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[[File:Osteoarthritis in the Hip.jpg|thumb|300x300px]]
== 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" />


== Definition/Description  ==
* 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.


[[Osteoarthritis]] is a condition that causes degeneration of a joint as a result of mechanical overload in a weight bearing joint.<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> The hip is defined as the second most painful joint (after the knee) as a result of osteoarthritis according to a Italian study.<ref>Cimmino MA, Sarzi-Puttini P, Scarpa R, Caporali R, Parazzini F, Zaninelli A, Marcolongo R. Clinical presentation of osteoarthritis in general practice: determinants of pain in Italian patients in the AMICA study. Seminars in arthritis and rheumatism 2005;35(1):17-23).</ref>
== 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.  


== Clinically relevant anatomy  ==
* Osteoarthritis is the most common cause of hip pain in older adults (older than 50 years of age).
For detailed information, see the [[Hip Anatomy|hip anatomy page]].
* Prevalence rates for adult hip OA range from 0.4% to 27%.
{| border="0" cellspacing="1" cellpadding="1"
* 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>.
|[[File:Hip-joint-acetabulum-femur-head-caput-femoris-greater-trochanter-lesser-minor-major-ilum-front-skin-names.png|left|thumb]]
* 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>
|[[Image:Muscles2.png|right]]
|}
== Epidemiology & etiology  ==


=== Prevalence ===
== Pathology ==
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,<ref name=":0" /> 
[[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


=== Primary osteoarthritis ===
* Hyaline cartilage: loses its structural integrity due to composition changes.
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 normally include acetabular displasia. Pistol grip deformities are 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>
* Subchondral bone
* Joint capsule
* Synovium
* Ligaments and the periarticular muscles.


=== Secondary osteoarthritis ===
== Risk Factors ==
Secondary osteoarthritis is caused by predisposing anatomic abnormalities such as developmental or congenital deformities.<ref name=":8" /><ref>Hoaglund FT, Steinbach LS. Primary osteoarthritis of the hip: etiology and epidemiology. Journal of the American Academy of Orthopaedic Surgeons 2001;9(5):320-7.</ref>
Risk factors that increase the likelihood of developing osteoarthritis of the hip are


=== Risk factors ===
* [[Older People - An Introduction|Older age]]
*Previous hip trauma (causing injury or [[Hip Fracture|fracture]]) - mostly resulting in unilateral hip osteoarthritis
* [[Obesity]]
*Primary inflammatory arthritis (e.g. [[Rheumatoid Arthritis|rheumatoid arthritis]], [[Ankylosing Spondylitis|ankylosing spondylitis]])
* [[Genetics and Health|Genetics]]
*Joint morphology
* Repetitive stress and mechanical overload
*Genetics
* Farmers, construction workers
*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]], [[Developmental Dysplasia of the Hip (DDH)|developmental hip dysplasia]])
* High impact sports eg football, handball, hockey, wrestling, weight-lifting, and long-distance running
*Subchondral bone defects
* [[Hip Dysplasia|Acetabular dysplasia]]
*[[Obesity]] - mostly resulting in bilateral hip osteoarthritis
* [[Femoroacetabular Impingement|Femoroacetabular impingement]]
*Occupation causing excessive strain on hips (e.g. manual labor causing repeated loading)
* [[Slipped Capital Femoral Epiphysis|Slipped capital femoral epiphysis]]
*Increase in age
* [[Legg-Calve-Perthes Disease|Perthes disease]]
*Gender (female > male)
* 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>
*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
<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><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>


== Characteristics/Clinical Presentation  ==
== 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:


