Osteoarthritis of the Hip (Hip Arthritis)

Edited By Seth S. Leopold M.D., Professor, UW Orthopaedics & Sports Medicine Seth S. Leopold	 M.D.

Last updated: February 14, 2011

Contact
If you have any questions regarding Hip Arthritis, feel free to email Seth S. Leopold M.D. at leopold@uw.edu

Overview

Basics of hip arthritis

Many kinds of arthritis can affect the hip joint but by far the most common is osteoarthritis which some people call "degenerative joint disease."

This occurs when the joint surface cartilage (also called hyaline cartilage or articular cartilage) becomes worn away leaving the raw bone beneath exposed. The cartilage normally serves as a “pad” or a bearing in the joint and under normal conditions the cartilage bearing is even slicker than a hockey puck on ice. When the bearing wears away, the result is a roughed joint surface that causes the pain and stiffness that people associate with osteoarthritis (See Fig 1 Fig 2 Fig 3 & Fig 4).

For most patients who have only mild arthritis the pain can be managed with simple things such as ice, rest, activity modifications, pills or joint injections.

However if the arthritis becomes severe, the pain may not respond to those kinds of interventions. Patients with severe arthritis sometimes can benefit from total hip replacement surgery (See Fig 5 and Fig 6).

Immediate medical attention

Osteoarthritis of the hip is not an emergency. It can however result in disturbing “flare ups ” with increased pain and stiffness. Many patients who experience a sudden flare-up will go to the doctor for care and for many patients, this apparently “acute” set of symptoms will result in the diagnosis of this chronic condition.

Typical symptoms of hip arthritis include pain in the groin, thigh or buttock; the pain is generally worse with weight bearing (walking, standing) or twisting.

Facts and myths


MYTH: Osteoarthritis of the hip is not usually the result of “overuse.” there have been studies of long-distance runners that show that they are not more likely to get arthritis than more sedentary individuals.

MYTH: Osteoarthritis of the hip is not a “normal result of aging.” Many older people – in fact most – don’t develop arthritis of the hip and many younger people do experience osteoarthritis.

MYTH: Osteoarthritis of the hip is not just “aches and pains.” It is a condition whose biology, x-ray appearance and clinical symptoms are defined.

MYTH: Not much can be done for osteoarthritis of the hip. In fact there are exercise programs that can alleviate the pain in mild arthritis, a variety of medications can be helpful for moderate arthritis, and severe arthritis of the hip is very commonly successfully treated with hip replacement surgery.

Prognosis

Osteoarthritis of the hip is a serious condition. Osteoarthritis is the most common of the more than 100 kinds of arthritis and the hip joint is the second most commonly affected large joint in the body.

Osteoarthritis of the hip results in pain, stiffness and joint deformity which can affect one’s ability to walk work and enjoy life.

It is a chronic disease meaning that it takes months to years to appear; while it is not “curable”, it most certainly is treatable using activity modifications, medications, injections and if those interventions don’t work, hip replacement surgery often will relieve the pain associated with hip arthritis.

Lethality

Osteoarthritis of the hip is not deadly.

Pain

Osteoarthritis of the hip indeed can and usually does cause pain. Other symptoms include swelling, stiffness, sometimes warmth and joint deformity.

The typical pain from hip arthritis is located in the groin, thigh or buttock; the pain is generally worse with weight bearing (walking, standing) or twisting.

Debilitation

Osteoarthritis of the hip is progressive and when it becomes severe, it indeed can severely affect one’s ability to walk, climb stairs, enter or exit a vehicle, sit or arise comfortably, engage in sexual intercourse and enjoy one’s day-to-day activities.

