Hip Osteoarthritis

Introduction[edit | edit source]

Hip Osteoarthritis

The hip joint is one of the body’s largest weight-bearing joints, only secondary to the knee joint, and is commonly affected by Osteoarthritis.[1] Many activities for people with hip OA become restricted, which has an impact on the health-related quality of life.

Osteoarthritis (OA) of the hip is a common problem in Western society and a common diagnosis in primary care.

  • Hip OA affects 7%–25% of people older than 55 years.
  • Pain in the hip and hip stiffness are the most common symptoms of hip OA.[2]
  • Aging and genetic factors are important contributing causes of hip OA[1].

Epidemiology[edit | edit source]

Hip Pain - Elderly lady

Osteoarthritis (OA) of the hip is a common problem in Western society.

  • Hip OA affects 7%–25% of people older than 55 years.
  • The number of affected hips will increase with further ageing of the population[2].
  • Lifetime risk for symptomatic hip OA is 18.5% for men and 28.6% for women[1].
  • Research suggest that there are a 25% risk of developing hip osteoarthritis for people who live to the age of 85,[3]

Etiology[edit | edit source]


  1. Idiopathic/unknown
  2. Previous trauma
  3. Others: acetabular dysplasia; femoroacetabular impingement; inflammatory joint disease, e.g. septic arthritis; hemochromatosis, hemophilia; iatrogenic, e.g. multiple intra-articular steroid injections.[4]

Risk factors

Attributes, characteristics or exposures that increase the likelihood of developing osteoarthritis of the hip are:

  • older age
  • obesity
  • genetics
  • repetitive stress and mechanical overload
  • high impact sports (eg football, handball, hockey, wrestling, weight-lifting, and long-distance running)[4]

Clinical Presentation[edit | edit source]

Advanced Hip OA 1. osteophytes 2. subchondral thickening 3. cyst 4. joint space narrowing

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.[4]

Diagnosis[edit | edit source]

Hip osteoarthritis can be diagnosed by a combination of the findings from a history and physical examination. Radiographic indicators joint space narrowing, marginal osteophytes, subchondral sclerosis, and bone cysts.[5][6].

Physical Examination[edit | edit source]

Advanced OA of a hip.
Measuring ROM hip

A physical examination includes (Also see the page for 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[7][8][9]

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.[10]

Treatment[edit | edit source]

Advanced OA of a hip.

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 exercises, weight loss (if appropriate), and education-complemented by topical or oral nonsteroidal anti-inflammatory drugs in those without contraindications.
  2. Intra-articular steroid injections provide short-term pain relief and duloxetine has demonstrated efficacy. Opiates should be avoided.[6]
  3. 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[4].

The RACPG 20188 guidelines Weight management – Hip OA[11]

  • 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.

A biopsychosocial approach to the management of hip osteoarthritis leads to patients experiencing less anxiety, even though the condition may not always improve.[12] It is important to consider the rest of the multidisciplinary team as well. Dietitians, occupational therapists, and psychologists can play an important part in the management of hip osteoarthritis.

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.[3][12]


  • 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[3][7][13]

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[11] 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 osteoarthrosis.[12] 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.[12][13] 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.[13]
  • 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.[14]
  • 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.[15] Clinical trials further suggest that it can postpone the need of total hip replacement surgery.[13]
Hip abduction exercise

The RACPG 20188 guidelines recommend as per below

1.Land-based exercise – Hip OA [11]

  • 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[11]

  • 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:[12]

  • 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.[3] 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.[16] 

The RACPG 20188 guidelines Massage and Manual therapy – Hip OA[11]

  • 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.[17]

Resources[edit | edit source]

References[edit | edit source]

  1. 1.0 1.1 1.2 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)
  2. 2.0 2.1 van Berkel AC, Schiphof D, Waarsing JH, Runhaar J, van Ochten JM, Bindels PJ, Bierma-Zeinstra SM. 10-Year natural course of early hip osteoarthritis in middle-aged persons with hip pain: a CHECK study. Annals of the rheumatic diseases. 2021 Apr 1;80(4):487-93.Available: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7958083/(accessed 23.1.2022)
  3. 3.0 3.1 3.2 3.3 Murphy NJ, Eyles JP, Hunter DJ. Hip osteoarthritis: Etiopathogenesis and implications for management. Advances in therapy 2016;33(11):1921-46.
  4. 4.0 4.1 4.2 4.3 Radiopedia OA of the hip Available: https://radiopaedia.org/articles/osteoarthritis-of-the-hip?lang=us(accessed 23.1.2022)
  5. Brandt CD. Diagnosis and non-surgical management of osteoarthritis. USA: Professional Communications, Inc. 2010.
  6. 6.0 6.1 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)
  7. 7.0 7.1 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).
  8. Crielaard JM, Dequeker J, Famaey JP, Franchimong P, Gritten CH., Huaux JP. Osteoartrose. Brussels: Drukkerij Lichtert, 1985.
  9. Walters J, editor. Orthopaedics - A guide for practitioners. 4th Edition. Cape Town: University of Cape Town, 2010.
  10. 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.
  11. 11.0 11.1 11.2 11.3 11.4 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)
  12. 12.0 12.1 12.2 12.3 12.4 Bennell K. Physiotherapy management of hip osteoarthritis. J Physiother. 2013; 59(3):145–157.
  13. 13.0 13.1 13.2 13.3 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.
  14. 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)
  15. 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.
  16. 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.
  17. 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)