Hip Osteoarthritis (Hip OA), Cartilage Damage and the Ageing Hip

What is hip OA?

Hip osteoarthritis (OA) is a condition that makes the joint painful and stiff. Osteoarthritis is the most common form of arthritis. There are other forms of arthritis (that may be related to a systemic health condition), for example, Rheumatoid Arthritis, but here we will only discuss osteoarthritis. Treatment will be different, so it is always important to know what type of arthritis you have. Discuss this with your Hip Pain Professional. Here, we will only discuss osteoarthritis.

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Figure 1: Anatomy of the normal hip joint, with a good bony relationship. Cross-section through the middle of the joint.

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Figure 2:The hip joint, viewed from the front. Cross-section through the middle of the joint.

Hip OA is associated with reduced health of the joint structures. The hip joint is a ball and socket joint (Figure 1). The bones on both sides of the joint are lined with smooth cartilage (Figure 2). OA is usually a slowly progressive condition, where the thickness and smoothness of the cartilage gradually reduces. In more advanced circumstances, the body lays down some extra bone, in an attempt to repair the area. This can be one of the reasons movement becomes restricted.

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A diagnosis is usually reached through patient interview regarding symptoms and a physical examination conducted by a qualified health professional. An X-ray may be requested if the health professional feels it is important to determine the stage of the joint changes.

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What are the usual symptoms of hip OA?

  • One of the most common symptoms is stiffness: typically, people report they are having difficulty putting their shoes and socks on or cutting their toe-nails.
  • Pain is generally felt deep at the front and/or buttock or side of the hip. A person with hip OA may describe the area of pain by grasping the side of their hip with their hand in a ‘C’ shape (referred to as the ‘C’ sign), or indicate a point deep between the front, back and side of the hip (the triangulation sign).
  • Pain may also extend down the thigh, most commonly down the front of the thigh to the knee and also into the front/outer side of the shin. In some cases, people only feel the pain in the thigh, knee or shin, without hip pain.
  • The ability to engage in activity or perform everyday tasks can become difficult, either due to the stiffness or pain.
  • Walking may become painful, particularly longer distances, at a faster pace, on uneven surfaces, or on hard floors such as in shopping centers.
Senior woman standing at a wall with a crutch, having severe hip pain.
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  • A limp may develop in walking, with pain as weight is transferred onto the sore side and particularly as the leg moves backwards to push off. This may result in a lurching pattern where the body moves over to the side, to reduce load on the painful side.
  • Positions where the hip is bent up can also aggravate the pain, such as prolonged sitting especially on a low chair or in a car or squatting to reach the ground, such as in cleaning or gardening.
  • The hip may ache at night and stiffness is often worst first thing in the morning or when rising from a chair to walk.

What causes hip OA?

  • Hip OA is a common condition worldwide. There is usually not a single cause but a combination of factors that increase the risk of developing OA. Age is a well-established risk factor for hip OA, with likelihood of developing signs of OA increasing with advancing age. However, it is possible for younger people to also develop OA if they have other strong risk factors.
  • Genetics may also play a role – likelihood of developing OA is increased if other family members have had OA.
  • Developmental disorders such as congenital hip dislocation, acetabular dysplasia, slipped capital femoral epiphysis and Perthes disease have all been shown to be associated with higher hip OA rates.1
  • More recently, femoroacetabular impingement (FAI) has been implicated in increasing the risk of hip OA.1
  • Obesity places higher loads on weightbearing joints such as the hips and knees. Carrying excess weight is thought to increase the rate at which the arthritis progresses.
  • Previous hip joint injury or surgery can both increase the likelihood of developing hip OA.2

Getting Help. What is the treatment for Hip OA?