Click to Enlarge
Figure 1 - drumstick	 cartilage; the white (or slightly yellow) smooth surface capping the end of the bone.
Figure 1 - If you have
ever eaten a drumstick,
you have seen cartilage;
it is the white (or slightly yellow)
smooth surface capping
the end of the bone.
Click to Enlarge
Figure 2 - normal X-ray of the hip
Figure 2 - This is a
normal X-ray of the hip
Click to Enlarge
Figure 3 - Joint with normal hip cartilage
Figure 3 - Joint with
normal hip cartilage
Click to Enlarge
Figure 4 - Joint with arthritic hip cartilage
Figure 4 - Joint with
arthritic hip cartilage
Click to Enlarge
 Figure 5 - Typical hip replacement components.
Figure 5 - Typical
hip replacement components.
Click to Enlarge
 Figure 6 - Typical hip replacement components in their position relative to the hip and pelvis.
Figure 6 - Typical
hip replacement components
in their position relative
to the hip and pelvis.

Curability

However while it is not “curable”, it most certainly is treatable using activity modifications, medications, injections and if those interventions, don’t work hip replacement surgery often will relieve the pain associated with hip arthritis.

Fertility and pregnancy

Osteoarthritis of the hip can cause sexual intercourse to be uncomfortable in some patients. However apart from that, it will not affect a patient’s ability to get pregnant or have children. It is important to note though that some medications used to treat arthritis need to be used with care (or not at all) during a pregnancy. It is important to inform one’s obstetrician and family physician about all medications and nutritional supplements that one takes.

Mobility and Independence

Osteoarthritis of the hip indeed can affect one’s ability to walk, climb stairs, enter or exit a vehicle and enjoy one’s day-to-day activities. These things do affect one’s ability to remain independent particularly as the disease reaches its more severe stages.

Daily activities

Osteoarthritis of the hip can affect one’s ability to walk, climb stairs, enter or exit a vehicle, sit or arise comfortably, perform housework and enjoy one’s day-to-day activities.

Even mild to moderate osteoarthritis of the hip can adversely impact athletic performance and enjoyment of sports, particularly impact sports and sports that involve running.

Although there is little “hard science” on this point, most hip surgeons and rheumatologists (doctors who treat arthritic conditions non-operatively) believe that patients with osteoarthritis of the hip should consider avoiding impact sports such as running in order to avoid increasing the rate at which the disease progresses.

Energy

Many patients indeed find that the chronic pain associated with osteoarthritis of the hip does contribute to fatigue.

Osteoarthritis of the hip does not affect metabolism but some patients attribute weight gain to the inactivity that results from the hip pain caused by osteoarthritis of the hip.

It is important that patients with osteoarthritis of the hip avoid decreasing their activity level and it is important that they remain fit. However this often does require some modification of exercise programs – running and walking programs are usually poorly tolerated by (and not recommended for) patients with osteoarthritis of the hip. Stationary bike, swimming and water aerobics usually are well-tolerated and they are recommended.

Diet

Diets do not cure or treat osteoarthritis so far as we know. However it is important to try to avoid weight gain when one has osteoarthritis of the hip as increased body weight is associated with worsening of symptoms.

Relationships

Osteoarthritis of the hip can affect relationships and social interactions to the extent that it makes getting around more difficult. In some patients with more severe hip arthritis, sexual intercourse can be uncomfortable because of the pain associated with moving the hips that accompanies the condition.

Other impacts

Osteoarthritis of the hip is not contagious and doesn’t predispose one to other diseases or conditions.

Osteoarthritis of the hip is associated with joint deformity that sometimes results in a leg-length inequality. These joint deformities including leg-length inequality are not readily managed by interventions other than surgery, but can be sometimes be corrected at the time of hip replacement for patients who elect to have that surgery. Shoe lifts can help patients before surgery who have leg-length inequalities and they are sometimes used if the leg length cannot be made equal at the time of hip replacement surgery.

Incidence

It is not possible to predict who will get osteoarthritis of the hip. However there are some risk factors that may increase the likelihood that hips will become arthritic. These risk factors include:

  1. Genetics. Arthritis often runs in families.
  2. Childhood hip diseases including developmental hip dysplasia (DDH), Legg-Calve-Perthe’s Disease and slipped capital femoral epiphysis (SCFE) all can predispose an individual to premature hip arthritis.
  3. Acquired conditions such as avascular necrosis (osteonecrosis) can result in hip arthritis if left untreated or if treatment fails.
  4. Variations in hip anatomy (the shape of the hip joint itself) including a condition called femoroacetabular impingement can cause the hip to become arthritic.
  5. Severe trauma. Fractures (broken bones) or traumatic dislocations of the ball from the hip socket can increase the likelihood of hip arthritis.
  6. Obesity. Some studies have associated this condition with arthritis of the hips though interestingly obesity is more strongly linked to arthritis of the knees than it is to arthritis of the hips.