'''Signs & symptoms:'''<ref name=":9" /><ref name=":5">Crielaard JM, Dequeker J, Famaey JP, Franchimong P, Gritten CH., Huaux JP. Osteoartrose. Brussels: Drukkerij Lichtert, 1985.</ref><ref>Walters J, editor. Orthopaedics - A guide for practitioners. 4th Edition. Cape Town: University of Cape Town, 2010.</ref><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>
# Moderate anterior or lateral hip pain during weight-bearing activities
* [[Pain]]:
# Morning stiffness less than 1 hour in duration after wakening
** Progressively increasing
# 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" />
** Aggravated - movement; when hip is loaded wrong or too long; cold weater
** Eased with continuous of movement
** Commonly in groin/thigh radiating to buttocks or knee
** End-stage:  Constant pain, night pain
* Stiffness:
** Morning stiffness with end-stage osteoarthritis, usually eased with movement
* "Locking" of hip movement
* Decreased rang of motion - leading to joint contractures and muscle atrophy
* Crepitis with movement
* Gait abnormalities - short limb gait, antalgic gait, [[Trendelenburg Gait|trendelenburg gait]], stiff hip gait
* Leg length discrepancy 
* Local inflammation 


== Differential diagnosis<ref>Fernandez M, Wall P, O’Donnell J, Griffin D. Hip pain in young adults. Aust Fam Physician. 2014;43(4):205–9.</ref> ==
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>.
* Muscle contusion
* Muscle strains - gluteus and adductors
* [[Pubalgia|Athletic pubalgia]]
* [[Piriformis Syndrome|Piriformis syndrome]]
* Hamstring syndrome
* Inflammatory disorders
* [[Snapping Hip Syndrome|Snapping hip syndrome]]
* [[Hip Bursitis|Hip bursitis]]
* Arthritis
* [[Septic (Infectious) Arthritis|Septic arthritis]] of the hip
* [[Avascular necrosis of the femoral head|Avascular necrosis]]
* [[Labral Tear|Labral tears]]
* [[Hip Fracture|Hip fractures]]
* Hip dislocations
* Tumors
* Chondral defect
* Ligamentus teres injury
* [[Sciatica]]
* Nerve irritation (especially obturator & lateral femoral cutaneous)
* Joint capsule disorders
* Inguinal ligament strain


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


The American College of Rheumatology published criteria in 1990 for the diagnosis of hip osteoarthritis:<ref name=":0" />
* 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.


'''Clinical criteria A'''
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>
* Hip pain
* Hip internal rotation <15°
* Erythrocyte sedimentation rate (ESR) ≤45mm/h OR hip flexion ≤115° if ESR not available


'''Clinical criteria B'''
=== Physical Examination ===
* Hip pain
[[File:Hip rotation rom.jpeg|thumb|Measuring ROM hip]]
* Pain with hip internal rotation
A physical examination includes (Also also [[Hip Examination|hip examination]])
* Morning stiffness ≤1 hour
* Observation
* >50 years
* 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>


'''Clinical plus radiographic criteria'''
== Management ==
* Hip pain
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.
* Two of the following:
** ESR <20mm/h
** Osteophytes on hip x-rays
** Joint space narrowing on x-rays


=== Special investigations ===
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.
[[File:Hip OA.jpg|alt=|thumb|260x260px|X-ray: Hip osteoarthritis]]
Hip osteoarthritis can be diagnosed by clinical presentation only, but special investigation (e.g. x-rays) are vital to monitor the progression of the disease.


* '''X-rays:''' Findings include 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> This is normally the first investigation done that aids in the diagnosis of hip osteoarthritis
# 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.
* '''[[MRI Scans|MRI]]:''' More effective in detecting early change in the bone 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>  
# 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" />
* '''[[CT Scans|CT scan]]'''
# Offer topical or oral [[NSAIDs|nonsteroidal anti-inflammatory drugs]] in those without contraindications.
* '''Bone scan:'''  Aids in assessing the condition of soft tissue and bone of the hip
# Intra-articular steroid injections provide short-term pain relief and duloxetine has demonstrated efficacy. Opiates should be avoided.<ref name=":7" />
<ref name=":9" />  


