Hip Osteoarthritis

The purpose of this blog is to answer the 10 most common questions about hip osteoarthritis.

Looking to improve the strength, range of motion, and control of your hips to enhance your function and performance? Check out our Hip Resilience program!

As a quick disclaimer, this blog is NOT a substitution for a consultation with a medical professional. It also doesn’t supersede, or take the place of, any information already provided to you by your doctor or physical therapist. With that out of the way, let’s get into the questions.

Question #1 – What Are The Signs and Symptoms of Hip Osteoarthritis?

A systematic review in the Journal of the American Medical Association by Metcalfe et al in 2019 titled “Does This Patient Have Hip Osteoarthritis?” helps us answer this question.

Aside from symptoms presenting in the groin or buttock region, you might report some of the following:

• Morning stiffness
• Pain with climbing stairs or walking down slopes
• Pain on initial steps after rest
• Pain on walking
• Or pain relieved by sitting

Additionally, your medical doctor may notice or find that you have:

• A limp with walking
• Hip muscle weakness when trying to stand on one leg
• Buttock pain while squatting
• Pain with resisted hip movements
• Or decreased hip range of motion compared to your uninvolved side

This is not an all-inclusive list, but if you’re older, you start gradually experiencing symptoms in the groin or buttock region, and you’re noticing an associated decline in strength, range of motion, or overall function, hip osteoarthritis becomes higher on the list of possible diagnoses.

And although the groin and buttock regions are the most common locations of pain, a study by Khan et al in 2004 discovered that people can report a distribution of symptoms into their thigh, knee, and even shin or calf.

Imaging is only recommended if surgery is a consideration or if there’s suspicion of an alternative diagnosis. Otherwise, a clinical examination by your medical doctor is sufficient. 

Question #2 – Does Hip Osteoarthritis Worsen With Age?

Not necessarily.

A study published in 2019 by Schiphof et al followed 1,000 people with early symptoms of knee and/or hip osteoarthritis for 10 years. They concluded that “The symptomatic course in subjects with hip or knee complaints suspected of OA remained fairly stable on [a] population level, though individual scores fluctuated.”

Therefore, some people got better, some people got worse, but “on average there was little to no progression of complaints during a 10-year follow-up period…”

Question #3 – What Should You Do If You’re Bone-on-Bone?

This is one of the most important questions because there’s actually a difference between radiographic hip osteoarthritis, which is what’s found on imaging, and symptomatic or clinical hip osteoarthritis, which is what you’re experiencing and what your medical doctor finds during their examination.

In that study by Schiphof et al in 2019, 17% of the participants had radiographic hip osteoarthritis at baseline, but 60% had radiographic hip osteoarthritis at the 10-year follow-up. So the hips looked “worse” on imaging, but as I just mentioned, on average there was little to no progression of symptoms over that time!

In one of the most well-known studies to date, Kim et al examined nearly 1,000 people over the age of 50 in the city of Framingham, Massachusetts. The researchers found that 19.6% of those individuals had radiographic hip osteoarthritis, but only 4.2% had symptomatic hip osteoarthritis.

Kim et al did a follow-up study on the Framingham group and another group known as the Osteoarthritis Initiative. 

“In the Framingham study (n=946), only 15.6% of hips in patients with frequent hip pain showed radiographic evidence of hip osteoarthritis, and 20.7% of hips with radiographic hip osteoarthritis were frequently painful.” 

“In the Osteoarthritis Initiative study (n=4366), only 9.1% of hips in patients with frequent pain showed radiographic hip osteoarthritis, and 23.8% of hips with radiographic hip osteoarthritis were frequently painful.”

They concluded the following: “We showed that pain was not present in many hips with evidence of osteoarthritis on radiography, and many painful hips did not show radiographic evidence of hip osteoarthritis.”

This means that you can be “bone-on-bone” based on your x-rays yet have minimal-to-no symptoms or loss of function. Similarly, your imaging might show very few changes, but you could be experiencing a lot of pain.

I’ve worked with too many people whose symptoms and function significantly worsened only after being told that they were “bone-on-bone.” I think it’s a phrase that needs to be eliminated because the words are oftentimes more harmful than what the image shows. 

Don’t let those words be the thing that holds you back.

Question #4 – Should You Stop Exercising?

No!

Regardless of the country, journal, or date of publication, every review and guideline recommends exercise as a first-line management option for hip osteoarthritis. 

A study by French et al in 2015 gathered 51 osteoarthritis experts from 13 different countries and 9 patients living with osteoarthritis to answer the question, “What Do People With Knee or Hip Osteoarthritis Need to Know?”

Out of the 21 key messages they identified, only one had 100% agreement – “Individualized exercise is an integral component of treatment for everyone with osteoarthritis.”

Question #5 – What Exercises Should You Do For Hip Osteoarthritis?

First and foremost, it’s important to understand that no exercise is off limits as long as it’s tolerable for you. This doesn’t mean that you’re purposely pushing into pain; it means that slight discomfort during exercise doesn’t necessarily indicate damage or worsening of your hip. 

Zampogna et al in 2020 concluded: “This review and meta-analysis show that all active exercise and sport are an effective conservative treatment for elderly people with OA, in order to improve pain and physical function.”

I’m going to present 3 categories of exercise in order of importance:

Category #1: General Physical Activity

A systematic review by de Rooij et al in 2016 found that “Deterioration in physical functioning has been investigated in 8 studies and is predicted by higher comorbidity count…”

This means that anything you can do to try to improve your overall health and well-being is going to be beneficial.

Many people find that riding a stationary upright or recumbent bike feels pretty good. Same thing with swimming. But if it’s comfortable for you and you enjoy it, you can do gardening, walking, or any other activity you can think of.