Acquisition

Osteoarthritis is not caused by an infection though severe bacterial infections certainly can cause “post-infectious arthritis ” which is in many ways even worse than osteoarthritis of the hip.

There are some risk factors that may increase the likelihood that hips will become arthritic. These risk factors include:

  1. Genetics. Arthritis often runs in families.
  2. Childhood hip diseases including developmental hip dysplasia (DDH) Legg-Calve-Perthe’s Disease and slipped capital femoral epiphysis (SCFE) all can predispose an individual to premature hip arthritis.
  3. Acquired conditions such as avascular necrosis (osteonecrosis) can result in hip arthritis if left untreated or if treatment fails.
  4. Variations in hip anatomy (the shape of the hip joint itself) including a condition called femoroacetabular impingement can cause the hip to become arthritic.
  5. Severe trauma. Fractures (broken bones) or traumatic dislocations of the ball from the hip socket can increase the likelihood of hip arthritis.
  6. Obesity. Some studies have associated this condition with arthritis of the hips though interestingly obesity is more strongly linked to arthritis of the knees than itis to arthritis of the hips.

Genetics

Some arthritis indeed appears to run in families.

Communicability

Osteoarthritis of the hip is not contagious.

Lifestyle risk factors

There are three important “environmental” risk factors associated with arthritis of the hip. These are:

  1. Severe trauma. Fractures (broken bones) and traumatic dislocations of the ball from the hip socket both increase the likelihood of hip arthritis.
  2. Acquired conditions such as avascular necrosis (osteonecrosis) can result in hip arthritis if left untreated or if treatment fails. Avascular necrosis can be caused by excessive alcohol intake some medications (including prednisone a medical steroid) and some medical conditions that affect blood clotting.
  3. Obesity. This is associated with arthritis of the hips in some studies on the subject although interestingly obesity appears to be more tightly linked to arthritis of the knees than arthritis of the hips.

Injury & trauma risk factors

Severe trauma including fractures (broken bones) and dislocations of the ball from the hip socket can in time result in arthritis of the hip. Whether this really is “osteoarthritis” or should be considered a separate kind of arthritis (post-traumatic arthritis) remains an open question though in the severe stages of this condition the treatments are the same.

Prevention

By maintaining an ideal body weight and avoiding severe trauma to the hip it is possible to minimize the risk of arthritis. However many patients with osteoarthritis are slender and have never severely injured their hips so there is no “guaranteed” way to avoid getting this condition.

Anatomy

Osteoarthritis of the hip occurs when the joint surface cartilage (also called hyaline cartilage or articular cartilage) becomes worn away leaving the raw bone beneath exposed. The cartilage normally serves as a "pad" or a bearing in the joint and under normal conditions the cartilage bearing is even slicker than a hockey puck on ice. When the bearing wears away the result is a roughed joint surface that causes the pain and stiffness that people associate with osteoarthritis.

The typical pain from hip arthritis is located in the groin thigh or buttock; the pain is generally worse with weight bearing (walking standing) or twisting.

Initial symptoms

Pain and stiffness are the main symptoms of hip arthritis. When it becomes more advanced joint deformities and leg-length differences can result.

The typical pain from hip arthritis is located in the groin thigh or buttock; the pain is generally worse with weight bearing (walking standing) or twisting.

Symptoms

Pain stiffness and joint deformity are the main symptoms of arthritis of the hip. Some patients in particular report "start-up" pain – an especially bad discomfort upon standing after being seated for a prolonged period of time. This sometimes works itself out after a few steps.

The typical pain from hip arthritis is located in the groin thigh or buttock; the pain is generally worse with weight bearing (walking, standing) or twisting.

Progression

Early in the course of arthritis the symptoms can be intermittent perhaps related only to particular activities or sustained activity. At that point usually rest and avoiding the precipitating activity will improve the symptoms.

