Hip Osteoarthritis: Difference between revisions

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== Introduction ==
[[File:Hip OA diagram.png|thumb|265x265px|Hip OA diagram|alt=]]
Osteoarthritis is a common disabling condition that causes joint pain and stiffness caused by the gradual erosion of cartilage. Hip osteoarthritis is a common form of osteoarthritis that causes restricted locomotor activity and functional disability, and may progress to the point where joint replacement is needed. Hip osteoarthritis is a major global public-health burden. <ref name=":2" />


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* For people with hip arthritis, physiotherapy may assist in conditioning and obtaining endurance of the surrounding muscles that support the joint.
== Definition/Description  ==
* A long term approach to the management of a hip OA should include some type of regular physical therapy or conditioning program.


Hip osteoarthritis is a common type of [[osteoarthritis]] (OA). Because the hip is a weight-bearing joint, osteoarthritis can cause significant problems.&nbsp;Hip osteoarthritis is caused by deterioration of the articular cartilage of the hip joint. Deterioration means a bone on bone contact in the hip, instead of cartilage to cartilage. The synovial fluid can decrease or disappear completely. <br>There is too much broken cartilage, and not enough created.<br>
== Epidemiology ==
Globally, from 1990 to 2019, the age-standardized incidence rate of hip osteoarthritis increased from 17.02 per 100,000 persons to 18.70 per 100,000 persons. The  burden of hip osteoarthritis has increased in almost all countries over the past 30 years, this increasing trend is expected to continue, due to the rapid aging of the world’s population.  


There are several risk factors<ref>Book: REGINSTER et al. 'Osteoarthritis. Clinical and Experimental Aspects'. Springer, Verlag Berlin Heiderlberg, 1999.</ref>:
* Osteoarthritis is the most common cause of hip pain in older adults (older than 50 years of age).
* Prevalence rates for adult hip OA range from 0.4% to 27%.
* The reported prevalence of hip OA shows great variability, with men showing higher prevalence of radiographic hip OA.<ref name=":2">Fu M, Zhou H, Li Y, Jin H, Liu X. Global, regional, and national burdens of hip osteoarthritis from 1990 to 2019: estimates from the 2019 Global Burden of Disease Study. Arthritis research & therapy. 2022 Dec;24(1):1-1.Available;https://arthritis-research.biomedcentral.com/articles/10.1186/s13075-021-02705-6#Sec9 (accessed 15.11.2022)</ref><ref name=":3">Cibulka MT, Bloom NJ, Enseki KR, MacDonald CW, Woehrle J, McDonough CM. Hip pain and mobility deficits—hip osteoarthritis: revision 2017: clinical practice guidelines linked to the international classification of functioning, disability and health from the orthopaedic section of the American Physical Therapy Association. Journal of Orthopaedic & Sports Physical Therapy. 2017 Jun;47(6):A1-37.Available:https://www.jospt.org/doi/10.2519/jospt.2017.0301 (accessed 15.11.2022)</ref>
* Lifetime risk for symptomatic hip OA is 18.5% for men and 28.6% for women<ref name=":8">Lespasio MJ, Sultan AA, Piuzzi NS, Khlopas A, Husni ME, Muschler GF, Mont MA. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5760056/ Hip osteoarthritis: a primer.] The Permanente Journal. 2018;22. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5760056/ (last accessed 19.11.2019)</ref>.
* Research suggest that there are a 25% risk of developing hip osteoarthritis for people who live to the age of 85,<ref name=":0">Murphy NJ, Eyles JP, Hunter DJ. [https://link.springer.com/article/10.1007/s12325-016-0409-3 Hip osteoarthritis: Etiopathogenesis and implications for management.] Advances in therapy 2016;33(11):1921-46.</ref>


*Previous hip injury: If you ever had a previous hip injury, there is a bigger chance that you get hip OA.  
== Pathology ==
*Previous fracture, which changes hip alignment
[[File:Hip OA schematic.jpeg|thumb|Severe OA 1. osteophytes 2. subchondral thickening 3. cyst 4. jt space narrowing|alt=]]Osteoarthritis is distinguished by an active progressive alteration of the whole synovial joint, being due to a combination of mechanical, inflammatory and metabolic factors. It is caused by an imbalance between the destruction and repair of the affected tissues. The disease affects the  
*Genetics: It is possible that OA can be genetically transferable.  
*Congenital and developmental hip disease
*Subchondral bone that is too soft or too hard
*Overweight: you have overweight if your BMI (body mass index) is between 25 and <br>29,9. Having overweight is a risk factor for OA, because there is a bigger load of weight <br>on the joint.
*Occupation
*Age: When you get older, you have a higher risk for OA.
*Gender: The risk of OA is higher by women than men.
*Sport: To make your cartilage stronger, it is important to encumber your cartilage by doing <br>sports. Sports with a lower impact (like swimming) are good but they do not change a lot to <br>the composition of the cartilage. It is better to do high impact sports (like jumping). These <br>kinds of actions are better for the cartilage because they must absorb the impact. This <br>ensures that your cartilage becomes stronger. When you have a stronger cartilage, you <br>have a lower chance of having OA.
*Menopause: There is a higher risk for OA in the menopause. It is not sure that this is due <br>to the hormonal changes. The menopause is common by women with an age of 55-60.  
*Sedentary Lifestyle: The most important thing for your articular cartilage is compression. If <br>there is not enough compression, the cartilage will be weak. This results in a higher risk for <br>having OA.
*FAI (Femoro-acetabulair impingement) This impingement can lead to OA.


== Clinically Relevant Anatomy  ==
* Hyaline cartilage: loses its structural integrity due to composition changes.
* Subchondral bone
* Joint capsule
* Synovium
* Ligaments and the periarticular muscles.


The hip joint is complex<span style="font-size: 13.28px;">&nbsp;and is a synovial ball and socket joint , with the convex&nbsp;</span>femoral head articulating with the concave acetabulum. Stability of the joint is achieved through a combination of muscle action and several ligaments forming a loose but strong joint capsule. Ligaments as the iliofemoral ligament, the ischiofemoral ligament and the pubofemoral ligament keep the femoral head at its place, in the acetabulum. Another ligamentum teres does not provide stability to the hip but offers a portion of blood supply to the femoral head in some individuals.<ref>Anerson L. The anatomy and biomechanics of the hip joint. J Back Musculoskeletal. Rehabil. 1994;4(15):145-153.</ref> The hip joint is extremely strong, due to its reinforcement by strong ligaments and musculature, providing a relatively stable joint.<ref>Levangie P, Norkin C. Joint structure and function: A comprehensive analysis.  4th ed. Philadelphia: The F.A. Davis Company; 2005.</ref> Unlike the weak articular capsule of the shoulder, the hip joint capsule is a substantialcontributor to joint stability.<ref>Dutton M. Orthopaedic: Examination, evaluation, and intervention. 2nd ed. New York: The McGraw-Hill Companies, Inc; 2008.</ref><ref>Levangie P, Norkin C. Joint structure and function: A comprehensive analysis. 4th ed. Philadelphia: The F.A. Davis Company; 2005.</ref> The muscles that play a great role in stabilizing the hip joint include m. gluteus medius, m. gluteus maximus, m. piriformis and deep core muscleswich are: m. gemellus superior, m.gemellus inferior, m.obturator externus, m. obturator internus, m. quadratus femorum.<ref name=":0">Bohn Stafleu van Loghum , Sobotta Atlas van de menselijke anatomie Deel 2: romp, organen, onderste extremiteit derde herziene druk Houten 2006.</ref> The m. gluteus medius might be the most important reason for weakness causes. The iliopsoas muscle helps with the stability of the hip joint as well.<br><br>There are a lot of muscles that contribute to the movement of the hip: the flexors (m. pectineus, m. rectus femoris, m. iliopsoas), the extensors (m. semitendinosus, m. semimembranosus, m. biceps femoris [long head], m. gluteus maximus), the adductors (m. adductor magnus, m. adductor longus, m. adductor brevis, m. gracilis, m. pectineus), the abductors (m. gluteus medius, m. tensor fasciae latae),the internal rotators ( tensor fasciae latae, m.gluteus minimus) and the external rotators (m.gluteus maximus, m. gemellus superior, m. gemellus inferior, m. obturator externus, m. obturator internus, m. quadratus femorum, m. piriformis).<ref name=":0" /> The basic motions that are available in the hip joint are flexion , extension , adduction, abduction, internal rotation and external rotation. &nbsp; &nbsp; &nbsp; Full extension of the hip joint is the closed packed position because this position draws the strong ligaments of the joint tight, resulting in stability. The hip joint is one of the only joints where the position of optimal articular contact (combined flexion, abduction, and external rotation) is the loose-packed position, rather than the closed packed position, since flexion and external rotation tend to uncoil the ligaments and make them slack.<ref>Levangie P, Norkin C. Joint structure and function: A comprehensive analysis. 4th ed. Philadelphia: The F.A. Davis Company; 2005.</ref><br>[[Image:Muscles2.png|right]]<br>The femoral head and acetabulum are covered by smooth cartilage , and the acetabulum contains a labrum with functions to facilitate movement and support the forces passed through the joint.<ref>Crawford M, Dy C, Alexander J, et al. The 2007 Frank Stinchfield Award. The Biomechanics of the hip labrum and the stability of the hip. Clinical Orthopaedics and Related Research. 2007;465:16-22.</ref> The hip contains a femoral triangle as well where numerous vascular and neural structures, including the femoral vein, artery, and nerve pass through. There’s always a normal femoral inclination angle, from 120 to 125 degrees. The angle is closer to 125 in the elderly. An increase in this angle, greater than 125 degrees, results in coxa valga, and a decrease is called coxa vara. Eventually there is still the femoral angle of torsion which is between 12 and 15 degrees in normal people. &nbsp; &nbsp; &nbsp; An increase in this angle is termed Fig 2: Hip joint capsule anteversion, while a decrease in this angle is termed retroversion.<ref>Levangie P, Norkin C. Joint structure and function: A comprehensive analysis. 4th ed. Philadelphia: The F.A. Davis Company; 2005.</ref> 
== Risk Factors ==
Risk factors that increase the likelihood of developing osteoarthritis of the hip are  


