Osteoarthritis is a normal part of aging and can affect any joint in your body. In the case of hip osteoarthritis this means damage to the cartilage that covers the joint surfaces. This damage causes friction between the two bones that make up the joint which may lead to pain and clicking or grating sounds. As the body tries to increase the stability of the joint, extra bony structures called osteophytes can also develop around the joints. You will notice that your hip osteoarthritis symptoms improve with movement and that you have stiffness after being in the same position for a while, like waking up in the morning or driving long distances.
When it comes to hip osteoarthritis “movement is medicine“, so physiotherapy can definitely help with pain relief. We can help you with the stiffness and pain in your hip so that you can get back to the things you want to do, like put on your shoes and climb stairs without pain, get back to walking & jogging.
What is the hip joint?
Your hip is one the largest joints in the body and connects your leg to the rest of your body. It is formed by the thigh bone (femur) at the bottom and the pelvis (specifically the acetabulum) at the top. Hip osteoarthritis is a collection of problems in multiple structures like the joint, ligaments and muscles.
It’s not only a condition of the hip joint – it’s all the “in between” bits that change in your hip. Each structurehas a role to play to allow you to move. Let’s look at each of these structures:
Articular cartilage
The top part of the femur and bottom part of the acetabulum are covered in articular cartilage. This cartilage prevents the pain sensitive bones from “rubbing” against each other. Articular cartilage is smooth, so it reduces friction between the two parts of the hip joint to make movement easier.
Acetabulum
The acetabulum is like a shallow bowl that contains the rounded head of the femur. This provides the movement surface for your femur head. However, this “bowl” is quite small relative to the head of the femur, so it has an extension that increases the contact area – the labrum.
Labrum
This connective tissue extension around the edge of the acetabulum is called the labrum – like a “washer” in a tap (like an O-ring seal). The labrum is a very important part of the hip joint, because it increases the stability of the hip joint, acts as a shock absorber and distributes pressure on the cartilage covering the head of the femur and acetabulum.
Capsule
The whole joint is surrounded by a strong, connective tissue capsule, like a protective sleeve keeping everything in place and increasing stability of the joint.
Ligaments
As the hip joint is a weight-bearing joint with a lot of movement, it needs a lot of stability to keep the head of the femur in its socket. A ligament connects one bone to another to limit certain movements – thereby increasing stability – and there are quite a few located in and around the hip joint.
- Ligamentum teres – this ligament is inside the hip joint connecting the acetabulum to the femur. It’s joined by nerves and blood vessels supplying the head of the femur.
- Ischiofemoral ligament – this ligament is attached to the back of the acetabulum and runs around the joint to attach to the front of the femur. Its function is to help limit extension (backwards movement) of the hip and internal rotation (turning in).
- Iliofemoral ligament – this is the strongest ligament in the body. It starts above the acetabulum and attaches to the front, inner part of the thigh bone. The different parts of the ligament limit extension, adduction (crossing over the other leg) and abduction (moving away from the other leg) of the hip.
- Pubofemoral ligament – this ligament runs over the front of the joint and limits abduction and extension of the hip.
What does the hip joint do?
Your hip joint connects your leg to your pelvis and, therefore, the rest of your body. It is a very mobile joint because it can move in all directions, but also needs to handle excessive loads when you jump & run.
- Flexion is forwards movement of your thigh, like climbing up a stair or kicking a ball.
Muscles responsible for this movement are psoas major & minor, iliacus, pectineus and rectus femoris. - Extension is when your hip moves backwards, like standing up from a chair.
This action is performed by the gluteus maximus, semitendinosus, semimembranosus and biceps femoris muscles. - Abduction is movement away from the midline, like sidestepping.
The muscles responsible for this movement are gluteus medius and tensor fascia latae. - Adduction is movement towards the midline, like crossing one leg over the other.
Muscles that adduct the hip joint are adductor magnus, adductor longus, adductor brevis, gracilis and pectineus. - Internal rotation is a turning movement of your hip, turning your foot inwards.
Internal rotators of the hip joint area tensor fascia latae and gluteus minimus. - External rotation is also a turning movement of your hip, but in this case your foot will turn outwards.
