Replacement (Prior Approval)

Referral for Primary Hip Replacement

Prior Approval from the Integrated Care Board (ICB) will be required before any treatment proceeds in secondary care unless an alternative contract arrangement has been agreed with the ICB that does not necessitate the requirement of prior approval before treatment

Background

This policy applies only to elective primary hip replacement for osteoarthritis

The majority of patients with osteoarthritis (OA) of the hip can initially be managed adequately in primary and intermediate care by following the NICE Clinical Guideline 226 (2022) and Quality Standard 87 (2015) for care and management of OA

Indication for Joint Replacement

The most common indication for elective primary total hip replacement (THR) is degenerative arthritis (osteoarthritis) of the joint

Other indications include rheumatoid arthritis, injury, bone tumour and necrosis of the hip bone

Adults aged 45 or over can be diagnosed with OA clinically, without investigations if they have activity-related joint pain and any morning joint stiffness lasts no longer than 30 minutes

Primary or intermediate care x-ray is not necessary as part of routine investigations

4. Eligibility Criteria

Referral for specialist assessment can be considered for patients who meet all the following criteria 1-6:

1. Patient experiences joint symptoms (pain, stiffness and reduced function) that have a substantial impact on their quality of life defined as interfering with their activities of daily living or their ability to sleep

2. Patient has been offered at least the core (non-surgical) treatment options recommended by NICE NG226;

Advise people with osteoarthritis where they can find further information on:

• Osteoarthritis and how it develops (including flares and progression over time), and information that challenges common misconceptions about the condition
• Activity and therapeutic exercise tailored to their needs appropriate to age, comorbidity, pain severity or disability. Exercise should include local muscle strengthening and general aerobic fitness
• Managing their symptoms
• How to access additional sources of information and support after consultations, such as peer-to-peer support and support groups
• Benefits and limitations of treatment

Referral to a recognised weight management programme for patients who are overweight or obese to improve outcomes

Evidence shows that lower BMIs have better surgical outcomes and therefore, patients who are overweight and obese must be offered support and interventions to lose weight and those who are obese must be offered a recognised weight management programme. This should be documented

All overweight and obese patients will be reviewed pre-operatively by the surgeon to ascertain medical fitness for surgery

Patient specific factors (including age, sex, smoking, obesity and co-morbidities) should not be barriers for surgery, however patients who smoke should be advised to attempt to stop smoking at least 4 weeks before surgery to reduce the risk of surgical and post-surgery complications

3. Joint symptoms are refractory to non-surgical treatments listed below including where appropriate; analgesia, steroid injections, local heat and cold therapy

4. Patients have a right to be fully informed about this procedure

As part of this process, clinicians should engage the patients (or their carers) in shared decision making about alternative management and the risks and benefits of surgery

5. Patient has confirmed they wish to have surgery

6. Any underlying medical conditions have been investigated and the patient’s condition has been optimised

Further advice and support

Currently some of this information is available on national websites, such as the Versus Arthritis (https://www.versusarthritis.org/about-arthritis/conditions/osteoarthritis/) however it has not been standardised in any way

Each hospital should have its own locally written information to distribute to patients in clinic. This local information may differ between centres, reflecting local practice, but there is no national standard for this information

The ICB expectation is that the information provided to patients includes the following as a minimum:

• Agree individualised self-management strategies with the person with osteoarthritis
• Manual therapy (such as manipulation, mobilisation or soft tissue techniques) should only be considered for people with hip or knee osteoarthritis and alongside therapeutic exercise
• If discussing manual therapy, explain to people with osteoarthritis that there is not enough evidence to support its use alone for managing osteoarthritis
• Devices – Consider walking aids (such as walking sticks) for people with lower limb osteoarthritis. Do not routinely offer insoles, braces, tape, splints or supports to people with osteoarthritis unless:

▪ there is joint instability or abnormal biomechanical loading and

▪ therapeutic exercise is ineffective or unsuitable without the addition of an aid or device and