== Outcome measures  ==
* Patient acceptable symptom state (PASS)
* 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
* Oxford hip score ([http://www.orthopaedicscore.com/scorepages/oxford_hip_score.html/ OHS])
* Algofunctional index (AFI)
* Intermittent and constant osteoarthritis pain index (ICOAP)
* Lequesne index
* [[Six Minute Walk Test / 6 Minute Walk Test|6 Minute Walking Test]]
* Timed up and go test 
* patients specific complaints list (PSC)
* [http://www.sf-36.org/ SF-36]
* Fear Avoidance Belief Score
* [[International Hip Outcome Tool (iHOT)|International Hip Outcome Tool]]
* [[Ibadan Knee/Hip Osteoarthritis Outcome Measure (IKHOAM)|Ibadan Knee/Hip Osteoarthritis Outcome Measure]]
== Medical management  ==


Medical management of hip osteoarthritis focuses on treating the symptoms. Effective disease-modifying interventions have not been estabilished yet, thus a major focus should be on primary prevention strategies.<ref name=":0" /> 


=== Primary prevention ===
* Patient education - especially in primary health care
* Muscle strengthening
* Joint preserving surgery prior to onset of hip osteoarthritis/early in disease process
* Modification of risk factors:
** Weight control
** Switching from high-impact to low-impact activities
** Minimization of pain aggravating activities
<ref name=":0" /><ref name=":9" /> 


=== Pharmacological management<ref name=":0" /> ===
'''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.
* Symptom-relief drugs:
** Start with paracetamol
** NSAIDs - low doses and duration due to side effects
** Duloxetine - works on central nervous system to inhibit pain
** Tramadol (non-narcotic opioid)
** Intra-articular injections:
*** Corticosteroids
*** Platelet-rich plasma
** Hyaluronic acid
* Disease-modifying osteoarthritis drugs (research on this topic still ongoing)


=== Surgical intervention ===
'''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" />.
[[File:THR X-ray.jpg|thumb|313x313px|Total hip replacement]]


==== [[Total Hip Replacement|Total hip replacement]] ====
== Physiotherapy Management ==
90% of total hip replacements are done as a result of end-stage hip osteoarthritis. It is a successful orthopaedic procedure in the treatment of hip osteoarthritis, when the conservative therapy has failed and is highly effective at relieving symptoms.  
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>


==== Hip resurfacing ====
'''Education'''
This is normally done for the younger, more active population.


==== [[Osteotomy|Hip osteotomy]] ====
* Role of physiotherapy and expected outcomes of physiotherapy interventions
An osteotomy is preformed to realign the hip joint to lessen pressure. This is not a common surgery to be done in the treatment of osteoarthritis.
* 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'''


=== ''Physical Examination'' ===
* [[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.
During the physical examination, your doctor will look for:
* Tenderness about the hip
* Range of passive (assisted) and active (self-directed) motion
* Crepitus (a grating sensation inside the joint) with movement
* Pain when pressure is placed on the hip
* Problems with your gait (the way you walk)
* Any signs of injury to the muscles, tendons, and ligaments surrounding the hip


{{#ev:youtube|8xrDWgIUMO4}}<ref>Physiotutors. Cluster of Sutlive | Hip Osteoarthritis Diagnostic Cluster. Available from: https://www.youtube.com/watch?v=8xrDWgIUMO4</ref>
* '''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.
<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.  
'''Exercise therapy'''[[File:Hip Theraband.png|right|frameless]]
</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.
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.  
</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">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>
* 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" />


<br>The five variables are:
[[File:Hip exercise 3.png|thumb|Hip abduction exercise]]
* Flexion
'''The RACPG 20188 guidelines recommend as per below'''
* 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  ==
1.Land-based exercise – Hip OA <ref name=":12" />
Rehabilitation for hip OA encompasses several different aspects, including patient education, weight management, land- and water-based exercise, and strength training [144]. While consistent evidence supports the efficacy of these strategies in the management of knee OA [145], the evidence in hip OA is far more variable [144]. Weight loss is recommended for people with hip OA who are overweight/obese; however unlike knee OA, there is a paucity of clinical trial evidence for weight loss in hip OA [146]. A cohort study reported that a combined dietary and exercise weight loss program improved functional symptoms and reduced pain [147]; however, much further study is needed to establish the efficacy of weight loss in hip OA conclusively.