External Link:&nbsp; [&lt;a href="http://www.hipsknees.info/flash/HTML-HIPS/demo.html"&gt;Hip Anatomy Video&lt;/a&gt;]<br>  
* [[Older People - An Introduction|Older age]]
* [[Obesity]]
* [[Genetics and Health|Genetics]]
* Repetitive stress and mechanical overload
* Farmers, construction workers
* High impact sports eg football, handball, hockey, wrestling, weight-lifting, and long-distance running
* [[Hip Dysplasia|Acetabular dysplasia]]
* [[Femoroacetabular Impingement|Femoroacetabular impingement]]
* [[Slipped Capital Femoral Epiphysis|Slipped capital femoral epiphysis]]
* [[Legg-Calve-Perthes Disease|Perthes disease]]
* Trauma, e.g. [[Hip Dislocation|hip dislocation]] or [[Femoral Neck Hip Fracture|hip fracture]]<ref>Radiopedia Hip OA Available:https://radiopaedia.org/articles/osteoarthritis-of-the-hip (accessed 15.11.2022)</ref>


<br>
== Diagnosis ==
[[File:Hip OA.jpg|250x250px|alt=|thumb|Advanced OA of a hip. ]]The following criteria should be used to  classify adults over the age of 50 with hip OA:


<br>  
# Moderate anterior or lateral hip pain during weight-bearing activities
# Morning stiffness less than 1 hour in duration after wakening
# Hip internal rotation range of motion less than 24° or internal rotation and hip flexion 15° less than the nonpainful side, and/or increased hip pain associated with passive hip internal rotation.<ref name=":3" />


Radiographic evidence: joint space narrowing, marginal osteophytes, subchondral sclerosis, and bone cysts.<ref>Brandt CD. Diagnosis and non-surgical management of osteoarthritis. USA: Professional Communications, Inc. 2010.</ref><ref name=":7">Katz JN, Arant KR, Loeser RF. [https://jamanetwork.com/journals/jama/article-abstract/2776205 Diagnosis and treatment of hip and knee osteoarthritis: a review.] Jama. 2021 Feb 9;325(6):568-78. Available: https://jamanetwork.com/journals/jama/article-abstract/2776205<nowiki/>(accessed 23.1.2022)</ref>.


== Clinical Presentation ==
[[File:Walking stick.jpeg|thumb|Hip OA - Elderly lady]]Pain characteristics:


== Epidemiology/etiology  ==
* Slowly progressive [[Hip Pain and Mobility Deficits|hip pain]], or hip-related groin pain radiating into the thigh, buttocks or knee.
* The [[Pain Behaviours|pain]] can be worse at night, at rest or with strenuous activity, reducing the [[Range of Motion|range of motion]] and limiting walking distance. It can be associated with stiffness particular in the morning or after rest.


Osteoarthritis is the most common disease causing joint complaints. Not only in women but also in men. It’s a disease that strikes many people worldwide, especially old persons. Research tells us that hip osteoarthritis has a prevalence of 11.5 percent in men and 11.6 <br>percent in women. This is almost equal but when we look at knee osteoarthritis, we see that this is more prevalent in women.<ref name=":1">Bennell K. Physiotherapy management of hip osteoarthritis. J Physiother. 2013; 59(3):145–157.</ref><br>Then we have some information about the incidence of hip OA.<ref>Prieto-Alhambra D, Judge A, Javaid MK, Cooper C, Diez-Perez A, Arden NK. Incidence and risk factors for clinically diagnosed knee, hip and hand osteoarthritis: influences of age, gender and osteoarthritis affecting other joints. Annals of the rheumatic diseases. 2014;73(9):1659-1664.</ref> The incidence rate for female was found 2.4/1000 a year and for males 1.7/1000 a year. <br>You have the personal level risk factors, described above, but you also have some joint level risk factors.<ref>Murphy NJ, Eyles JP, Hunter DJ. Hip Osteoarthritis: Etiopathogenesis and Implications for Management. Advances in Therapy. 33.11 (2016): 1921–1946.</ref> There are several causes for hip osteoarthritis:<br><br>1. Direct damage by trauma, arthritis, ...<br>2. Cartilage damage by metabolic process disorders (when there is a disrupt in homeostasis in the joint, more degradation of the cartilage matrix than synthesis)<br>3. The genetic factor (studies report the genetics are 60% of the risk)<br>4. Cartilage damage by repeated intra-articular bleedings<br>5. Congenital hip dislocation<br>6. Abnormality in stance of the joint (This will lead to a pathological loading pattern resulting in shear stresses)<br>7. Overload of the cartilage caused by obesity, prolonged overload, sensibility impediment<br><br>Additional to 6.&nbsp;:There is also more and more evidence these days that femoroacetabular impingement is an important factor causing hip osteoarthritis. This is what happens if the head of the femur scratches against the labrum what will lead to damage of the labrum and cartilage underneath. With the aid of time, this will result in degeneration of the joint.<br><br>A comparable problem is called developmental dysplasia of the hip. This is when the acetabulum doesn’t cover the femoral head enough and lead to instability of the femoral head. The result is shear forces onto the acetabular rim what also will lead to damage and degeneration of the hip joint.
Other symptoms include locking, grinding and joint instability, fatigue and pain-related psychological [[Stress and Health|stress]].<ref name=":6">Radiopedia OA of the hip Available: https://radiopaedia.org/articles/osteoarthritis-of-the-hip?lang=us<nowiki/>(accessed 23.1.2022)</ref>


== Characteristics/Clinical Presentation ==
=== Physical Examination ===
[[File:Hip rotation rom.jpeg|thumb|Measuring ROM hip]]
A physical examination includes (Also also [[Hip Examination|hip examination]])
* Observation
* Subjective interview:
** Complaints of pain, deformity, stiffness and/or limp
** Previous history linked to hip pain (congenital or childhood problems, previous trauma)
* Physical examination in Standing and Supine (look for [[Leg Length Discrepancy|leg length discrepancy]], [[Gait: Antalgic|antalgic gait]]  and  [[Trendelenburg Test|Trendelenberg gait)]]
* Objective observation (posture, deformities, muscle atrophy)
* Palpation:
** Tenderness at the hip
** Pain and sensitivity over greater trochanter
* Range of motion:
** Early signs of hip osteoarthritis is limited abduction and rotation. As the disease progresses, flexion, extension and adduction becomes more difficult.
** Normally painful at end of available range of motion
* Crepitis with movement<ref name=":9">American Academy of Orthopaedic Surgeons. Diseases and conditions: Osteoarthritis of the hip.https://orthoinfo.aaos.org/en/diseases--conditions/osteoarthritis-of-the-hip (accessed 14/07/2018).</ref><ref name=":5">Crielaard JM, Dequeker J, Famaey JP, Franchimong P, Gritten CH., Huaux JP. Osteoartrose. Brussels: Drukkerij Lichtert, 1985.</ref><ref name=":10">Walters J, editor. Orthopaedics - A guide for practitioners. 4th Edition. Cape Town: University of Cape Town, 2010.</ref>
Five variables for detecting hip osteoarthritis are:
# Self-reported squatting as an aggravating factor
# Active hip flexion causing lateral hip pain
# [[Hip Quadrant Test|Hip Quadrant test]] with adduction causing lateral hip or groin pain
# Active hip extension causing pain
# Passive internal rotation of less than or equal to 25°
If there are 3/5 variables present, the chance of having OA is 68%. With 4-5/5 the chance increases to 91%. The variables are positive when there’s pain or a limited range of motion in the tests.<ref>Sutlive TG, Lopez HP, Schnitker DE, Yawn SE, Halle RJ, Mansfield LT et al. [https://www.jospt.org/doi/pdfplus/10.2519/jospt.2008.2753 Development of a clinical prediction rule for diagnosing hip osteoarthritis in individuals with unilateral hip pain.] J Orthop Sports Phys Ther. 2008;38(9):542-50.</ref>