▪ the addition of an aid or device is likely to improve movement and function

Pharmacological management

If pharmacological treatments are needed to manage osteoarthritis, use them alongside non-pharmacological treatments and to support therapeutic exercise and at the lowest effective dose for the shortest possible time

Offer a topical non-steroidal anti-inflammatory drug (NSAID) to people with knee osteoarthritis

Consider a topical NSAID for people with osteoarthritis that affects other joints

If topical medicines are ineffective or unsuitable, consider an oral NSAID for people with osteoarthritis and take account of:

potential gastrointestinal, renal, liver and cardiovascular toxicity

any risk factors the person may have, including age, pregnancy, current medication and comorbidities

Offer a gastroprotective treatment (such as a proton pump inhibitor) for people with osteoarthritis while they are taking an NSAID

Do not routinely offer paracetamol or weak opioids unless they are only used infrequently for short-term pain relief and all other pharmacological treatments are contraindicated, not tolerated or ineffective

Explain to people with osteoarthritis that there is no strong evidence of benefit for paracetamol

For more information about opioids, see NICE’s guideline on medicines associated with dependence or withdrawal symptoms

Do not offer glucosamine or strong opioids to people to manage osteoarthritis.

If the person with osteoarthritis asks about glucosamine or strong opioids, explain that there is no strong evidence of benefit for glucosamine and the risks of strong opioids outweigh the benefits

Review with the person whether to continue treatment. Base the frequency of reviews on clinical need

Intra-articular injections: Do not offer intra-articular hyaluronan injections to manage osteoarthritis. Consider intra-articular corticosteroid injections when other pharmacological treatments are ineffective or unsuitable, or to support therapeutic exercise. Explain to the person that these only provide short-term relief (2 to 10 weeks)

Patients who smoke should be advised to attempt to stop smoking at least 4 weeks before surgery to reduce the risk of surgical and post-surgery complications

For patients who DO NOT meet the eligibility criteria, the ICB will only consider funding the treatment if an Individual Funding Request (IFR) detailing the patient’s clinical presentation is submitted to the ICB

6. Guidance/References

https://www.nice.org.uk/guidance/ng157/resources/joint-replacement-primary-hip-knee-and-shoulder-pdf-66141845322181

https://www.nice.org.uk/guidance/ng226/resources/osteoarthritis-in-over-16s-diagnosis-andmanagement-pdf-66143839026373

https://www.nice.org.uk/guidance/qs87/resources/osteoarthritis-in-over-16s-pdf-2098913613253

https://www.nice.org.uk/guidance/ng226/evidence/e-clinical-and-cost-effectiveness-of-manual-therapy-for-the-management-of-osteoarthritis-pdf-11250452850

https://www.nice.org.uk/guidance/mtg76/resources/aposhealth-for-knee-osteoarthritis-pdf-64372240535749

https://www.versusarthritis.org/about-arthritis/conditions/osteoarthritis/

Hip Resurfacing Policy

Metal on Metal hip resurfacing arthroplasty involves removal of the diseased or damaged surfaces of the head of the femur and the acetabulum

The femoral head is fitted with a metal surface and the acetabulum is lined with a metal cup to form a pair of metal bearings

Evidence supports short-term effectiveness, mainly in patients <65 years

Hip resurfacing may only be considered where:

• The patient qualifies for a primary total hip replacement AND
• They are younger and more active, and likely to outlive a conventional hip replacement AND
• The procedure and prosthesis comply with current NICE (TA304) and MHRA guidance.

Funding Criteria

ICB will fund MoM hip resurfacing only if:

• The patient qualifies for primary THR; AND
• The patient is likely to outlive conventional hip replacements.
• Prosthesis must have ≤5% revision rate at 10 years (or consistent shorter-term data)

Post-Operative Joint Replacement Management 

See link right for full leaflet

Summary:

• Antibiotics may mask a joint infection temporarily but are unlikely to cure it.
• They may compromise the success of any further treatment.
• If you have concerns, leave a voicemail on: 024 7696 8333.
• We will organise investigations and arrange an appointment if required.

We will organise the necessary investigations and arrange an appointment if required.

Contact: 024 7696 8333