This movement is performed by the gluteus maximus, gemelli, obturator and piriformis muscles.
Stability
The hip is a weight-bearing joint, so with every step there is stress on the joint. That’s why it’s so important that every muscle and ligament around your hip does its job to create stability around the joint. If some muscles are weak or tight it will affect the function of the whole structure, causing abnormal load on the cartilage and ligaments. Over time this load will lead to degeneration – “wear & tear” – inside your hip joint leading to hip arthritis.
How does it happen?
Hip osteoarthritis is a degenerative condition of the articular cartilage (the cartilage inside) and the other structures in and around your hip joint. This degeneration also affects the bone, ligaments and joint capsule, causing thickening over time and formation of osteophytes. These osteophytes are extra bony structures that form when your body tries to increase the stability of the joint. This is the end result of years and years of normal use, not just a result from trauma or acute injury.
The injured and degenerated structures in your hip joint produce chemicals called cytokines and chemokines. Under normal circumstances this is the result of inflammation, so your body responds by healing the area. When you have hip osteoarthritis these chemicals can cause further joint damage and inflammation which leads to more of these chemicals being produced. Cytokines and chemokines also activate the nerve cells in your hip joint responsible for carrying “danger” messages to your brain, leading to more pain.
Causes of hip osteoarthritis
Primary osteoarthritis
This condition has no known cause and affects more than one joint in your body, for example if you arthritis in your hip, knee and neck. It occurs mostly in persons over 65.
Secondary osteoarthritis
If you only have osteoarthritis in your hip, it is called secondary hip arthritis which develops due to an injury or abnormality of the joint.
Risk factors for secondary hip osteoarthritis include:
- Previous injury to the hip
- Other inflammatory conditions like rheumatoid arthritis or ankylosing spondylitis.
- Genetics
- Congenital hip conditions like Perthe’s disease, slipped upper femoral epiphysis or developmental hip dysplasia. These conditions are found in children and need proper surgical management as soon as possible.
- Bone defects
- Obesity
- Occupations that cause a lot of load/strain on the hips
- Increased age
- Gender: Women are more likely to develop hip osteoarthritis than men.
- Menopause
- Inactive lifestyle
- Femoroacetabuluar impingement (FAI)
- Avascular necrosis
Symptoms of hip osteoarthritis
How bad is it?
The symptoms of hip osteoarthritis do not develop overnight; your discomfort and pain will gradually get worse. Over time you will also notice that the stiffness takes longer to ease with movement and that too much activity will aggravate your symptoms. As the condition progresses you will experience pain more frequently, it will last for longer periods of time and eventually your pain will be constant.
Pain will get worse with too much activity and relieved by rest, but complete rest will also cause more pain. Symptoms are worse in the mornings with stiffness in all directions, which takes about 30 minutes to ease. The longer it takes to ‘settle’ or ‘get moving’ the more progressed the hip arthritis has become.
As the condition gets worse you will find that you lose range of motion of your hip, like when you lift your foot to put on your shoes.
Stage 1
In the first stage of hip osteoarthritis you will only have minor symptoms. There could be some osteophytes on X-rays, but often patients will describe their symptoms as discomfort rather than pain. These symptoms come and go and don’t interfere with your daily routine. You could feel some stiffness in the morning when you get up, but this eases as soon as you start moving around. Jogging or running starts causing discomfort.
Stage 2
You will start to notice stiffness more often, like after a long drive or sitting at your desk for a couple of hours. You will experience pain in your groin or buttock at times, but still be able to carry on with your daily routine. Jumping or fast movements like stepping over a puddle become sensitive.
X-rays will show osteophytes around the hip joint, but no narrowing of the joint space.
Stage 3
In the third stage of hip osteoarthritis your symptoms will become more noticeable. You will find that your discomfort has changed to pain which can interfere with your daily activities. You might notice that you start avoiding certain movements or positions, like sitting in low chairs or running. At this stage you will probably also walk with a limp and pain can start radiating to the outside of the hip or down to your thigh and knee. Other activities that cause pain are getting up from sitting, driving for more than an hour brings on the stiffness and you’ll even have difficulty crouching/kneeling.