The most important characteristic of hip osteoarthritis is that there’s damage to or loss of the articular cartilage.<ref>Book: CRIELAARD J.M., DEQUEKER J., FAMAEY J.P., FRANCHIMONG P., GRITTEN Ch., HUAUX J.P. et al. ‘Osteoartrose’. Brussel, België: drukkerij Lichtert; maart 1985.</ref> Another typical characteristic is pain, especially pain that starts when the patient starts moving. This pain decreases when the patient keeps on moving or increases when they load the joint for too long or the wrong way. Later on, they will typically complain of a continuous pain and night pain.<ref>Book: CRIELAARD J.M., DEQUEKER J., FAMAEY J.P., FRANCHIMONG P., GRITTEN Ch., HUAUX J.P. et al. ‘Osteoartrose’. Brussel, België: drukkerij Lichtert; maart 1985.</ref> 
== Management ==
A [[Biopsychosocial Model|biopsychosocial approach]] offers the best outcome.<ref name=":1" /> A multidisciplinary team may be involved including: doctors, physiotherapists, dietitians, and occupational therapists.


== Differential Diagnosis  ==
Management of hip osteoarthritis varies according to the severity of the condition. A combination of pharmaceutical and non-pharmaceutical modalities is recommended for the optimal management of the condition. Physiotherapy plays an important role in customized exercise programmes for patients living with hip osteoarthritis.


A thorough patient history and physical examination should aid the clinican in his/her differential diagnosis.&nbsp; Pain location is often a good indicator of intraarticular versus extraarticular disorders.<ref>DeAngelis NA, Busconi BD. Assessment and differential diagnosis of the painful hip. Clinical Orthopaedics. 2003;406:11-18.</ref> The clinician should differentiate between a multitude of conditions such as:&nbsp;contusions, strains, athletic pubalgia, piriformis syndrome, hamstring syndrome, inflammatory disorders, snapping hip syndrome, bursitis, arthritis, septic arthritis, osteonecrosis, labral tears, fractures and dislocations and tumors.&nbsp;
# OA management includes patient education combined with exercise and/or manual therapy. Education should include teaching activity modification, exercise <ref>Dalmas I, Agius TP, Sciriha A. Core muscle strengthening exercises in the management of hip osteoarthritis: outcomes of a 12-week programme. European Journal of Physiotherapy. 2023 Mar 27:1-8.</ref>, supporting weight reduction when overweight (see below), and methods of unloading the arthritic joints.
# Management includes providing impairment-based functional, gait, and balance training, including the proper use of assistive devices (canes, crutches, walkers), to patients with hip osteoarthritis and activity limitations, balance impairment, and/or gait limitations when associated problems are observed.<ref name=":3" />
# Offer topical or oral [[NSAIDs|nonsteroidal anti-inflammatory drugs]] in those without contraindications.
# Intra-articular steroid injections provide short-term pain relief and duloxetine has demonstrated efficacy. Opiates should be avoided.<ref name=":7" />


Patients with OA complain about joint pain, stiffness, reduced movement and local inflammation. Further on in the development of this disorder, people can be confronted with joint contractures, muscle atrophy and limb deformity. Early in the development of OA, the pain comes in episodes, as it progresses, the pain becomes more constant, also with episodes of sharp pain. Morning stiffness and pain at night can also be a symptom of advanced hip osteoarthritis.<ref name=":2">Kim C, Nevitt MC, Niu J, Clancy MM, Lane NE, Link TM et al. Association of Hip Pain with Radiographic Evidence of Hip Osteoarthritis: Diagnostic Test Study. BMJ. 2015 Dec 2;351:h5983.</ref><br><br>The hip is stiff and rigid, there is an unpleasant tension and a higher resistance while moving. This is something that does not last long, after moving a little bit around the stiffness goes away. The range of motion decreases, this is because of the pain and the stiffness of the hip.When you start moving it will be better, but not as good as in the beginning. There can also be a crispy noise if the hip is moving.<ref>DeAngelis NA, Busconi BD. Assessment and differential diagnosis of the painful hip. Clinical Orthopaedics. 2003;406:11-18.</ref> <ref name=":3">Sutlive TG, Lopez HP, Schnitker DE, Yawn SE, Halle RJ, Mansfield LT et al. Development of a Clinical Prediction Rule for Diagnosing Hip Osteoarthritis in Individuals With Unilateral Hip Pain. J Orthop Sports Phys Ther. 2008;38(9):542-50.</ref> 


== Differential diagnosis  ==


A thorough patient history and physical examination should aid a therapist in making his differential diagnosis. Patients will often come to the physiotherapist, complaining they have some pain issues. Pain location often gives a good indication whether it’s an intra-articular or extra-articular disorder.<br>


Possible intra-articular hip disorders are: FAI ( Femoroacetabular impingement), Osteoarthritis, avascular necrosis, fractures (fig.3), dislocations, Septic arthritis, labral tear, chondral defect and an injury of ligamentum teres.<br>Possible extra-articular hip disorders are: abductor and gluteus muscle injuries, sciatica, obturator and LFC nerve irritation, piriformis syndrome, snapping hip, bursa, trochanteric bursitis, an inguinal ligament strain and a disorder of the joint capsule.<ref>Fernandez M, Wall P, O’Donnell J, Griffin D. Hip pain in young adults. Aust Fam Physician. 2014;43(4):205–9.</ref> <br>[[Image:Fractuur heup.png|right|Fig. 3: fractured hip]]<br>
'''Weight management''' – Hip OA<ref name=":12">2018 RACGP [https://www.racgp.org.au/download/Documents/Guidelines/Musculoskeletal/guideline-for-the-management-of-knee-and-hip-oa-2nd-edition.pdf Guidelines for hip and knee arthritis] Available from: https://www.racgp.org.au/download/Documents/Guidelines/Musculoskeletal/guideline-for-the-management-of-knee-and-hip-oa-2nd-edition.pdf (last accessed 19.11.2019)</ref>(RACPG 2018 guidelines): We strongly recommend weight management for people with hip OA. For those who are overweight ([[Body Mass Index|body mass index]] [BMI] ≥25 kg/m2 ) or obese (BMI ≥30 kg/m2 ), a minimum weight loss target of 5–7.5% of body weight is recommended. It is beneficial to achieve a greater amount of weight loss given that a relationship exists between the amount of weight loss and symptomatic benefits. Weight loss should be combined with exercise for greater benefits. For people of healthy body weight, education about the importance of maintaining healthy body weight is essential.


Patients who probably have hip osteoarthritis have a constant pain and stiffness in the groin <br>region. This pain can be related to many causes, and doesn’t mean that every patient has arthritis. But the combination of groin pain and the limited movement and pain with internal rotation identifies people with this disorder. To make the diagnosis, radiography is usually done. If patients with osteoarthritis don’t have radiographic evidence, they often don’t receive a diagnosis of OA and don’t get the <br>treatment herefore.<ref name=":2" /> <br>
'''Surgical interventions:''' [[Total Hip Replacement|Total hip replacement]] - The option in patients with symptomatic and radiographic osteoarthritis characterized by refractory pain and disability; [[Osteotomy]] and hip resurfacing - Should be considered in younger patients with symptomatic secondary osteoarthritis due to acetabular dysplasia, femoroacetabular impingement, varus or valgus deformity<ref name=":6" />.


