Hip Osteoarthritis: Difference between revisions

No edit summary
No edit summary
 
(58 intermediate revisions by 8 users not shown)
Line 4: Line 4:
'''Top Contributors''' - {{Special:Contributors/{{FULLPAGENAME}}}}
'''Top Contributors''' - {{Special:Contributors/{{FULLPAGENAME}}}}
</div>
</div>
== Definition/Description  ==
== 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" />


[[Osteoarthritis]] is a condition that causes degeneration of a joint as a result of mechanical overload.<ref name=":0">Murphy NJ, Eyles JP, Hunter DJ. Hip osteoarthritis: etiopathogenesis and implications for management. Advances in therapy 2016;33(11):1921-46.</ref> Hip osteoarthritis mainly affects the articular cartilage, as well as causing changes to the subcondral bone, synovium, ligaments and capsules.<ref name=":6">Cooper C, Javaid MK, Arden N. Epidemiology of osteoarthritis. In: Atlas of Osteoarthritis. Tarporley: Springer Healthcare, 2014. p22.</ref> This degeneration lead to loss of joint space, which can potentially be symptomatic.<ref name=":6" /> It is one of the top 15 contributors of global disability.<ref>Cross M, Smith E, Hoy, Nolte S, Ackerman I, Fransen M, Bridgett L, Williams S, Guillemin F, Hill CL, Laslett LL, Jones G, Cicuttini F, Osborne R, Vos T, Buchbinder R, Woolf A, March L. The global burden of hip and knee osteoarthritis: estimates from the Global Burden of Disease 2010 study. Annals of the Rheumatic Diseases 2014;73:1323-1330.</ref> Hip osteoarthritis is prevalent in 10% of people above 65, where 50% of these cases are symptomatic.<ref name=":7">Nüesch E, Dieppe P, Reichenbach S, Williams S, Iff S, Jüni P. All cause and disease specific mortality in patients with knee or hip osteoarthritis: population based cohort study. Bmj 2011;342:1165.</ref>
* 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.


== Clinically relevant anatomy  ==
== Epidemiology ==
For detailed information, see the [[Hip Anatomy|hip anatomy page]].
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.
{| border="0" cellspacing="1" cellpadding="1"
|-
|[[File:Hip-joint-acetabulum-femur-head-caput-femoris-greater-trochanter-lesser-minor-major-ilum-front-skin-names.png|left|thumb]]
|[[Image:Muscles2.png|right]]
|}
== Epidemiology & etiology ==


=== Prevalence ===
* Osteoarthritis is the most common cause of hip pain in older adults (older than 50 years of age).
Hip osteoarthritis is prevalent in 10% of people above 65, where 50% of these cases are symptomatic.<ref name=":7" /> Research suggest that there are a 25% risk of developing hip osteoarthritis for people who live to the age of 85,
* 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>


=== Primary osteoarthritis ===
== Pathology ==
Mostly caused by abnormality of the articular cartilage, but can also be a secondary result of developmental changes and abnormalities such as femeroacetbular impingement.<ref name=":8">Ganz R, Leunig M, Leunig-Ganz K, Harris WH. The etiology of osteoarthritis of the hip. Clinical orthopaedics and related research 2008;466(2):264-72.</ref> Abnormalities include acetabular displasia. Pistol grip deformities are also seen in some cases, mostly linked with slipped upper femoral epiphysis. Although seen as a specific condition, it is often linked with metabolic abnormalities.<ref>Harris WH. Etiology of osteoarthritis of the hip. Clinical orthopaedics and related research 1986; 213:20-33.</ref>
[[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


=== Secondary osteoarthritis ===
* Hyaline cartilage: loses its structural integrity due to composition changes.
As a result of developmental or congenital deformities.<ref name=":8" />
* Subchondral bone
* Joint capsule
* Synovium
* Ligaments and the periarticular muscles.


=== Risk factors<ref name=":0" /><ref name=":7" /><ref>Reginister J-Y, Pelletier J-P, Martel-Pelletier J, Henrotin Y, editors. Osteoarthritis: Clinical and Experimental Aspects. Berlin: Springer, 1999.</ref> ===
== Risk Factors ==
*Previous hip trauma (causing injury or [[Hip Fracture|fracture]]) - mostly resulting in unilateral hip osteoarthritis
Risk factors that increase the likelihood of developing osteoarthritis of the hip are
*Primary inflammatory arthritis (e.g. [[Rheumatoid Arthritis|rheumatoid arthritis]], [[Ankylosing Spondylitis|ankylosing spondylitis]])
*Genetics
*Congenital and developmental hip disease (e.g. congenital hip dislocation, [[Legg-Calve-Perthes Disease|Perthe's disease]], [[Slipped Capital Femoral Epiphysis|slipped upper femoral epiphysis]])
*Subchondral bone defects
*[[Obesity]] - mostly resulting in bilateral hip osteoarthritis
*Occupation causing excessive strain on hips (e.g. manual labor causing repeated loading)
*Increase in age
*Gender (female > male)
*Sport (higher impact sport at a younger age can cause increase in articular cartilage strength, where low impact sport do no change the composition of the cartilage)
*Menopause
*Metabolic diseases and acromegaly
*Sedentary lifestyle
*[[Femoroacetabular Impingement|Femoroacetabular impingement]]
*[[Avascular necrosis of the femoral head|Avascular necrosis]]
*Ethnicity - 80-90% less prevalent in the Asian population when compared to the Caucasian population in the USA
*Diet - low Vitamin D, C and K levels


== Characteristics/Clinical Presentation  ==
* [[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>


The most important characteristic of hip osteoarthritis is that there’s damage to or loss of the articular cartilage.<ref name=":5">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 name=":5" /> 
== 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:  


== Differential Diagnosis  ==
# 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" />


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;
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>.