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1.Education:
  • Understanding what the problem is and what types of positions and activities are likely to irritate the hip joint can help significantly in controlling the symptoms of hip OA.3
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2.Exercise:
  • Another key component of a treatment plan for hip OA is an exercise program. Targeted exercise in both the water and on land has been shown to be helpful in managing the symptoms of hip OA.4
  • Exercise can have many benefits such as:
    • improving the condition and co-ordination of muscles around the hip joint
    • reducing pain
    • improving ‘function’ – ability to perform normal daily and recreational activities
    • increasing confidence in being able to maintain normal activities
    • improving quality of life
  • Aquatic exercise or hydrotherapy may be the best option when pain is more severe and land-based exercise is difficult to accomplish.4 However, as we all need to function against the forces of gravity, an exercise plan should include or progress to some land-based exercise. Exercise for hip OA is most likely to be maximally effective when prescribed by a qualified health professional, such as a Hip Pain Professional.
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3. Aquatic exercise:
  • Aquatic exercise or hydrotherapy may be the best option when pain is more severe and land-based exercise is difficult to accomplish.4 However, as we all need to function against the forces of gravity, an exercise plan should include or progress to some land-based exercise. Exercise for hip OA is most likely to be maximally effective when prescribed by a qualified health professional, such as a Hip Pain Professional.
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4.Manual Therapy:
  • Manual therapy provided by a health professional has also been demonstrated to assist in reducing symptoms associated with hip OA in the short term. This might include various ‘hands-on’ techniques to mobilise – stretch or move – the hip joint and surrounding soft tissues. As with exercise interventions, these types of techniques are best performed by a qualified health professional, such as a Hip Pain Professional as inappropriate manual therapy may aggravate the problem or even cause damage.
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5.Medications:
  • Medications may be prescribed by your doctor to help control pain, maintain activity levels and assist with sleep. Medications are sometimes also used temporarily to provide a window of opportunity to participate in a rehabilitative exercise program.
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6.Injections:
  • Your doctor may also suggest an injection into the hip joint, such as:
  1. a cortisone (corticosteroid) injection – to reduce inflammation and pain within the joint. The effect is short-term however, so injections are likely to be most effective when paired with an education and exercise program.
  2. viscosupplementation – a joint lubricant injection (hyaluronan and/or hyaluronic acid). Hyaluronic acid is a naturally occurring substance in the body that assists in maintaining the elasticity of joint cartilage. These injections aim to reduce pain and improve mobility in those with hip OA.
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7.Surgery:
  • For more advanced cases of hip OA where symptoms are not adequately controlled by the other measures mentioned above, surgery is the final option. The main surgical option for advanced hip OA is a Total Hip Replacement, which involves replacing the head of the femur and relining the socket. This procedure is a very successful surgical procedure with excellent outcomes but, as with any surgery, there are risks which makes this the last option. You can discuss with your doctor, the risks, benefits and suitability of this procedure for you. It is important to know that a large percentage of those with hip OA never require a hip replacement.

Summary

There are many options for managing the symptoms of hip osteoarthritis. Sometimes people believe that there is nothing that can be done and that they should just wait until the symptoms are bad enough to have surgery. This is simply WRONG!

Evidence suggests that the non-surgical measures for managing hip OA discussed on this page can provide meaningful impacts on pain, function and quality of life. Furthermore, even if surgery is required in the longer term, those who have performed a targeted exercise program prior to surgery are less likely to require extended inpatient rehabilitation5 and have been shown to recover a higher quality of life over the medium term6. A Hip Pain Professional can assist with ‘pre-habilitation’.

A Hip Pain Professional can assist you with your hip OA by providing:

  • Skilled assessment
  • Advice and Education
  • Quality treatment
  • Appropriate Referral
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(1) Harris-Hayes, M. and Royer, N. (2011). Relationship of Acetabular Dysplasia and Femoroacetabular Impingement to Hip Osteoarthritis: A Focused Review. PM&R, 3(11), pp.1055-1067.e1.
(2) Richmond, S., Fukuchi, R., Ezzat, A., Schneider, K., Schneider, G. and Emery, C. (2013). Are Joint Injury, Sport Activity, Physical Activity, Obesity, or Occupational Activities Predictors for Osteoarthritis? A Systematic Review. Journal of Orthopaedic & Sports Physical Therapy, 43(8), pp.515-B19.
(3) Bennell, K. (2013). Physiotherapy management of hip osteoarthritis. Journal of Physiotherapy, 59(3), pp.145-157.
(4) Beumer, L., Wong, J., Warden, S., Kemp, J., Foster, P. and Crossley, K. (2015). Effects of exercise and manual therapy on pain associated with hip osteoarthritis: a systematic review and meta-analysis. British Journal of Sports Medicine, 50(8), pp.458-463.
(5) Rooks, D., Huang, J., Bierbaum, B., Bolus, S., Rubano, J., Connolly, C., Alpert, S., Iversen, M. and Katz, J. (2006). Effect of preoperative exercise on measures of functional status in men and women undergoing total hip and knee arthroplasty. Arthritis & Rheumatism, 55(5), pp.700-708.
(6) Fernandes, L., Roos, E., Overgaard, S., Villadsen, A. and Søgaard, R. (2017). Supervised neuromuscular exercise prior to hip and knee replacement: 12-month clinical effect and cost-utility analysis alongside a randomised controlled trial. BMC Musculoskeletal Disorders, 18(1).

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