<br>  
== Physiotherapy Management ==
Physiotherapy plays in major role in the management of patients with hip osteoarthritis. The goal is to  improve strength, mobility and increase range of motion. Physiotherapy also helps relieve pain and restores normal movement in the hip and legs and also addresses pain management and functional adaptions. Patient-specific exercise programmes has shown to decrease pain and improve function in hip osteoarthritis.<ref name=":0" /><ref name=":1">Bennell K. [https://pubmed.ncbi.nlm.nih.gov/23896330/ Physiotherapy management of hip osteoarthritis]. J Physiother. 2013; 59(3):145–157.</ref>


<br><br>
'''Education'''


== Diagnostic Procedures  ==
* Role of physiotherapy and expected outcomes of physiotherapy interventions
* Importance of weight reduction (combination of diet and exercise)
* Self-management of pain: Use of modalities such as heat and ice; Relaxation techniques; Coping strategies; Exercise<ref name=":0" /><ref name=":9" /><ref name=":11">Zhang W, Doherty M, Arden N, Bannwarth B, Bijlsma J, Gunther KP, Hauselmann HJ, Herrero-Beaumont G, Jordan K, Kaklamanis P, Leeb B. [https://ard.bmj.com/content/annrheumdis/64/5/669.full.pdf EULAR evidence based recommendations for the management of hip osteoarthritis: Report of a task force of the EULAR Standing Committee for International Clinical Studies Including Therapeutics (ESCISIT).] Annals of the rheumatic diseases 2005;64(5):669-81.</ref>


Hip osteoarthritis can also be seen on radiographs. The visible findings of this disorder are joint space narrowing, marginal osteophytes, subchondral sclerosis, and bone cysts. Magnetic resonance imaging is more effective in detecting early change in the bone <br>structure, such as focal cartilage defects and bone marrow lesions in the subchondral bone.<ref name=":1" /> <br>
'''Assistive devices'''


== Outcome Measures ==
* [[Walking Aids|Mobility assistive devices]] like [[Walking stick|walking sticks]]/[[canes]], [[crutches]], or [[Walkers|walking frames]] can improve mobility and independence of the patient. Occupational therapy also plays a role here, as they often also assists the patients with functional assistive devices like a long-handled reacher to pick up low-lying things, which will helps to avoid movements that may cause pain.


The first test was the hip disability and osteoarthritis outcome score ([[Hip Disability and Osteoarthritis Outcome Score|HOOS]]). This is a questionnaire which is used to gain the patients' history about their hip and associated problems, as well to evaluate symptoms and functional limitations related to the hip <br>during a therapeutic process. There are other questionnaires that can be used to get the patients opinion like Western Ontario and McMaster universities osteoarthritis index ([[WOMAC Osteoarthritis Index|WOMAC]]), the algofunctional index (AFI), the intermittent and constant osteoarthritis pain index (ICOAP), lequesne index, 6-minute walk test,timed up and go test and the patients specific complaints list (PSC).<br>
* '''The RACPG 20188 guidelines''' '''Assistive walking device – Hip OA'''<ref name=":12" /> It may be appropriate to offer an assistive walking device (eg cane) for some people with knee and/or hip OA, depending on a person’s preference and capability.


The HOOS test judges functions and anatomical qualities combined with activities and participation.&nbsp;This is recommended when you are talking of hip disability with or without osteoarthritis. This test is meant to be used over short and long term intervals to view changes induced by treatment. It looks at the changes over a year time or at post traumatic osteoarthritis changes.<br>The HOOS questionnaire is a very simple test, which is user friendly and only takes 7-10 <br>minutes to complete. The score consists of 40 items assessing 5 subscales: 5 separate patient-relevant dimensions: Pain (P), Symptoms (S), Activity limitations daily living (ADL), Function in sport and recreation (SP) and hip related quality of life (QOL).&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;To interpret the score, the outcome measure is transformed in a worst to best scale from 0 to 100, with 100 indicating no symptoms and 0 indicating extreme symptoms. To calculate the total HOOS score the subscales need to be summed up, using following formula for all dimension: 100 – [(patient's score of the subscale x 100)/(total score of the subscale)]<br>This test has a high reliability , a good validity except for the floor and ceiling effects, a high responsiveness thanks to the addition of two subscales(SP and QOL).[35]<br>
'''Exercise therapy'''[[File:Hip Theraband.png|right|frameless]]
Exercise therapy is an effective treatment modality for hip osteo-arthrosis.<ref name=":1" /> Specific exercises can increase range of motion and flexibility, as well as strengthen the muscles of the hip and leg. Physiotherapists work together with the patient to develop an individualized, customized exercise program that meets the needs and lifestyle of the patient.<ref name=":1" /><ref name=":11" /> The benefits of exercise can assist the patients in their self-management of hip osteoarthritis.  


== Medical management  ==
* Hydrotherapy is effective in the management of  hip osteoarthritis. The combination of buoyancy and the reduction of gravity greatly assists patients that are struggling to weight-bear as a result of the pain from the hip osteoarthritis.<ref name=":11" />
* A 2016 study of 210 people with hip OA found that those who participated in a 12-week exercise program had less pain and more mobility than the placebo or no-treatment groups.<ref>Arthritis Foundation [https://www.arthritis.org/about-arthritis/types/osteoarthritis/articles/hip-oa-exercises.php Exercise Benefits for Hip Osteoarthritis] Available from: https://www.arthritis.org/about-arthritis/types/osteoarthritis/articles/hip-oa-exercises.php (last accessed 19.11.2019)</ref>
* A study on a 6 week education and exercise programme has shown significant and sustained improvements in pain and disability on patients wait-listed for joint replacement surgery. Further positive results included improvements in function, knowledge and psycho-social aspects.<ref>Saw MM. [https://open.uct.ac.za/bitstream/handle/11427/15719/thesis_hsf_2015_saw_melissa_michelle.pdf?sequence=1&isAllowed=y <nowiki>The effects of a six-week physiotherapist-led exercise and education intervention in patients with osteoarthritis, awaiting an arthroplasty in the South Africa [dissertation]</nowiki>]. Cape Town: University of Cape Town. 2015.</ref> Clinical trials further suggest that it can postpone the need of total hip replacement surgery.<ref name=":11" />


Osteoarthritis is a common joint disorder, and the prevalence only increases with the aging of the population. This goes hand in hand with the increase of THR. THR, total hip replacement, is a successful orthopaedic procedure in the treatment of hip osteoarthritis, when the conservative therapy has failed. The number of total hip replacements per year increases by 73% overall. For those between 45 and 64 years, the total number of THR increases with 123% and 54% for people between 65 and 84 years old.<br>In THR, prosthetic substitutes replace the original hip joint partly or fully with the purpose to repair the hip joint. There is no age or weight limit in undergoing a total hip replacement, they have been performed successfully at all ages.&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; But a hip replacement at higher age can result in a worse functional outcome, major technical difficulties and higher operative risks.<br>A good choice of implant and the right surgical technique are essential for a successful result. <br>A good focus on the patient is also very important, so all the elements that can have a bad impact on the result can be deleted.<ref>Bottai V, Dell'Osso G, Celli F, Bugelli G, Cazzella N, Cei E et al. Total hip replacement in osteoarthritis: the role of bone metabolism and its complications. Clin Cases Miner Bone Metab. 2015 Sep-Dec;12(3):247-50.  
[[File:Hip exercise 3.png|thumb|Hip abduction exercise]]
</ref> <br>There are several techniques for implanting a prosthesis. In a study of Rosenlund et al, they investigated the difference in outcome in the two most commonly approaches of hip replacement: the lateral and posterior approach.<ref>Rosenlund S, Broeng L, Jensen C, Holsgaard-Larsen A, Overgaard S. The effect of posterior and lateral approach on patient-reported outcome measures and physical function in patients with osteoarthritis, undergoing total hip replacement: a randomised controlled trial protocol. BMC Musculoskelet Disord. 2014;15:354.
'''The RACPG 20188 guidelines recommend as per below'''
</ref>&nbsp;The lateral approach is set to have a reduced outcome in pain and physical function, and also in a decrease of strength of the adductor muscles. In a case-control study of Nilsdotter et al, the authors investigated the relevant outcomes of a patient after a total hip replacement, they were followed 3,6 years after the surgery.<ref>Nilsdotter AK, Petersson IF, Roos EM, Lohmander LS. Predictors of patient relevant outcome after total hip replacement for osteoarthritis: a prospective study. Ann Rheum Dis. 2003;62(10):923-30.
</ref> 57% reported a WOMAC score less than 40 preoperatively, only 5,4% did this at the final follow-up. There was a significant increase in this score between the preoperatively measurement and the final one. 31% had an increased WOMAC score of less than 10 after 3,6 years for pain or function or function and pain.&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; 40 patients reported a increase in WOMAC score of less than 20. The experimental group had a worse score than the reference group.