On X-rays there will be some damage to the cartilage inside the hip joint and we will see narrowing of the joint space.
Stage 4
At this point you will have constant, severe pain that also wakes you up during the night. You will struggle to find a comfortable position to fall asleep in. Walking and climbing stairs will be extremely painful and all movements of your hip will be limited and painful. After walking for awhile you’ll feel that you need to sit down. Your hip will be painful when you get out of bed in the morning and you could notice be locking and clicking of the joint with movement.
On X-rays there will be no visible joint space – which means that the cartilage is worn away – and a large number of osteophytes.
Diagnosis
To make a diagnosis of hip osteoarthritis we will take a thorough history of the condition to find out where your pain is, when it started and what you cannot do anymore. We also need to identify any contributing factors – what else could be making your pain worse and any other problems that may have developed.
During our physical assessment we will test the different areas that could be causing your pain. Hip arthritis presents with groin, buttock, thigh or knee pain, but this could also be caused by other conditions like sciatica hip pain or piriformis syndrome. The goal of our examination will be to either confirm the diagnosis of osteoarthritis, or to rule it out and diagnose the real cause of your pain.
Physical assessment
Our physical assessment includes testing the range of motion of the hip joint actively (your muscles do the movement) and passively (we move your leg) to find out if the problem is with the joint or the muscles. The range of motion also gives us an idea of which structures around the hip are tight. We test the strength of the muscles around the joint and also stress these muscles to find out if they contribute to your pain.
Tests we do to confirm hip osteoarthritis are the Scour test, FABER test and range of motion of hip flexion and internal rotation.
X-rays
X-rays are our first choice of investigation to confirm hip arthritis. Depending on the stage of your hip osteoarthritis, the X-rays will show narrowing of the joint space, osteophytes and damage to the underlying bone.
MRI or CT scan
These are very expensive tests that can be ordered by an orthopaedic surgeon. A CT can or MRI will also show the soft tissue (muscles, cartilage etc.) in and around the hip joint, so this will be our first choice if we suspect other injuries like a labrum tear.
Bone scan
If we suspect other soft tissue lesions like infections or tumours a bone scan will be the investigation of choice. This test is also ordered by an orthopaedic surgeon in necessary.
Why is my pain not going away?
Hip osteoarthritis is a degenerative process affecting the structures in and around your hip joint. The damage is irreversible, but only about 50% of people with hip arthritis have pain. This means that osteoarthritis is a complex condition and the damage to your joint does not necessarily determine how much pain you have.
Your pain will be worse after too much activity. Over time your stiffness will increase as joint mobility decreases. As your condition gradually gets worse you will notice that your pain is even aggravated by less activity and lasts longer than before. Not doing enough will also cause stiffness that lasts longer than in the earlier stages.
We will help you find the balance between activity and rest to minimize your flare-ups. Education is a major part of how we treat hip arthritis, so we will treat your pain and also teach you how to manage flare-ups.
Physiotherapy cannot reverse the joint damage, but we can help you get back to doing the things you enjoy. Stop avoiding life, make a choice to actively work on your pain and you’ll be amazed how your body can adapt. Physiotherapists are here to coach you through the process.
A big problem we see with hip osteoarthritis
Misdiagnosis leading to mismanagement of hip osteoarthritis. There are different conditions that cause groin and buttock pain and these different areas must be stressed during an assessment to make the correct diagnosis. If the wrong structures are treated you may have temporary relief without the long-term benefits.
Lack of education and advice. Hip arthritis is a degenerative condition, so no treatment can “fix” the problem. Educating patients about their condition and how to manage flare-ups is a crucial part of treatment of hip osteoarthritis symptoms.
Chiropractic manipulation of a hip joint with arthritis can aggravate your symptoms quite severely due to bony changes inside the joint.
Using crutches or a walking stick for a prolonged period of time without correcting your walking pattern or muscle imbalances. This affects your posture during walking which leads to back pain.
Overuse of medication is another big problem with hip osteoarthritis. As your pain gets worse over time you will need more and more medication to get relief. This becomes quite expensive over time and makes you vulnerable to side effects.