Exercise therapy is widely recommended in clinical guidelines for hip OA management [5, 6, 7]. Overall there is evidence that exercise offers small to moderate benefit in reducing pain and improving function in hip OA [146, 148, 149], although the strength of this evidence is less than for knee OA [150]. Small clinical trials have recently suggested exercise therapy may postpone the need for THA [151] and may reduce medical expenditure for people with hip OA [152]. There are various activities included under the banner of exercise therapy, including strengthening, aerobic, and flexibility activities, many of which can be carried out on land or in the water. No particular activity type has been shown to produce superior results, and thus it is recommended that exercise programs be personalized to reflect the unique needs of each patient [153].
* 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)


Physiotherapy for hip OA usually includes physiotherapist-led exercise therapies in conjunction with manual therapy. The value of physiotherapy in the management of hip OA is a hotly contested issue, with recent evidence suggesting it offers little benefit beyond what could be expected from a self-guided exercise program [149]. Systematic reviews on the topic have reported no benefit from the use of manual therapy in treating hip OA, nor any additional benefit when manual therapy is combined with an exercise program than is obtained from exercise alone [154, 155]. A recent clinical trial comparing physiotherapy-led management to sham therapy found no benefit of physiotherapy on pain or function [156]. More high-quality research is needed in this area, but the limited evidence currently available does not establish physiotherapy as effective in treating hip OA. A novel strategy being investigated for a potential role in modifying biomechanics to treat hip OA is bracing, although this research is still very much in its infancy [157, 158, 159, 160].
2. Aquatic exercise/ hydrotherapy – Hip OA<ref name=":12" />


<ref name=":0" />
* 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. 


Physical therapy. Specific exercises can help increase range of motion and flexibility, as well as strengthen the muscles in your hip and leg. Your doctor or physical therapist can help develop an individualized exercise program that meets your needs and lifestyle.
'''Manual therapy'''
[[File:Prone Hip Posterior to Anterior Glide.JPG|thumb|Hip Posterior to Anterior Glide]]
A range of manual therapies is used in the treatment of hip osteoarthritis:<ref name=":1" />
* Soft tissue techniques and stretches
* Mobilization of accessory and physiological movements
* Manipulation


Assistive devices. Using walking supports like a cane, crutches, or a walker can improve mobility and independence. Using assistive aids like a long-handled reacher to pick up low-lying things will help you avoid movements that may cause pain.
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> 


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


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.
* 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.


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" />
* 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.


=== Exercise Therapy ===
== Outcome Measures ==
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" /> 
* [[Visual Analogue Scale|Visual analogue scale]] (VAS)
 
* Hip disability and osteoarthritis outcome score ([[Hip Disability and Osteoarthritis Outcome Score|HOOS]])
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.
* Western Ontario and McMaster universities osteoarthritis index ([[WOMAC Osteoarthritis Index|WOMAC]])  
 
* [[Harris Hip Score|Harris hip score]]
[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.)
* 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]]
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.
* [[Timed Up and Go Test (TUG)|Timed up and go test]]
</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.  
* [[International Hip Outcome Tool (iHOT)|International Hip Outcome Tool]]
</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.  
* [[Ibadan Knee/Hip Osteoarthritis Outcome Measure (IKHOAM)|Ibadan Knee/Hip Osteoarthritis Outcome Measure]]
</ref>
=== 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>
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" /> 
 
=== Manual Therapy ===
A range of manual therapies is used as manual therapy treatment. These therapies are:<ref name=":1" />
* soft tissue techniques and stretches
* mobilisation of accessory and physiological movements
* manipulation/ mobilisation
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>
 
<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, Eric Robertson, Kai A. Sigel, 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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