Hip Osteoarthritis (OA)

Where is it painful for a patient with Hip OA?


Classical patient features for Hip OA

Age: vast majority > 60 years old // each year the prevalence increases

Gender: female > male

Activity: highest prevalence with sedentary individuals

Sport: marathon runners have higher prevalence, no link with recreational runners // if anything reduced prevalence

Area of symptoms for Hip OA

– deep in the groin

– deep in the buttock

– can refer down the buttock and as low as the knee however commonly localised

Characteristics of symptoms for a client with Hip OA

– stiffness

– deep ache

– Patient reports: clicking, clunking, grinding, catching

Typical activity capability/restriction for Hip OA

– activities with large hip ranges or high levels of hip muscle recruitment become progressively more difficult including walking, running, bending, transferring, stairs, ramps

– patients have commonly made autonomous adaptations continue to perform activities of daily living

– common for patients to be deconditioned locally and remotely

Behaviour of symptoms for Hip OA

Aggs: walking, running, bending, transferring, stairs, ramps

Ease: Heat, exercise (whilst performing it), NSAIDs

24 hour: Morning stiffness < 30min, stiffness following activity

Typical history for a client with Hip OA

– Insidious onset

– progressive in nature

– may have other joint involvement (ask about knees)

Pathobiological mechanisms underlying Hip OA

– Plausible nociceptive mechanism on initial presentation

– Due to the insidious and progressive nature of symptoms patients likely have some nociplastic pain components

– Enquire about how the patient is coping especially with activities of daily living

– Understand patients beliefs about what the problem is and when they might need // some patients will have strong the surgical preferences for intervention competitively to rehab

Proposed pathology for Hip OA

Can have a pathogenic trigger

– could be in the form of mechanical stress or an abnormal biochemical environment

– Collagen matrix at the joint can become disorganized // cartilage degradation and then eventually subchondral bone degrades

– Osteophytes can develop in reaction to this

– reduction in joint space

– Reduced proteoglycans

– Reduced water content

– Increased inflammatory reaction

Physical impairments & associated structure/tissue sources (ie P/E findings)


– restricted ROM (AROM and PROM) capsular pattern (IR and flexion will be first to show signs of deterioration)

– positive FABER

– reduced strength all hip muscles

– muscle wastage

– differentiation: pain with compression, relief with distraction

– position: pain in closed packed and rief in open packed


– look for involvement of other joints (ie knees)

– muscle wastage

– reduced balance/proprioception


– functional decline

– deconditioning

– falls history



Typical contributing factors for Hip OA

– Age // increased every year

– Hip dysplasia

– History of FAI

– Previous surgery at the hip

– Weight (likely metabolic influences)

– Genetics

– Diabetes (metabolic influences)

– History of inflammatory conditions (RA, AS)

– menopause

– diet

– previous hip dislocation

Relevant precautions/ contraindications to P/E and treatment

– questions regarding comorbidities needed to be asked prior

– if evidence for subchondral bone loss or neck of femur fracture indicated // send for imaging prior

– if the acute incident (especially if the patient has a fall) // send to hospital for further investigations

Relevant diagnostic imaging for Hip OA

– x-ray sufficient to observe joint changes

– note that levels of degradation and pain do not have a close association

– if less than 2mm joint space then send for surgical opinion // does not mean that surgery is indicated however

– MRI: due to increased detail will be better able to establish changes in the early onset

Typical prognosis for Hip OA

Surgical management (high-level evidence)

– favourable outcome in 77-93% of cases

Conservative (high-level evidence)

– exercise therapy + education reduced the risk of surgery by 44% in hip OP patients

– exercise pre-op improved pain, range, QOL

Management/treatment selection for Hip OA

Monitoring patients with hip OA (high-level evidence)

– hip dysfunction and OA outcome score (HOOS) has been validated

Symptom management

– Triage and referral for a surgical opinion if necessary

– unload through activity changes

– refer to Dr for review of medications (high-level evidence)

Exercise (high-level evidence)

– exercise in the initial phase can be used for pain relief

– increase the load as able

– Want to strengthen locally and then incorporate into full body

Joint mobilisation (high-level evidence)

– RCT with mobs + exercise vs exercise. No difference in outcome measures functionally however patients had higher satisfaction when MT was used for the patients

– Individualize for patient

– makes sense that the patient would get some benefit (especially longitudinal and laterally directed glides)

– note: clear serious pathology prior to mobilisation

Total hip replacement (high-level evidence)

– showed operation had significant benefit mid/long term

– Indications for surgical opinion: if less than 2mm joint space, failed conservative management and if the patient has high levels of pain and disability

Hip arthroscopy (low levels evidence)

– only shown to have small temporary benefits

– very high conversion rates ~90% to THR

NSAIDs (high-level evidence)

– effective for pain relief in 60% of patients

CSI (high-level evidence)

– 1-month significant increase in pain and function

– in mild cases more effective (75-90%) compared to severe cases (9-20%)

Hydrotherapy (high-level evidence)

Differential diagnosis for Hip OA

NOF // need a scan to rule out if trauma

FAI // subjective questioning and imaging as required

GT/ GT bursitis// palpation and dynamic assessment

Cancer // special questions

Infection // special questions

muscle strain (groin, hip flexor, hamstring, glutes) // dynamic assessment

labral pathology // special questions

Sciatica // positive neuropathic signs and neurological symptoms

Referral from lumbar spine // lumbar spine assessment

ligamentum teres // trauma, instability, avascular necrosis or vascular signs


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