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


== Differential diagnosis  ==
* 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.


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>  
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>


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>  
=== 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>


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>
== 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.


<br>
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.


<br><br>  
# 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" />


== Diagnostic Procedures  ==


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">Bennell K. Physiotherapy management of hip osteoarthritis. J Physiother. 2013; 59(3):145–157.</ref> <br>


== Outcome Measures  ==


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>
'''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.


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>
'''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" />.


== Medical management ==
== 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>


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.
'''Education'''
</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.
</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. 


almost 10% lifetime risk of undergoing a total hip replacement for end-stage OA [2]. 
* 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>


== Examination  ==
'''Assistive devices'''
{{#ev:youtube|8xrDWgIUMO4}}<ref>Physiotutors. Cluster of Sutlive | Hip Osteoarthritis Diagnostic Cluster. Available from: https://www.youtube.com/watch?v=8xrDWgIUMO4</ref>
<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>


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.
* [[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.
</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" /> 
* '''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.


<br>The five variables are:  
'''Exercise therapy'''[[File:Hip Theraband.png|right|frameless]]
* Flexion
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.  
* Internal rotation
* Scour test: external and internal rotation in abduction and adduction of the hip.  
* Patrick’s or FABER test: flexion,abduction and external rotation of the hip.  
* Hip flexion test<br>  
[[Image:Patrick test.jpg|center|400x150px|Fig. 4: Patrick test]]<br>


== Physical Therapy 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 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" />
* 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" />


=== Exercise Therapy ===
[[File:Hip exercise 3.png|thumb|Hip abduction exercise]]
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" /> 
'''The RACPG 20188 guidelines recommend as per below'''


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


[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.)
* 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)


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.
2. Aquatic exercise/ hydrotherapy – Hip OA<ref name=":12" />
</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.
</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.
</ref>  


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" /> 
* 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 ===
'''Manual therapy'''
A range of manual therapies is used as manual therapy treatment. These therapies are:<ref name=":1" />
[[File:Prone Hip Posterior to Anterior Glide.JPG|thumb|Hip Posterior to Anterior Glide]]
* soft tissue techniques and stretches
A range of manual therapies is used in the treatment of hip osteoarthritis:<ref name=":1" />
* mobilisation of accessory and physiological movements  
* Soft tissue techniques and stretches
* manipulation/ mobilisation
* Mobilization of accessory and physiological movements
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" />
* Manipulation


“''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" />  
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.
</ref> 


'''<u></u><u></u>'''<u></u>
'''The RACPG 20188 guidelines''' '''Massage'''  '''and Manual''' '''therapy –''' '''Hip OA'''<ref name=":12" />


<br><br>
* 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.


== Resources  ==
* 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.


http://www.guidelines.gov/content.aspx?id=36893<br>  
== Outcome Measures ==
* [[Visual Analogue Scale|Visual analogue scale]] (VAS)
* Hip disability and osteoarthritis outcome score ([[Hip Disability and Osteoarthritis Outcome Score|HOOS]])
* Western Ontario and McMaster universities osteoarthritis index ([[WOMAC Osteoarthritis Index|WOMAC]])
* [[Harris Hip Score|Harris hip score]]
* 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]]
* [[Timed Up and Go Test (TUG)|Timed up and go test]]
* [[International Hip Outcome Tool (iHOT)|International Hip Outcome Tool]]
* [[Ibadan Knee/Hip Osteoarthritis Outcome Measure (IKHOAM)|Ibadan Knee/Hip Osteoarthritis Outcome Measure]]
=== The Future  ===
'''<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>


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
== Resources  ==
 
* [https://open.uct.ac.za/bitstream/handle/11427/12697/Living%20with%20Osteoarthritis_2018.pdf?sequence=18 Patient workbook] on "living with osteoarthritis"
== Clinical Bottom Line  ==
* [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]
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.
* [https://oaaction.unc.edu/health-care/ Physical activity implementation guide for osteoarthritis]


== References ==
=== References ===
<references />
[[Category:Older People/Geriatrics]]
[[Category:Osteoarthritis]]
[[Category:Anatomy]]
[[Category:Older People/Geriatrics - Conditions]]
[[Category:Hip - Conditions]]
[[Category:Rheumatology]]

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, Scott Buxton, Van Horebeek Erika, Vidya Acharya, Kai A. Sigel, Eric Robertson, Areeba Raja, Loïc Byl, Marius De Bruyn, Kevin Vandebroucq, 127.0.0.1, Bram Van Roost, Shaimaa Eldib and Lauren Lopez

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)
Retrieved from "https://www.physio-pedia.com/index.php?title=Hip_Osteoarthritis&oldid=340928"