And there’s no minimum time limit or frequency at which you have to do these activities. You could start with 5 minutes every other day and gradually build up to 30 minutes per day over the course of several months.

Some exercise will always be better than no exercise.

Category #2: Exercises that help you stand up, sit down, and go up and down stairs. 

There are two options here: squats and step ups.

For squats, gently tap your butt to a chair and stand back up. If they’re too challenging or painful, shorten the range of motion and/or use your hands for assistance. If you want to make them harder, you can add weight.

For step ups, start as low as you need to while using your hands for assistance. Over time, you can do them without your hands and gradually increase the height of the step.

An added benefit of these exercises is that they can reduce your risk of falling. If you want to improve your ability to get up from the floor, you can eventually progress to split squats.

For split squats, start in a stride stance and lower yourself down so that your back knee taps an egg that you don’t want to crack. If they’re too difficult for your front or back leg, shorten the range of motion or use your hands for assistance.

Category #3: Exercises that strengthen your hips.

The examples here emphasize the muscles on the back and side of your hips.

For the back of your hips, you can do bridges. Perform them single leg if you want to make them harder.

For the side of your hips, there are a lot of options. You can do hip abductions in standing or side lying with or without the use of a band or weight. Other possibilities include short side planks, regular side planks, or side steps with a band. 

Before concluding this section, there are three things that I want to mention:

1. These are just some options. Some people respond better initially to non-weight bearing exercises like leg extensions, hamstring curls, or various movements with ankle weights. Your exercise selection will be based on your symptoms, preferences, equipment availability, etc.

2. You don’t have to do or start with all three categories. Once again, you get to choose based on your function, time availability, resources, and other factors.

3. The frequency, sets, and reps of categories 2 and 3 are less important than just doing something consistently. You could do 2-3 exercises twice per week for 3 sets of anywhere between 5 and 20 repetitions.

As you feel better or stronger, you can do them more frequently, with more weight or for more repetitions, or expand your exercise program in other ways.

Question #6 – Should You Try To Lose Weight?

Since hip osteoarthritis is significantly less prevalent than knee osteoarthritis, there is much less research on the topic.  

However, a recent study by Salis et al in 2022 concluded that “In people with or at risk of clinically significant knee osteoarthritis, every 1% weight loss was associated with a 2% reduced risk of knee replacement and – in those people who also had one or more persistently painful hips – a 3% reduced risk of hip replacement, regardless of baseline BMI.”

Perhaps more importantly, though, is the information mentioned earlier that “Deterioration in physical functioning… is predicted by higher comorbidity count…”

The focus should likely be on developing and maintaining healthy habits that improve your overall well-being. Weight loss may result from incorporating regular exercise into your weekly routine and making changes to your dietary choices, but it may not be necessary to chase a specific number on the scale.

Question #7 – What Supplements Should You Take?

A systematic review by Liu et al in 2018 found that “The most widely used supplements (eg, glucosamine, chondroitin) do not provide a clinically important effect on osteoarthritis.”

This is not to say that you can’t take supplements that are low risk and low cost, but to optimize long-term outcomes, the focus should likely be on developing and maintaining healthy habits that improve your overall well-being.

Question #8 – Should You Get An Injection?

As the title of the paper suggests, a systematic review by Gazendam et al in 2021 found that intra-articular saline injections, also referred to as placebo injections, are just as effective as corticosteroids, platelet-rich plasma (PRP), and hyaluronic acid. The authors concluded that the “Evidence suggests that intra-articular hip saline injections performed as well as all other injectable options in the management of hip pain and functional outcomes.”

Question #9 – Should You Get Acupuncture, Massage Therapy, or Other Treatments?

A Cochrane systematic review by Manheimer et al in 2018 reported that “We found moderate quality evidence of little or no effect in reduction in pain or improvement in function for acupuncture relative to sham acupuncture.”

A clinical practice guideline for physical therapy in patients with hip or knee osteoarthritis by van Doormaal et al in 2020 stated that “It is not recommended to offer massage therapy to patients with hip or knee OA.”

The same authors also suggested not to offer continuous passive motion (after total joint replacement surgery), pulsed electromagnetic field therapy, low-level laser therapy (LLLT), passive mobilizations, shock wave therapy, taping, thermotherapy, and ultrasound therapy to patients with hip or knee OA.

This is not to say that some of these treatments can never be used, especially if they’re low cost, low risk, and provide temporary relief, but, once again, rehab should emphasize physical activity and lifestyle modifications.

Question #10 – When is a Total Hip Replacement Indicated?

There’s no perfect answer here.

Two authors suggest the following: “Referral of patients with end-stage osteoarthritis to a surgeon should be considered if all appropriate conservative options, delivered for 6 months, have been unsuccessful. Furthermore, the decision to refer to an orthopaedic surgeon should be made if patient quality of life is greatly reduced because of end-stage osteoarthritis.”

According to Sansom et al in 2010, individuals who eventually opt for a total hip replacement get to that destination by one of two routes: they wait until symptoms are unbearable (known as “holding off”) or they seek care preemptively (“before symptoms get worse”). 

However, the authors also found that there is often anxiety, concern, and disappointment associated with the process, especially if there is a mismatch between the beliefs of the patient and doctor. 

This is highlighted by a study by Neuprez et al in 2016 that found that preoperative expectations were the best predictor of post-surgery satisfaction one year after a total hip replacement.

It’s never an easy decision. You might receive suggestions from your medical doctor, physical therapist, family members, and even friends, but ultimately the choice is up to you.

Regardless of when you decide to get a total hip replacement (if it’s indicated), a systematic review by Moyer et al in 2017 found that preoperative exercise can help improve outcomes after surgery.