Physiotherapy treatment of hip osteoarthritis
Unfortunately we cannot reverse the cartilage damage and hip joint changes, it is not as simple as that. However, we can relieve a great deal of your pain and assist you in some lifestyle adaptations that will help you minimize your hip pain. In doing things differently you can slow down the degeneration process and limit painful episodes.
The best strategy to manage your hip osteoarthritis is having a good understanding of what is going on inside your hip joint, knowing how to load it appropriately and when to do which exercises. We can help you understand the pathology, when and how to do to manage your symptoms, to ultimately slow down the disease progression.
Treatment will include:
- electrotherapy, including laser and ultrasound, to help with pain relief
- myofascial release and dry needling to get rid of muscle spasm and tightness
- joint mobilisation to improve or restore the movement of the joints
- nerve mobilisations to restore the normal gliding movements of the nerves
- taping/strapping to support the area
- exercises to strengthen the stabilizing muscles around your hip
- advice and education to help you to understand your condition and know what you can change to be in control of your symptoms.
Protection
We have found that patients tend to continue walking on the injured leg with a limp. Your hip joint still has to carry the load every time that your weight is put onto the leg. It’s better to use crutches or a walking stick to keep some of the load off your hip. This will help with pain relief and decrease the risk of falling.
Education
A major part of physiotherapy is education. There are different possible diagnoses for groin and buttock pain and we do a thorough assessment to confirm or rule out areas. From this information we can make a diagnosis and give you the necessary information about your condition. We can answer your questions about the condition and give you advice on management of your symptoms.
Load
It’s important to manage load appropriately with any painful condition. Too little loading can delay healing and cause other problems like stiffness, but too much load will aggravate your pain and possibly cause more damage to the joint. We can guide you through this process to get you moving again.
Avoid anti-inflammatories
Anti-inflammatory medication can interfere with your body’s normal healing process and long-term use of medication increases your risk of side effects.
Exercise
The right exercises are important to get you moving, regain strength and speed up the recovery process. Complete rest will aggravate your hip arthritis symptoms and you will find that your stiffness and pain increases if you stop moving.
1st Phase: Protection and initial healing
The first phase of your treatment will involve lots of information about your hip osteoarthritis. We will explain the treatment plan and give you advice on everyday things to help manage your pain, from sitting positions to how to get up from a chair.
During this phase of treatment we will use joint mobilisations and myofascial release techniques to decrease your pain. Electrotherapy like ultrasound and laser will also help with pain relief during this stage.
We use strapping or taping to help support and protect the area while we start with gentle, pain free exercises. If you continue walking on the sore leg, you may start to limp. Even though limping eases the load on the painful hip joint, it influences the rest of the kinetic chain and you may start to experience back or knee pain too. The load placed on your hip can increase the inflammation during an acute flare up. It’s better to decrease the load on your hip joint by avoiding climbing stairs or long walks during this first phase. You could substitute your walking or jogging with swimming or cycling.
Heat improves mobility by easing tension in the muscles around the hip. You can use a hot water bottle or bean bag for 20 minutes 3 times a day. Be sure to put a towel between the heat pack and your skin.
2nd Phase: Establish pain free range of movement
During your examination and testing, it’ll become clear what you can do and what makes your pain worse. We identify factors that contribute to your pain, specific to your case.
The aim is to maintain the available movement in your hip joint. We use joint and neurodynamic mobilizations to maintain or gain range of movement. Pain management is still key during this phase and we will use laser, soft tissue mobilizations and ultrasound therapies. Strengthening of the stabilizing muscles around your hip is also essential. Therefore, your physiotherapist will give you exercises to do at home to gain strength.
3nd Phase: Isometric exercises
If you have pain with all movements of your hip we will start with isometric exercises – giving you the benefits of exercise, but without the pain.
An isometric exercise means that the muscles contract, but the joints don’t move. It may not feel like much, but the benefits are great. We use these muscle contractions to help with initial activation of the muscles around your hip joint. These exercises start retraining control of the small movements of your hip joint to help distribute the load more evenly.
