What is osteoarthritis of the hip?
The hip joint is formed by the top of the thigh bone and the pelvis. Its primary functions are to support the weight of the body and enable the legs to move. The hip joint consists of a ball at the top of the thigh bone which fits into a socket in the pelvis.
Osteoarthritis (OA) of the hip is a common condition which affects men and women of all ages. The cartilage (which normally cushions the bones in the hip joint) becomes damaged. This inhibits the smooth movement of the joint. The chances of it developing increase with age. It is more likely to develop, or to be more severe, if you are overweight because there is an increased load on the joints. Osteoarthritis sometimes settles down and becomes easier to manage. The reason for this is not known.
How will it affect me?
Stiffness and reduced range of movement are common. There can be periods of either days or weeks when your symptoms are more severe. The pain experienced from OA of the hip may be felt in your lower back, buttocks and groin. You might also feel pain from your hip in your leg and down into your knee. This is called referred pain.
If your hip is badly affected, you may have problems walking and be more likely to have a fall. It can be more difficult to stand up or bend down, making it harder to put on shoes and socks and get in and out of a car. The hip might also ‘lock’ for a few moments. Severe OA of the hip can cause pain when you change positions during sleep. Very commonly, muscles around the joint can waste due to lack of use and become weaker.
Symptoms of Hip Arthritis
Hip joint 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 activities (e.g., walking, standing, or twisting).
Some patients 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.
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. For many of these patients, this “acute” set of symptoms will result in the diagnosis of osteoarthritis.
Early in the course of arthritis, symptoms can be intermittent, perhaps related only to particular activities or sustained activity. Rest and avoiding the precipitating activity will improve the symptoms.
As arthritis worsens, 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. When arthritis is severe, the hip can remain painful even after one stops walking.
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.
Impacts on Daily Life
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.
Many patients 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.
Mobility and independence
Osteoarthritis of the hip 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.
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.
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.
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 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 are sometimes used if the leg length cannot be made equal at the time of hip replacement surgery.
Conditions with similar symptoms
A number of conditions that are not actually related to the hip joint can cause hip joint pain and symptoms in the “hip” area. These include:
Spinal stenosis (arthritis of the lower back)
This condition most commonly causes pain in the buttock, low back, and back of the upper thigh Spinal stenos is a lower-back problem, not a hip problem. Spinal stenosis causes pain in the buttock area that some identify as part of the “hip.”
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 . It also causes tenderness and sensitivity to pressure. Although this seems like a “hip” problem, it is a problem well away from the joint itself and is related to an inflammation in a “lubrication point” called a bursa. Greater trochanteric bursitis is not a joint problem (and only rarely is it a surgical problem).
Very occasionally, non-orthopedic conditions can cause pain in the groin that masquerades as hip joint symptoms – ovarian cysts, hernias, and other intra-pelvic conditions can sometimes cause pain that is mistaken for hip joint pain.
Other types of arthritis
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, affect 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.
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:
- Genetics – Arthritis often runs in families.
- 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.
- 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.
- Variations in hip anatomy (the shape of the hip joint itself) including a condition called femoroacetabular impingement can cause the hip to become arthritic.
- Severe trauma. Fractures (broken bones) or traumatic 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.
- 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 to arthritis of the hips.
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.
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.
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.
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 paracetamol, piroxicam) 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, joint injections generally 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.
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 their arthritic symptoms.
Managing arthritis pain and fatigue
Several approaches can be used to manage the pain associated with osteoarthritis of the hip including:
- Activity modification appropriate kinds of exercise and weight loss when necessary may alleviate some hip arthritis symptoms
- Nutritional supplementation (glucosamine and chondroitin) are helpful to some patients, although the literature on these supplements is not consistently in favor of their use
- Non-narcotic pain tablets (acetaminophen/Tylenol), or over-the-counter non-steroidal anti-inflammatory drugs, if medically appropriate, sometimes are helpful
- Prescription strength, non-steroidal, anti-inflammatory drugs (NSAID) are useful for some patients, though, in general, long-term use of these drugs is discouraged
- Arthritis unloader braces or hip sleeves are helpful for some patterns of arthritis
- Joint injections (corticosteroid or “cortisone” injections) might help
- Total hip replacement surgery may be used if non-operative interventions don’t suffice.
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.
How might exercise help?
Physiotherapy and exercise should be a big part of your treatment. It is important to keep your muscles strong because this will reduce the pressure on your joints. If you are referred to a physiotherapist, you should be provided with a specific exercise programme. It is very important that you follow the programme to give your hip the best chance possible, but keep your physiotherapist updated on how you are finding things.
Muscle strengthening is helpful if you are weak (e.g. have difficulty getting out of chairs). Walking laps in a swimming pool is a good way to strengthen leg muscles. Hydrotherapy likewise can be very helpful because these activities have a low impact on your hips. Walking is also good for exercising the muscles, tendons and ligaments around your hips. If walking is difficult, set yourself reasonable limits on how long you walk. Allow for plenty of breaks to sit down, and try not to overdo it. You may find it best to start with short strides, gradually lengthening the strides as you loosen up. You may also want to try exercising in a class setting as well as at home, as some people find this approach more enjoyable than exercising by themselves. Excess weight creates more stress and pressure for your hips when you are standing, walking, and moving around. Maintaining a healthy weight by combining regular, gentle exercise with a long-term change in your eating habits is the best approach.
It is important to do gentle exercises to maintain your range of movement. A few are described below (each should be repeated several times). Speak to your doctor or a physiotherapist before trying these to find out what might be appropriate for you. Some exercises will not be suitable if you have had a hip or other joint replacement. Only exercises which are within your capabilitiy should be undertaken.
Exercises for range of movement
- Stand, holding onto something firm like a banister or a table. Then slowly sway your leg back and forth in front and behind you.
- Lie on your back with your knees bent and feet together. Then allow your knees to fall outwards to the sides as far as possible.Stretching and strengthening the muscles around your hip is particularly important. The exercises below focus on the muscles around your hip to help maintain stability and strength.
Exercises to strengthen the hips
- Lie on your back on the floor or a firm bed, tighten your thigh muscles and push the back of your knees downwards. Hold for 10 seconds then relax.
- Lie on your back with your knees bent and feet flat, lift your bottom off the floor, squeezing your buttocks together.
- Lie on your side, with your bottom leg bent and top leg in line with your body, tighten the front thigh muscle then lift the top leg about 10 inches away from the floor. Hold then lower. Repeat on the other side.
Many of these exercises can be adapted to be done in water which can help take the pressure off the joint.
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.
Joint injections can be effective at relieving the symptoms associated with osteoarthritis of the hip. Broadly speaking, there are two kinds of injections:
- 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.
- “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, Durolane,and Orthovisc. They are given as a single injection intra-particularly under Image intensifier control. They are FDA approved for treating early osteoarthritis of the hip joint. They function to replace the arthritis synovial fluid, which has low viscosity, with thicker and normal synovial fluid. But when the arthritis has progressed to a stage when there is significant cartilage defects, then Hip replacement is the treatment of choice to regain normal function and activity.