The typical pain from hip arthritis is located in the groin, thigh or buttock; the pain is generally worse with weight bearing (walking standing) or twisting.

As the arthritis worsens, the symptoms can become more persistent or more severe such that simply walking on level ground can result in pain.

When arthritis is severe the pain with activities can linger even after the activity stops such that the hip can remain painful even after one stops walking.

Conditions with similar symptoms

A number of conditions that are not actually related to the hip joint can cause symptoms in the "hip" area. These include

  1. Spinal stenosis (arthritis of the lower back). This condition most commonly causes pain in the buttock low back and back of the upper thigh (See Fig 7). This condition is really a lower-back problem not a hip problem even though people identify the buttock area as part of the “hip.”
  2. Greater trochanteric bursitis. This causes pain over the “point” of the hip (imagine the part of the hip that would touch the ground if one were to lie directly on one’s side (See Fig 8). It also causes tenderness and sensitivity to pressure. Although this too seems like a “hip” problem it is a problem well away from the joint itself related to an inflammation in a “lubrication point” called a bursa and is not a joint problem (and only rarely is it a surgical problem).
  3. Very occasionally non-orthopedic conditions can cause pain in the groin that masquerade as hip joint symptoms – ovarian cysts hernias and other intra-pelvic conditions can sometimes cause pain that is mistaken for hip joint pain.
Click to Enlarge

Figure 7 - Hip pain
in the lower back
and/or buttocks area
is often from spinal
stenosis (spine arthritis)
rather than from
the hip joint itself.
Click to Enlarge

Figure 8 - Hip pain
over the outside of the hip
is often from bursitis
which not related to
arthritis of the joint at all.

In addition other forms of arthritis can cause similar symptoms to osteoarthritis of the hip; in particular post-traumatic arthritis and avascular necrosis (osteonecrosis) are almost indistinguishable in many cases from osteoarthritis of the hip.

Rheumatoid arthritis the next most common cause of arthritis can also affect the hip. It tends to cause other joints to be involved and often causes more of an inflammatory set of symptoms (swelling and warmth as well as pain) and can in fact effect other organ systems as well.

The diagnosis of osteoarthritis versus rheumatoid arthritis can be made by a physician with experience in treating conditions of this type.

Effects

Pain and stiffness are the main symptoms of hip arthritis. When it becomes more advanced joint deformity (including leg-length inequality) can occur.

As the condition worsens it often becomes less responsive to medical treatments such as pills or injections.

In many patients with advanced arthritis particularly if those medical approaches are no longer helpful surgery can offer relief of symptoms. Some patients with severe osteoarthritis sometimes can benefit from total hip replacement surgery.

Diagnosis

To diagnose osteoarthritis of the hip, a physician will take a thorough history and perform a thorough physical examination first. Following this simple x-rays taken with the patient standing are an effective way to diagnose this condition.

Diagnostic tests

The simplest test to diagnose osteoarthritis of the hip is the x-ray. Taken with the patient standing up plain x-rays can diagnose the condition with great accuracy.

Very mild arthritis can be seen on a bone scan or an MRI even before it is visible on plain x-rays but in reality these tests are seldom helpful clinically for this purpose.

Effects

The diagnostic tests for osteoarthritis of the hip including x-rays and MRIs are generally not painful and they are well-tolerated by most patients.

Health care team

Osteoarthritis of the hip is common and generally straightforward to diagnose. Family physicians, internists, orthopedic surgeons, rheumatologists and physiatrists often are the ones who make the diagnosis of osteoarthritis of the hip.

Finding a doctor

Both rheumatologists and orthopedic surgeons are “specialists” in arthritis care.

If surgery is being considered to manage osteoarthritis of the hip, visiting with a fellowhip-trained high-volume hip replacement surgeon would be a reasonable step to consider.

Treatment

Simple steps that can be taken which don’t have much risk include avoidance of the activities that cause symptoms (activity modification) and weight loss (if appropriate). Some patients find nutritional supplements such as glucosamine and chondroitin to be helpful; however the data on these products is somewhat inconsistent. They don’t help everyone.