4nd Phase: Regain range of movement
When you walk, get up in the morning or get into your car there are forces in different directions around your hip joint, for instance when you sit down gravity causes a downward force on your hip while your hip flexors cause an upward force to resist gravity. If there is stiffness in the joint due to hip osteoarthritis, it will affect the line of these forces. We treat this stiffness using joint mobilisation, myofascial release, dry needling and stretches to improve the movements of your hip.
If your degeneration is advanced or severe, there will be a loss of movement that isn’t reversible. Our treatment will focus on restoring the available range and then strengthening your muscles to maintain the range of movement we have gained . This muscle strength is very important for long-term improvements in your condition. The stability of your hip improves when the muscles are stronger, so your body doesn’t have to use muscle spasm and osteophytes to help with stability.
5nd Phase: Concentric strengthening
After the initial phases of treatment you will have more pain free movement of your hip, so now we can start strengthening these ranges. A concentric contraction is when the muscle fibers shorten, allowing the joint to move. For example, the gluteus maximus muscle shortens when the hip is extended.
If there are muscle imbalances around your hip, it will affect which areas take strain when you are loading your hip joint. Strengthening the muscles around your hip helps to correct this during walking, standing etc. As you progress through this phase and your muscles get stronger we will add resistance to the exercises using weights or resistance bands. This ensures that the muscles will be strong enough to support your hip during walking or climbing stairs.
6rd Phase: Strengthening the kinetic chain
Your leg is made up of different joints connected to each other by muscles, working together to do everyday activities like when you move furniture or pick up heavy boxes. This means that movement or dysfunction in one joint in your leg will affect the other areas. For example a stiff hip can limit the movement of your knee when you pick something up off the floor.
During this phase of rehabilitation exercises will also be aimed at strengthening other parts of the kinetic chain like your knee and lower back. This phase is important to ensure that weaknesses in other areas of your leg don’t cause extra strain on your hip osteoarthritis causing flare-ups of your pain.
7th Phase: Referral for long-term management
When you have completed your rehabilitation you should know how to manage your symptoms, what to do when you have a flare-up and be strong enough for everyday activities like walking, climbing stairs and getting up from a chair.
After we’re reached all the range of movement and strengthening milestones, we will refer you to for exercise classes of to a biokineticist for “maintenance” exercises. It’s very important to stay active after completing your physiotherapy treatment, because the degeneration of your hip joint doesn’t heal, but if you stay strong and keep moving pain from your hip osteoarthritis shouldn’t stop you from doing the things you love.
Will my hip arthritis heal over time?
Osteoarthritis is a degenerative condition, so we cannot reverse or heal the damage. However, we can make a huge difference to your pain and quality of life. Our treatment plan and how often we need to see you will depend on the severity of your condition and your current pain.
If you have constant pain we will see you twice a week until your pain is under control. Thereafter we will make an appointment once a week to maintain the joint movement we have gained and to increase the intensity of your exercises. As your exercises get progressively harder the time between treatments will increase to two weeks and later a month to check on your progress and adapt your exercises as necessary. You could have a flare-up sometime during the course of treatment if there is a sudden increase in your activity, but this will settle down after one or two treatments, because you have already started the rehabilitation process. Short term discomfort for long term gains.
Without treatment or if you don’t finish your rehabilitation, the pain and stiffness will always return and get worse over time. At some point you will find that you have constant discomfort or pain that isn’t relieved by rest. Working with your physiotherapist you can make sure that this doesn’t happen.
Unfortunately there is no cure for osteoarthritis. However, with an appropriately designed physiotherapy program, your condition will be well managed and you will be able to maintain an active and healthy lifestyle.
Another very important thing to remember is that even if your doctor has suggested surgery, you don’t have to wait until after your procedure to start physiotherapy treatment. Prehabilitation ensures that you are strong before surgery and can dramatically shorten your recovery after surgery.
Other medical treatments
Orthopaedic surgeon
This is the most common option that patients choose for their hip osteoarthritis. Surgery should never be your first option when dealing with pain. Physiotherapy offers you a non-surgical solution before you decide to go for surgery.
General Practitioner
Your doctor can prescribe pain medication and anti-inflammatory medication if necessary. However, this will only control the pain and won’t give you long-term relief. Physiotherapy treatment for hip osteoarthritis combined with medication can help with improvements in the long-term and you won’t have to take the pain medication as often as you would without physiotherapy.