== Examination  ==
1.Land-based exercise – Hip OA <ref name=":12" />


<span lang="EN-US" style="font-family: arial">The beginning of OA is characterized by limited abduction and&nbsp; </span>rotation in the hip joint. Later on flexion, extension, and adduction become more difficult.<br>Physiotherapeutic examination <ref>CRIELAND, e.a., Osteoartrose, Lichtert, Brussel, 1985</ref><br><br>1) Palpation of M. gluteus medius.<br>&nbsp;&nbsp;&nbsp; Position: patient lies on his side. Upper leg in adduction and flexion<br>&nbsp;&nbsp;&nbsp; OA: Zone of greater Trochanter is sensitive and painful.<br>
* We strongly recommend offering land-based exercise for all people with hip OA to improve pain and function, regardless of their age, structural disease severity, functional status or pain levels. Exercise has also been found to be beneficial for other comorbidities and overall health. However, we are unable to specifically recommend either for or against different types of land-based exercise at this stage. Clinicians should prescribe an individualised progressive exercise [[File:Hydrotherapy Pool Exercises.jpg|thumb|Hydrotherapy Pool Exercises]]program, taking into account the person’s preference, capability and the availability of local facilities. Realistic goals should be set. Dosage should be progressed with full consideration given to the frequency, duration and intensity of exercise sessions, number of sessions, and the period over which sessions should occur. The clinician should monitor the person’s response to the exercise program and could try a different form of land-based exercise if improvements are not evident. Attention should be paid to strategies to optimise adherence. Strong for recommendation (when combining all studies of land-based exercise) Conditional (neutral) for recommending one type of land-based exercise over another (eg walking, muscle strengthening, stationary cycling, Tai Chi, Hatha yoga) Moderate (land-based) Very low (walking, muscle strengthening, stationary cycling, Tai Chi, Hatha yoga)


2)Flexion and forced flexion<br>Position: patient lies on his back. The physiotherapist lifted one leg to flexion. The knee is <br>in flexion so there is not too much muscle tension. The pelvis has to be at the same place. <br>OA: Flexion is limited for the final degrees.<ref>Bennell KL, Egerton T, Pua YH, Abbott JH, Sims K, Metcalf B et al. Efficacy of a multimodal physiotherapy treatment program for hip osteoarthritis: a randomised placebo-controlled trial protocol. BMC Musculoskelet Disord. 2010;11:238.
2. Aquatic exercise/ hydrotherapy – Hip OA<ref name=":12" />
</ref> <br><br>3) Extension<br>Position: 1. Patient stands in prone. Physiotherapist stabilizes the pelvis and raises the <br>leg. or 2. patient lies on his chest and lift the leg with flexion in the knee. You need a <br>flexion in the knee for a lower tension from the muscles<br>OA: Amplitude is limited.<br><br>4) Abduction<br>Position: Patient lies on his back. Physiotherapist stabilizes the pelvis and <br>performs abduction.<br>OA: abduction is limited and painful when the physiotherapist goes to the final degrees.<br><br>5) Adduction<br>Position: Patient lies on his back. The physiotherapist lift one leg and performs an <br>adduction with the other leg. The leg has to be in a normal position, no rotations.<br>OA: Keeps normal amplitude.<ref>Pisters MF, Veenhof C, Schellevis FG, De Bakker DH, Dekker J. Long-term effectiveness of exercise therapy in patients with osteoarthritis of the hip or knee: a randomized controlled trial comparing two different physical therapy interventions. Osteoarthritis Cartilage. 2010;18(8):1019-26.
</ref><ref>Veenhof C, Köke AJ, Dekker J, Oostendorp RA, Bijlsma JW, van Tulder MW et al. Effectiveness of behavioral graded activity in patients with osteoarthritis of the hip and/or knee: A randomized clinical trial. Arthritis Rheum. 2006;55(6):925-34.
</ref> <br>  


Hip osteoarthritis can be diagnosed by a combination of the findings from a history and physical examination, so we don’t need to expose the patient to unnecessary radiation in an X-ray. The most used criteria in the diagnosis of hip osteoarthritis are those from the <br>American College of Rheumatology, which includes two sets of clinical features.<ref name=":1" /> <br><br>Clinical Set A:<br>- Age: 50+<br>- Hip pain<br>- Hip internal rotation ≥ 15 degrees <br>- Pain with hip internal rotation<br>- Morning stiffness of the hip less than 60min<br><br>Clinical Set B:<br>- Age: 50+ <br>- Hip pain<br>- Hip internal rotation &lt; 15 degrees <br>Hip flexion ≤ 115 degrees<br><br>Later on, Sutlive et al. published a list of variables for detecting hip osteoarthritis in patients with unilateral hip pain.&nbsp;If there are 3 present variables out of the list of 5 variables, the chance of having OA is 68%. With 4 or 5 variables that are noticed, the <br>chance increases to 91%. The variables are positive when there’s pain or a limited range of motion in the tests.<ref name=":3" />  
* It may be appropriate to offer aquatic exercise/hydrotherapy for some people with knee and/or hip OA. This will depend upon personal preference and the availability of local facilities.   


<br>The five variables are:  
'''Manual therapy'''
* Flexion
[[File:Prone Hip Posterior to Anterior Glide.JPG|thumb|Hip Posterior to Anterior Glide]]
* Internal rotation
A range of manual therapies is used in the treatment of hip osteoarthritis:<ref name=":1" />
* Scour test: external and internal rotation in abduction and adduction of the hip.
* Soft tissue techniques and stretches
* Patrick’s or FABER test: flexion,abduction and external rotation of the hip.
* Mobilization of accessory and physiological movements
* Hip flexion test<br>
* Manipulation
[[Image:Patrick test.jpg|center|400x150px|Fig. 4: Patrick test]]<br>


== Physical Therapy Management  ==
Research is inconclusive on the effect of manual therapy in the treatment of hip osteoarthritis.<ref name=":0" /> The immediate effect of a manual therapy, specifically joint mobilization decrease pain and improve hip range of motion, especially in the elderly population. Joint mobilization might reduce pain, might ''‘provide a stretching effect on the joint capsules and muscles, thus restoring normal arthrokinematics or may induce pain inhibition and improved motor control’''  and might reduce kinesiophobia.<ref name=":4">Beselga C, Neto F, Alburquerque-Sendín F, Hall T, Oliveira-Campelo N. [https://espace.curtin.edu.au/bitstream/handle/20.500.11937/34768/239353_239353.pdf?sequence=2 Immediate effects of hip mobilization with movement in patients with hip osteoarthritis: A randomised controlled trial.] Man Ther. 2016;22:80-5.
A systematic review by Bennel (2013) found that treatment goals should be made in cooperation between therapist and patient.<ref name=":1" /> The therapy must be centered and applied around the patient. This way it suggests that the patients experience less anxiety to handle with the symptoms even though the condition may not always improve. The review states that patients using a self-management strategy have no difference in pain or function.<ref name=":1" />
</ref> 


=== Exercise Therapy ===
'''The RACPG 20188 guidelines''' '''Massage'''  '''and Manual''' '''therapy –''' '''Hip OA'''<ref name=":12" />
Currently the amount of research on exercise therapy for patients with hip osteoarthritis is limited and the effect of treatment is rather low. However, Bennel states that multiple trials and reviews suggest that exercise therapy might be an effective treatment strategy for hip osteoarthrosis.<ref name=":1" />


Below you can see a link to a summarised table with relevant studies using exercise therapy on land or in water (aquatherapy) and what they researched.  
* It may be appropriate to offer a short course of massage therapy for some people with hip osteoarthritis (OA). This should be considered only as an adjunctive treatment to enable engagement with active management strategies, and only for short term, cognisant of issues related to cost and access.


[http://www.journalofphysiotherapy.com/action/showFullTableImage?isHtml=true&tableId=tbl0005&pii=S1836955313701796 Table] (from Bennell, K., “Physiotherapy management of hip osteoarthritis Journal of Physiotherapy”, Volume 59, Issue 3, September 2013, Pages 145–157.)
* Manual therapy (stretching, soft tissue and/or joint mobilisation and/ or manipulation) It may be appropriate to offer a short course of manual therapy (stretching, soft tissue and/or joint mobilisation and/ or manipulation) for some people with hip OA. This should be considered only as an adjunctive treatment to enable engagement with active management strategies and only for short term, cognisant of issues related to cost and access.