Should those interventions not be satisfying in consultation with one’s physician the next steps might include over-the-counter pain remedies such as acetaminophen (Tylenol) and over-the-counter anti-inflammatories such as ibuprofen (Advil Motrin) or naproxen (Naprosyn) among others. However these pills are not for everyone and if one hasn’t used them before one should consider consulting one’s family physician first. Sometimes prescription-strength non-steroidal anti-inflammatory drugs (NSAIDs) can be prescribed but again this must be done in consultation with a physician and these drugs do have risks and side effects associated with them.

In general narcotic pills (“painkillers” like Tylenol #3 Vicoden Percocet oxycodone) and narcotic pain patches (fentanyl Duragesic) should be avoided for most patients with osteoarthritis of the hip.

Joint injections including intra-articular corticosteroid injections can be helpful for some patients; however in general these appear to be less useful for hip arthritis than they are for arthritis in other joints in part because of the difficulty of injecting the hip joint accurately.

Patients with severe arthritis who have tried the above remedies sometimes can benefit from total hip replacement surgery.

Self-management

Keeping one’s body weight appropriate and choosing activities that don’t reproduce the arthritic pain are two things patients with osteoarthritis of the hip can do to help decrease the arthritic symptoms.

Health care team

Several kinds of health care providers participate in the management of osteoarthritis of the hip including:

  1. Family physicians and internists
  2. Rheumatologists
  3. Physical Medicine and Rehabilitation Specialists (Physiatrists)
  4. Orthopedic Surgeons

Pain and fatigue

Several approaches can be used to manage the pain associated with osteoarthritis of the hip including:

  1. Activity modification appropriate kinds of exercise and weight loss when necessary may alleviate some hip arthritis symptoms
  2. Nutritional supplementation (glucosamine and chondroitin) are helpful to some patients although the literature on these supplements is not consistently in favor of their use
  3. Non-narcotic pain tablets (acetaminophen/Tylenol) or over-the-counter non-steroidal anti-inflammatory drugs if medically appropriate sometimes are helpful
  4. Prescription strength non-steroidal anti-inflammatory drugs (NSAID) are useful for some patients though in general long-term use of these drugs is discouraged
  5. Arthritis unloader braces or hip sleeves are helpful for some patterns of arthritis
  6. Joint injections (corticosteroid or “cortisone” injections) might help
  7. Total hip replacement surgery may be used if non-operative interventions don’t suffice.

Diet

Keeping one’s weight proportional to one’s height can decrease the likelihood of developing osteoarthritis of the hip and can decrease the symptoms of the condition once it has set in.

Exercise and therapy

There is some limited evidence that appropriately-designed exercise programs can decrease the pain of hip arthritis in particular earlier stages of the condition. In general staying fit and height-weight proportional also are helpful.

Medications

  1. Nutritional supplementation (glucosamine and chondroitin) are helpful to some patients although the literature on these supplements is not consistently in favor of their use
  2. Non-narcotic pain tablets (acetaminophen/Tylenol) or over-the-counter non-steroidal anti-inflammatory drugs if medically appropriate sometimes are helpful
  3. Prescription strength non-steroidal anti-inflammatory drugs (NSAID) are useful for some patients though in general long-term use of these drugs is discouraged
  4. Joint injections (corticosteroid or “cortisone” injections) might help

Narcotic painkillers whether in pill form (oxycodone Tylenol #3 Vicoden Percocet Lortab etc. or patch form (Duragesic fentanyle etc.) in general should be avoided for the treatment of osteoarthritis of the hip.

Surgery

Hip replacement is a surgical procedure that decreases pain and improves the quality of life in many patients with severe arthritis of the hips. Typically patients undergo this surgery after non-operative treatments (such as activity modification anti-inflammatory medications or hip joint injections) have failed to provide relief of arthritic symptoms. Surgeons have performed hip replacements for over four decades generally with excellent results; most reports have ten-year success rates in excess of 90 percent. Total hip replacement surgery is covered in much greater detail elsewhere on this educational website.