Dietician
Obesity causes extra stress on the weight-bearing joints, so losing weight can make a difference to your pain. A dietician can help you with dietary adjustments if you are overweight.
Assistive devices
Walking with crutches or a walking stick reduces load on the joint and can help with pain relief. However, it is still important to see a physiotherapist to correct your walking pattern and address any muscle imbalances. Without these measures you will find that you develop back- or knee pain due to the extra stress caused by an abnormal walking pattern.
Biokineticist After completing your treatment with a physiotherapist to help with walking pattern, muscle imbalances, pain and joint stiffness a biokineticist can help you with a long-term exercise program and rehabillitation.
Orthotics
If you have a leg length disrepancy due to severe osteoarthritis or overpronation when walking orthotics can be useful to help manage pain.
Cortisone injections
In the earlier phases of hip osteoarthritis a cortisone injection can suppress the inflammation and help with pain relief. However, this doesn’t take away the degeneration, so it will only be temporary pain relief. Repeated cortisone injections affect the ligaments and tendons which will cause further damage to your hip joint.
Hyaluronic acid injections
In hip osteoarthritis the normal gliding movement of the joint is affected. Hyaluronic acid can be injected directly into the joint to increase the fluid and thereby improve the gliding movements. This treatment can take up to 5 weeks to make a difference to your pain and will only work in the earlier phases of hip arthritis, but pain relief can last from 2 to 6 months. As it doesn’t reverse the damage to the joint it isn’t a quick fix, but it can give temporary pain relief which gives us a window of opportunity to treat your stiffness and muscle weakness for long-term results.
Surgery for hip osteoarthritis
Hip osteoarthritis develops over a long period of time, so it is not a condition that improves overnight. If you receive physiotherapy treatment for 3 months with no significant improvement we can refer you to an orthopaedic surgeon for an opinion on surgery. There are different options for hip arthritis, depending on the degree of joint damage.
Total hip replacement
This is usually the best option for the treatment of stage 4 hip osteoarthritis when conservative management is not successful. A total hip replacement is very successful at relieving symptoms, but is never the first choice of treatment. With any surgery there is always a risk of complications and the recovery period can take 6 to 12 months.
Even if you have a total hip replacement scheduled physiotherapy treatment is still worthwhile. We can help you to manage your pre-operative pain and start correcting muscle imbalances and gait abnormalities before surgery. This will give you a head start on the rehabilitation process after your operation.
Hip resurfacing
This option is more appropriate for younger patients and involves removal of the damaged bone in the hip joint. The surgeon will replace this bone with a metal shell or cover.
Hip osteotomy
If you have an osteotomy the orthopaedic surgeon will remove a piece of bone to realign the hip joint. This treatment is not effective in stage 4 hip arthritis due to the existing degree of joint damage.
Hip arthroscopy
In the early stages of hip osteoarthritis a hip arthroscopy can help with pain relief, especially if you have a labrum tear or osteophytes. As your hip osteoarthritis progresses this isn’t an effective treatment as there is already too much damage to the different parts of your hip joint.
What else could it be?
- Gluteus muscle strain – your pain will be more to the outside and back of the buttock.
- Adductor muscle tear – there will be an incident where you overstretch the muscle (like a split) with acute onset pain.
- Labrum tear – clicking and locking of the hip joint.
- Quadriceps muscle tear – your pain will be at the front of the hip and will have a sudden onset.
- Piriformis syndrome – tingling or numbness over your buttock and your pain will increase when sitting.
- Hip Bursitis – pain will be a dull ache on the outside part of the hip, especially when lying on that side.
- Inguinal ligament sprain – you will remember a “popping”or “snapping”with the injury followed by sudden pain in your groin.
- Sciatica hip pain – there will be areas of burning pain or numbness on your buttock.
- Stress fracture of head of the femur – movement will make your pain worse.
- Avascular necrosis – you won’t have morning stiffness and will have pain when putting weight on the leg.
- Septic arthritis of the hip – you will have systemic symptoms with your pain, like high fever and general body aches.
Also known as
- Hip arthritis
- Hip joint degeneration
- Wear & tear of the hip joint