Exercises could be done in water as well, in order to facilitate recovery of the motorfuntion. In this situation, gravity is greatly reduced thus the burdensome weight and tension at the height of the effected joint will be reduced as well.   Advice and education is important in treatment, tell the patient about their condition. Why does it occur? What's the treatment? What's the importance of exercise? This will make the patient have a clear understanding in his condition and will improve the healing process.However, it is unclear if aquatic exercises are more effective than exercises on land. There is also no clear evidence on balneotherapy. Currently, there doesn’t exist evidence that balneotherapy might be a beneficial therapy approach.<ref name=":1" /><ref>Wright A, O'Hearn MA. Differential diagnosis and early management of rapidly progressing hip pain in a 59-year-old male. J Man Manip Ther. 2012;20(2):96-101.
== Outcome Measures ==
</ref><ref>Verhagen AP, Cardoso JR, Bierma-Zeinstra SM. Aquatic exercise & balneotherapy in musculoskeletal conditions. Best Pract Res Clin Rheumatol. 2012;26(3):335-43.
* [[Visual Analogue Scale|Visual analogue scale]] (VAS)
</ref><ref name=":4">Beselga C, Neto F, Alburquerque-Sendín F, Hall T, Oliveira-Campelo N. Immediate effects of hip mobilization with movement in patients with hip osteoarthritis: A randomised controlled trial. Man Ther. 2016;22:80-5.
* Hip disability and osteoarthritis outcome score ([[Hip Disability and Osteoarthritis Outcome Score|HOOS]])  
</ref>
* Western Ontario and McMaster universities osteoarthritis index ([[WOMAC Osteoarthritis Index|WOMAC]])  
 
* [[Harris Hip Score|Harris hip score]]
Ultrasound therapy has been used across the globe in clinical practice, but as there is little evidence surrounding its use in the management of hip osteoarthritis, it is not recommended to use.<ref name=":1" /> 
* Oxford hip score ([http://www.orthopaedicscore.com/scorepages/oxford_hip_score.html/ OHS])
 
* [[Six Minute Walk Test / 6 Minute Walk Test|6 Minute Walking Test]]
=== Manual Therapy ===
* [[Timed Up and Go Test (TUG)|Timed up and go test]]
A range of manual therapies is used as manual therapy treatment. These therapies are:<ref name=":1" />
* [[International Hip Outcome Tool (iHOT)|International Hip Outcome Tool]]
* soft tissue techniques and stretches
* [[Ibadan Knee/Hip Osteoarthritis Outcome Measure (IKHOAM)|Ibadan Knee/Hip Osteoarthritis Outcome Measure]]
* mobilisation of accessory and physiological movements
=== The Future ===
* manipulation/ mobilisation
'''<u></u><u></u>'''<u></u>Highly prevalent among the elderly, Hip osteoarthritis (OA) is highly prevalent among the elderly and carries a heavy burden of disease. Guidelines for the management of hip OA are often extrapolated from knee OA research, despite clear differences in the etiopathogenesis and response to treatments of OA at these sites. True inroads in reducing the burden of hip OA are most likely to be seen with an increased focus on risk factor modification prior to or in the early stages of the condition’s pathogenesis. Risk calculators such as those that currently exist for heart disease could be developed, incorporating imaging and even genetic biomarkers to enable stratification of people into varying risk levels for appropriate monitoring and management. With improved understanding of the etiopathogenesis of hip OA, intervention prior to or early in the disease course in a disease-modifying manner is likely to become feasible in the future. The management of hip OA has the potential to be an area of medicine undergoing substantial advancement in the decades to come.<ref>Murphy NJ, Eyles JP, Hunter DJ. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5083776/ Hip osteoarthritis: etiopathogenesis and implications for management.] Advances in therapy. 2016 Nov 1;33(11):1921-46. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5083776/ (last accessed 19.11.2019)</ref>
The immediate effect of a mobilization intervention on elderly patients with osteoarthritis has been researched by Beselga et al (2016), they found that after an intervention pain decreased and that the range of motion in the hip joint improved. The study suggests that mobilization might reduce pain, might ''‘provide a stretching effect on the joint capsules and muscles, thus restoring normal arthrokinematics or may induce pain inhibition and improved motor control’'' and might reduce kinesiophobia.<ref name=":4" /> However, these effects are currently not proven as studies regarding long-term effects are lacking. Further research for these effects is needed.<ref name=":4" />
 
“''While there have been no reports of serious adverse events associated with the use of manual therapy in patients with hip osteoarthritis, therapists should advise patients about the possibility of self-limiting posttreatment soreness''.”<ref name=":1" />
 
'''<u></u><u></u>'''<u></u>
== Key Research  ==
 
Hoeksma HL, Dekker J, Ronday HK, Heering A, van der Lubbe N, Vel C, Breedveld FC, van den Ende CH. Comparison of manual therapy and exercise therapy in osteoarthritis of the hip: a randomized clinical trial. Arthritis Rheum. 2004 Oct 15;51(5):722-9.
 
Peter WF, Jansen MJ, Hurkmans EJ, Bloo H, Dekker J, Dilling RG, Hilberdink W, Kersten-Smit C, de Rooij M, Veenhof C, Vermeulen HM, de Vos RJ, Schoones JW, Vliet Vlieland TP; Guideline Steering Committee - Hip and Knee Osteoarthritis. Physiotherapy in hip and knee osteoarthritis: development of a practice guideline concerning initial assessment, treatment and evaluation. Acta Reumatol Port. 2011 Jul-Sep;36(3):268-81.
 
French HP, Cusack T, Brennan A, Caffrey A, Conroy R, Cuddy V, FitzGerald OM, Gilsenan C, Kane D, O'Connell PG, White B, McCarthy GM Exercise and manual physiotherapy arthritis research trial (EMPART) for osteoarthritis of the hip: a multicenter randomized controlled trial. Arch Phys Med Rehabil. 2013 Feb;94(2):302-14. doi: 10.1016/j.apmr.2012.09.030
 
Abbott JH, Robertson MC, Chapple C, Pinto D, Wright AA, Leon de la Barra S, Baxter GD, Theis JC, Campbell AJ; MOA Trial team. Manual therapy, exercise therapy, or both, in addition to usual care, for osteoarthritis of the hip or knee: a randomized controlled trial. 1: clinical effectiveness. Osteoarthritis Cartilage. 2013 Apr;21(4):525-34. doi: 10.1016/j.joca.2012.12.014.<br><br>  


== Resources  ==
== Resources  ==
* [https://open.uct.ac.za/bitstream/handle/11427/12697/Living%20with%20Osteoarthritis_2018.pdf?sequence=18 Patient workbook] on "living with osteoarthritis"
* [https://new-learning.bmj.com/course/10052313 The health benefits of physical activity: osteoarthritis and low back pain]
* [http://www.fyss.se/wp-content/uploads/2018/01/37.-Osteoarthritis.pdf Physical activity in the prevention and treatment of the disease- Osteoarthritis]
* [https://oaaction.unc.edu/health-care/ Physical activity implementation guide for osteoarthritis]


http://www.guidelines.gov/content.aspx?id=36893<br>
=== References ===
 
<references />
https://www.ncbi.nlm.nih.gov/pubmed?otool=vublib<br><br>http://apps.webofknowledge.com.ezproxy.vub.ac.be:2048/WOS_GeneralSearch_input.do?product=WOS&amp;search_mode=GeneralSearch&amp;SID=U2HYlXJGBQdVzdFFDhX&amp;preferencesSave d=<br><br>https://scholar.google.be/?inst=vub.ac.be
[[Category:Older People/Geriatrics]]
 
[[Category:Osteoarthritis]]
== Clinical Bottom Line  ==
[[Category:Anatomy]]
 
[[Category:Older People/Geriatrics - Conditions]]
Depending on the severity of the condition, managment will vary from patient to patient. It is important that the clinician individualizes treatment to each of their patients in order to ensure optimal outcomes.
[[Category:Hip - Conditions]]
 
[[Category:Rheumatology]]
== References  ==

Latest revision as of 03:29, 3 September 2023

Original Editor - Eric Robertson, Kim Presiaux

Top Contributors - Kim Presiaux, Dorien De Strijcker, Lucinda hampton, Davy Duverger, Leana Louw, Kim Jackson, Admin, Rachael Lowe, Laura Ritchie, Johnathan Fahrner, Van Horebeek Erika, Scott Buxton, Vidya Acharya, Kai A. Sigel, Eric Robertson, Areeba Raja, 127.0.0.1, Bram Van Roost, Shaimaa Eldib, Lauren Lopez, Loïc Byl, Marius De Bruyn and Kevin Vandebroucq

Introduction[edit | edit source]

Hip OA diagram

Osteoarthritis is a common disabling condition that causes joint pain and stiffness caused by the gradual erosion of cartilage. Hip osteoarthritis is a common form of osteoarthritis that causes restricted locomotor activity and functional disability, and may progress to the point where joint replacement is needed. Hip osteoarthritis is a major global public-health burden. [1]

  • For people with hip arthritis, physiotherapy may assist in conditioning and obtaining endurance of the surrounding muscles that support the joint.
  • A long term approach to the management of a hip OA should include some type of regular physical therapy or conditioning program.