Joint aspiration

Joint injections can be effective at relieving the symptoms associated with osteoarthritis of the hip. Broadly speaking there are two kinds of injections:

1. Corticosteroid injections ("cortisone shots") These injections have been used to relieve arthritis symptoms--including pain swelling and inflammation--for over 50 years. Despite this there have been surprisingly few well-designed scientific studies to determine which patients might benefit from this treatment or how long the relief might last.

Just the same cortisone shots are commonly used--and often are successful--in helping to relieve arthritis symptoms temporarily. Some patients are able to use them to get enough pain relief to hold off joint replacement surgery for months or even years. Cortisone shots are a treatment for pain; they do not alter the course of arthritis and they do not cure the condition. In general they are more commonly used for arthritis of other joints than they are for arthritis of the hip joint.

2. "Viscosupplement" injections. These are any of several compounds that are made up of hyaluronic acid which is a component of normal joint fluid. Some of the common ones include Synvisc Hyalgan Supartz and Orthovisc. They are given as a series of injections usually weekly for 3-5 weeks. There is some disagreement as to how and whether they work.  Read more details on JBJS Article - Corticosteroids VS. Hylan GF20 in pdf format (0.13MB). They are FDA-approved for managing the pain associated with arthritis of the knee but they are not as of December 2007 FDA-approved for use in the hip joint.

Splints or braces

Braces and splints are not generally effective for management of hip arthritis.

Hip arthritis patients who have perceptible leg-length inequalities can be managed with a shoe lift either inside the shoe (typically if the difference is <1/4”) or built onto the outside of the shoe (if the difference is larger).

Alternative remedies

Nutritional supplementation (glucosamine and chondroitin are the most common forms of this) is helpful to some patients though the science on this is not entirely supportive of their effectiveness.

There are some studies to suggest that acupuncture can decrease the pain associated with osteoarthritis of the hip.

Work

Looking for a "light duty" alternative to heavy manual labor is one good approach for coping with osteoarthritis of the hip.

Many patients who work at desks find that prolonged sitting in one position is associated with stiffness and pain upon first arising so periodically standing stretching or moving the hip through an arc of motion can be helpful at minimizing this “start-up” pain.

Adaptive aids

For some patients particularly those who cannot tolerate surgical interventions for medical or other personal reasons use of a cane crutches or a walker can be of use.

Resources

For more information about arthritis contact the Arthritis Foundation (www.arthritis.org).

For more information about orthopedic surgery contact the American Academy of Orthopedic Surgeons (www.aaos.org).

Condition research

Medical researchers continue to look into the causes and best treatments for symptoms of osteoarthritis of the hip which is very common and sometimes disabling.

Pharmaceutical research

There is considerable research being done into the medical management of osteoarthritis. Recently increasing awareness of the complications and problems associated with use of non-steroidal anti-inflammatory drugs (NSAIDs) including effects on the kideys the stomach and the heart.

Surgical research

There is considerable research being done studying the surgical approaches for this condition including newer approaches for total hip replacements and newer implants.

Other surgical interventions including osteotomy (cutting and re-orienting the bones around the hip) and arthroscopy (using a surgical camera and small motorized shavers to "clean up" the raw bone ends) also are topics of surgical research that may someday be relevant to patients with hip arthritis.

Summary of hip arthritis

  1. Osteoarthritis of the hip is common and can result in severe pain and disability; as a result of this condition several hundred thousand people each year in the U.S. undergo total hip replacement.
  2. Most people with osteoarthritis of the hip can be managed without surgery.
  3. The cause of osteoarthritis of the hip is not known but some risk factors include obesity severe hip trauma acquired conditions in adulthood such as osteonecrosis (avascular necrosis) and genetics.
  4. There are many other kinds of arthritis that can affect the hip; it is important to make sure that the correct diagnosis is made as some of these other conditions are treated very differently.
  5. The diagnosis of osteoarthritis of the hip is usually very straightforward and is made in almost all cases by a physician taking a thorough history performing a physical examination and getting x-rays with the patient standing up. Patients usually seek care for the typical symptoms of hip arthritis including pain located in the groin thigh or buttock; the pain is generally worse with weight bearing (walking standing) or twisting. Stiffness and leg-length inequality are other symptoms.