Epidemiology[edit | edit source]

Globally, from 1990 to 2019, the age-standardized incidence rate of hip osteoarthritis increased from 17.02 per 100,000 persons to 18.70 per 100,000 persons. The burden of hip osteoarthritis has increased in almost all countries over the past 30 years, this increasing trend is expected to continue, due to the rapid aging of the world’s population.

  • Osteoarthritis is the most common cause of hip pain in older adults (older than 50 years of age).
  • Prevalence rates for adult hip OA range from 0.4% to 27%.
  • The reported prevalence of hip OA shows great variability, with men showing higher prevalence of radiographic hip OA.[1][2]
  • Lifetime risk for symptomatic hip OA is 18.5% for men and 28.6% for women[3].
  • Research suggest that there are a 25% risk of developing hip osteoarthritis for people who live to the age of 85,[4]

Pathology[edit | edit source]

Severe OA 1. osteophytes 2. subchondral thickening 3. cyst 4. jt space narrowing

Osteoarthritis is distinguished by an active progressive alteration of the whole synovial joint, being due to a combination of mechanical, inflammatory and metabolic factors. It is caused by an imbalance between the destruction and repair of the affected tissues. The disease affects the

  • Hyaline cartilage: loses its structural integrity due to composition changes.
  • Subchondral bone
  • Joint capsule
  • Synovium
  • Ligaments and the periarticular muscles.

Risk Factors[edit | edit source]

Risk factors that increase the likelihood of developing osteoarthritis of the hip are

Diagnosis[edit | edit source]

Advanced OA of a hip.

The following criteria should be used to classify adults over the age of 50 with hip OA:

  1. Moderate anterior or lateral hip pain during weight-bearing activities
  2. Morning stiffness less than 1 hour in duration after wakening
  3. Hip internal rotation range of motion less than 24° or internal rotation and hip flexion 15° less than the nonpainful side, and/or increased hip pain associated with passive hip internal rotation.[2]

Radiographic evidence: joint space narrowing, marginal osteophytes, subchondral sclerosis, and bone cysts.[6][7].

Clinical Presentation[edit | edit source]

Hip OA - Elderly lady

Pain characteristics:

  • Slowly progressive hip pain, or hip-related groin pain radiating into the thigh, buttocks or knee.
  • The pain can be worse at night, at rest or with strenuous activity, reducing the range of motion and limiting walking distance. It can be associated with stiffness particular in the morning or after rest.

Other symptoms include locking, grinding and joint instability, fatigue and pain-related psychological stress.[8]

Physical Examination[edit | edit source]

Measuring ROM hip

A physical examination includes (Also also hip examination)

  • Observation
  • Subjective interview:
    • Complaints of pain, deformity, stiffness and/or limp
    • Previous history linked to hip pain (congenital or childhood problems, previous trauma)
  • Physical examination in Standing and Supine (look for leg length discrepancy, antalgic gait and Trendelenberg gait)
  • Objective observation (posture, deformities, muscle atrophy)
  • Palpation:
    • Tenderness at the hip
    • Pain and sensitivity over greater trochanter
  • Range of motion:
    • Early signs of hip osteoarthritis is limited abduction and rotation. As the disease progresses, flexion, extension and adduction becomes more difficult.
    • Normally painful at end of available range of motion
  • Crepitis with movement[9][10][11]

Five variables for detecting hip osteoarthritis are:

  1. Self-reported squatting as an aggravating factor
  2. Active hip flexion causing lateral hip pain
  3. Hip Quadrant test with adduction causing lateral hip or groin pain
  4. Active hip extension causing pain
  5. Passive internal rotation of less than or equal to 25°

If there are 3/5 variables present, the chance of having OA is 68%. With 4-5/5 the chance increases to 91%. The variables are positive when there’s pain or a limited range of motion in the tests.[12]

Management[edit | edit source]

A biopsychosocial approach offers the best outcome.[13] A multidisciplinary team may be involved including: doctors, physiotherapists, dietitians, and occupational therapists.

Management of hip osteoarthritis varies according to the severity of the condition. A combination of pharmaceutical and non-pharmaceutical modalities is recommended for the optimal management of the condition. Physiotherapy plays an important role in customized exercise programmes for patients living with hip osteoarthritis.

  1. OA management includes patient education combined with exercise and/or manual therapy. Education should include teaching activity modification, exercise [14], supporting weight reduction when overweight (see below), and methods of unloading the arthritic joints.
  2. Management includes providing impairment-based functional, gait, and balance training, including the proper use of assistive devices (canes, crutches, walkers), to patients with hip osteoarthritis and activity limitations, balance impairment, and/or gait limitations when associated problems are observed.[2]
  3. Offer topical or oral nonsteroidal anti-inflammatory drugs in those without contraindications.
  4. Intra-articular steroid injections provide short-term pain relief and duloxetine has demonstrated efficacy. Opiates should be avoided.[7]



Weight management – Hip OA[15](RACPG 2018 guidelines): We strongly recommend weight management for people with hip OA. For those who are overweight (body mass index [BMI] ≥25 kg/m2 ) or obese (BMI ≥30 kg/m2 ), a minimum weight loss target of 5–7.5% of body weight is recommended. It is beneficial to achieve a greater amount of weight loss given that a relationship exists between the amount of weight loss and symptomatic benefits. Weight loss should be combined with exercise for greater benefits. For people of healthy body weight, education about the importance of maintaining healthy body weight is essential.

Surgical interventions: Total hip replacement - The option in patients with symptomatic and radiographic osteoarthritis characterized by refractory pain and disability; Osteotomy and hip resurfacing - Should be considered in younger patients with symptomatic secondary osteoarthritis due to acetabular dysplasia, femoroacetabular impingement, varus or valgus deformity[8].

Physiotherapy Management[edit | edit source]

Physiotherapy plays in major role in the management of patients with hip osteoarthritis. The goal is to  improve strength, mobility and increase range of motion. Physiotherapy also helps relieve pain and restores normal movement in the hip and legs and also addresses pain management and functional adaptions. Patient-specific exercise programmes has shown to decrease pain and improve function in hip osteoarthritis.[4][13]

Education

  • Role of physiotherapy and expected outcomes of physiotherapy interventions
  • Importance of weight reduction (combination of diet and exercise)
  • Self-management of pain: Use of modalities such as heat and ice; Relaxation techniques; Coping strategies; Exercise[4][9][16]

Assistive devices

  • Mobility assistive devices like walking sticks/canes, crutches, or walking frames can improve mobility and independence of the patient. Occupational therapy also plays a role here, as they often also assists the patients with functional assistive devices like a long-handled reacher to pick up low-lying things, which will helps to avoid movements that may cause pain.
  • The RACPG 20188 guidelines Assistive walking device – Hip OA[15] It may be appropriate to offer an assistive walking device (eg cane) for some people with knee and/or hip OA, depending on a person’s preference and capability.

Exercise therapy

Hip Theraband.png

Exercise therapy is an effective treatment modality for hip osteo-arthrosis.[13] Specific exercises can increase range of motion and flexibility, as well as strengthen the muscles of the hip and leg. Physiotherapists work together with the patient to develop an individualized, customized exercise program that meets the needs and lifestyle of the patient.[13][16] The benefits of exercise can assist the patients in their self-management of hip osteoarthritis.

  • Hydrotherapy is effective in the management of hip osteoarthritis. The combination of buoyancy and the reduction of gravity greatly assists patients that are struggling to weight-bear as a result of the pain from the hip osteoarthritis.[16]
  • A 2016 study of 210 people with hip OA found that those who participated in a 12-week exercise program had less pain and more mobility than the placebo or no-treatment groups.[17]
  • A study on a 6 week education and exercise programme has shown significant and sustained improvements in pain and disability on patients wait-listed for joint replacement surgery. Further positive results included improvements in function, knowledge and psycho-social aspects.[18] Clinical trials further suggest that it can postpone the need of total hip replacement surgery.[16]
Hip abduction exercise

The RACPG 20188 guidelines recommend as per below

1.Land-based exercise – Hip OA [15]

  • We strongly recommend offering land-based exercise for all people with hip OA to improve pain and function, regardless of their age, structural disease severity, functional status or pain levels. Exercise has also been found to be beneficial for other comorbidities and overall health. However, we are unable to specifically recommend either for or against different types of land-based exercise at this stage. Clinicians should prescribe an individualised progressive exercise
    Hydrotherapy Pool Exercises
    program, taking into account the person’s preference, capability and the availability of local facilities. Realistic goals should be set. Dosage should be progressed with full consideration given to the frequency, duration and intensity of exercise sessions, number of sessions, and the period over which sessions should occur. The clinician should monitor the person’s response to the exercise program and could try a different form of land-based exercise if improvements are not evident. Attention should be paid to strategies to optimise adherence. Strong for recommendation (when combining all studies of land-based exercise) Conditional (neutral) for recommending one type of land-based exercise over another (eg walking, muscle strengthening, stationary cycling, Tai Chi, Hatha yoga) Moderate (land-based) Very low (walking, muscle strengthening, stationary cycling, Tai Chi, Hatha yoga)

2. Aquatic exercise/ hydrotherapy – Hip OA[15]

  • It may be appropriate to offer aquatic exercise/hydrotherapy for some people with knee and/or hip OA. This will depend upon personal preference and the availability of local facilities.

Manual therapy

Hip Posterior to Anterior Glide

A range of manual therapies is used in the treatment of hip osteoarthritis:[13]

  • Soft tissue techniques and stretches
  • Mobilization of accessory and physiological movements
  • Manipulation

Research is inconclusive on the effect of manual therapy in the treatment of hip osteoarthritis.[4] The immediate effect of a manual therapy, specifically joint mobilization decrease pain and improve hip range of motion, especially in the elderly population. Joint mobilization might reduce pain, might ‘provide a stretching effect on the joint capsules and muscles, thus restoring normal arthrokinematics or may induce pain inhibition and improved motor control’ and might reduce kinesiophobia.[19] 

The RACPG 20188 guidelines Massage and Manual therapy – Hip OA[15]

  • It may be appropriate to offer a short course of massage therapy for some people with hip osteoarthritis (OA). This should be considered only as an adjunctive treatment to enable engagement with active management strategies, and only for short term, cognisant of issues related to cost and access.
  • Manual therapy (stretching, soft tissue and/or joint mobilisation and/ or manipulation) It may be appropriate to offer a short course of manual therapy (stretching, soft tissue and/or joint mobilisation and/ or manipulation) for some people with hip OA. This should be considered only as an adjunctive treatment to enable engagement with active management strategies and only for short term, cognisant of issues related to cost and access.

Outcome Measures[edit | edit source]

The Future[edit | edit source]

Highly prevalent among the elderly, Hip osteoarthritis (OA) is highly prevalent among the elderly and carries a heavy burden of disease. Guidelines for the management of hip OA are often extrapolated from knee OA research, despite clear differences in the etiopathogenesis and response to treatments of OA at these sites. True inroads in reducing the burden of hip OA are most likely to be seen with an increased focus on risk factor modification prior to or in the early stages of the condition’s pathogenesis. Risk calculators such as those that currently exist for heart disease could be developed, incorporating imaging and even genetic biomarkers to enable stratification of people into varying risk levels for appropriate monitoring and management. With improved understanding of the etiopathogenesis of hip OA, intervention prior to or early in the disease course in a disease-modifying manner is likely to become feasible in the future. The management of hip OA has the potential to be an area of medicine undergoing substantial advancement in the decades to come.[20]

Resources[edit | edit source]

References[edit | edit source]

  1. ↑ 1.0 1.1 Fu M, Zhou H, Li Y, Jin H, Liu X. Global, regional, and national burdens of hip osteoarthritis from 1990 to 2019: estimates from the 2019 Global Burden of Disease Study. Arthritis research & therapy. 2022 Dec;24(1):1-1.Available;https://arthritis-research.biomedcentral.com/articles/10.1186/s13075-021-02705-6#Sec9 (accessed 15.11.2022)
  2. ↑ 2.0 2.1 2.2 Cibulka MT, Bloom NJ, Enseki KR, MacDonald CW, Woehrle J, McDonough CM. Hip pain and mobility deficits—hip osteoarthritis: revision 2017: clinical practice guidelines linked to the international classification of functioning, disability and health from the orthopaedic section of the American Physical Therapy Association. Journal of Orthopaedic & Sports Physical Therapy. 2017 Jun;47(6):A1-37.Available:https://www.jospt.org/doi/10.2519/jospt.2017.0301 (accessed 15.11.2022)
  3. ↑ Lespasio MJ, Sultan AA, Piuzzi NS, Khlopas A, Husni ME, Muschler GF, Mont MA. Hip osteoarthritis: a primer. The Permanente Journal. 2018;22. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5760056/ (last accessed 19.11.2019)
  4. ↑ 4.0 4.1 4.2 4.3 Murphy NJ, Eyles JP, Hunter DJ. Hip osteoarthritis: Etiopathogenesis and implications for management. Advances in therapy 2016;33(11):1921-46.
  5. ↑ Radiopedia Hip OA Available:https://radiopaedia.org/articles/osteoarthritis-of-the-hip (accessed 15.11.2022)
  6. ↑ Brandt CD. Diagnosis and non-surgical management of osteoarthritis. USA: Professional Communications, Inc. 2010.
  7. ↑ 7.0 7.1 Katz JN, Arant KR, Loeser RF. Diagnosis and treatment of hip and knee osteoarthritis: a review. Jama. 2021 Feb 9;325(6):568-78. Available: https://jamanetwork.com/journals/jama/article-abstract/2776205(accessed 23.1.2022)
  8. ↑ 8.0 8.1 Radiopedia OA of the hip Available: https://radiopaedia.org/articles/osteoarthritis-of-the-hip?lang=us(accessed 23.1.2022)
  9. ↑ 9.0 9.1 American Academy of Orthopaedic Surgeons. Diseases and conditions: Osteoarthritis of the hip.https://orthoinfo.aaos.org/en/diseases--conditions/osteoarthritis-of-the-hip (accessed 14/07/2018).
  10. ↑ Crielaard JM, Dequeker J, Famaey JP, Franchimong P, Gritten CH., Huaux JP. Osteoartrose. Brussels: Drukkerij Lichtert, 1985.
  11. ↑ Walters J, editor. Orthopaedics - A guide for practitioners. 4th Edition. Cape Town: University of Cape Town, 2010.
  12. ↑ Sutlive TG, Lopez HP, Schnitker DE, Yawn SE, Halle RJ, Mansfield LT et al. Development of a clinical prediction rule for diagnosing hip osteoarthritis in individuals with unilateral hip pain. J Orthop Sports Phys Ther. 2008;38(9):542-50.
  13. ↑ 13.0 13.1 13.2 13.3 13.4 Bennell K. Physiotherapy management of hip osteoarthritis. J Physiother. 2013; 59(3):145–157.
  14. ↑ Dalmas I, Agius TP, Sciriha A. Core muscle strengthening exercises in the management of hip osteoarthritis: outcomes of a 12-week programme. European Journal of Physiotherapy. 2023 Mar 27:1-8.
  15. ↑ 15.0 15.1 15.2 15.3 15.4 2018 RACGP Guidelines for hip and knee arthritis Available from: https://www.racgp.org.au/download/Documents/Guidelines/Musculoskeletal/guideline-for-the-management-of-knee-and-hip-oa-2nd-edition.pdf (last accessed 19.11.2019)
  16. ↑ 16.0 16.1 16.2 16.3 Zhang W, Doherty M, Arden N, Bannwarth B, Bijlsma J, Gunther KP, Hauselmann HJ, Herrero-Beaumont G, Jordan K, Kaklamanis P, Leeb B. EULAR evidence based recommendations for the management of hip osteoarthritis: Report of a task force of the EULAR Standing Committee for International Clinical Studies Including Therapeutics (ESCISIT). Annals of the rheumatic diseases 2005;64(5):669-81.
  17. ↑ Arthritis Foundation Exercise Benefits for Hip Osteoarthritis Available from: https://www.arthritis.org/about-arthritis/types/osteoarthritis/articles/hip-oa-exercises.php (last accessed 19.11.2019)
  18. ↑ Saw MM. The effects of a six-week physiotherapist-led exercise and education intervention in patients with osteoarthritis, awaiting an arthroplasty in the South Africa [dissertation]. Cape Town: University of Cape Town. 2015.
  19. ↑ Beselga C, Neto F, Alburquerque-Sendín F, Hall T, Oliveira-Campelo N. Immediate effects of hip mobilization with movement in patients with hip osteoarthritis: A randomised controlled trial. Man Ther. 2016;22:80-5.
  20. ↑ Murphy NJ, Eyles JP, Hunter DJ. Hip osteoarthritis: etiopathogenesis and implications for management. Advances in therapy. 2016 Nov 1;33(11):1921-46. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5083776/ (last accessed 19.11.2019)
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