The encouraging truth about Hip Osteoarthritis

Hip osteoarthritis (often referred to as “hip OA”) describes a long, very gradual process that affects the osteochondral (hard) cartilage of the hip joint.

Signs of hip OA can be present on imaging, like X-ray and MRI, from 30 years of age, depending on your activity levels, bodyweight and body morphology.

Despite these early signs of OA on scans, it doesn’t tend to be symptomatic until age 40-50 years.

As a Physiotherapist, I get frustrated with the many myths floating around about OA.

“If you’ve got hip osteoarthritis, you’ll need a hip replacement”

“The damage will never go away so you just have to live with the pain”

“If it hurts, you shouldn’t be walking on it”

“It’s because you run too much”

You can’t reverse the internal structural changes but you can reverse the symptoms and get back to pain-free exercise.

That’s because the pain doesn’t come from the cartilage degeneration, it comes from the irritation of these patches of degeneration.

It’s an important distinction to make, and easier to comprehend with an analogy.

Think of a road surface (= joint cartilage) with a pothole (= worn patch) on the edge of the road. That pothole doesn’t bother anyone (= cause pain) simply because it exists.

One day, you decide to drive a little wild and you’re all over the road (I’ll let you make up the reason for the crazy driving…). It’s the equivalent of a fatiguing day of walking, or carrying heavy items, or staying in a crouched position for a period of time.

That out-of-the-ordinary loading hits the pothole on occasion – now you start to notice the pothole (= causing pain).

So let’s go through what hip osteoarthritis feels like, how it progresses and what you can do about it.

What does hip osteoarthritis feel like?

Hip osteoarthritis can cause a wide variety of symptoms, making it hard to describe a “classic” case of hip OA.

So when we get asked “what does a bad hip joint feel like?”, we’ll tend to give a list of possible symptoms rather than a clearly defined pattern of symptoms.

The pain is typically felt deep, so you can’t put your finger on the exact location of it.

It often has a dull aching quality to it, but may still have the occasional sharp or stabbing pain.

Where is hip arthritis pain felt?

Pain from hip osteoarthritis can shift around and be felt in some strange locations, making it difficult to tell if it’s actually your hip playing up.

The pain is commonly felt in the groin, front of hip, side of hip or in the buttock. It can even move around between those locations with different episodes of the pain, so it’s not even consistent for an individual.

However it doesn’t refer pain up to your lower back – that’s usually due to lower back issue that’s been irritated by the hip stiffness or the way you’re moving.

And it doesn’t radiate down the leg into your calf and foot – that’s usually a nerve irritation in the buttock or in the lower back.

What aggravates hip arthritis symptoms?

Hip osteoarthritis doesn’t like the extremes of movement and exercise.

It can become painful if it’s pushed to the end of range. This can typically happen during exercise classes (like Pilates) or getting up/down off the floor (like playing with small children).

It can also become painful with too much OR TOO LITTLE exercise within a day.

Too little exercise causes the joint to stiffen up and become painful. That’s not to say that you can’t have a day off, just that you can’t have too many lazy days in a row.

Too much exercise tends to cause muscle fatigue which reduces control of the movement and leads to irritation (see our crazy driving analogy above).

This only applies to exercise where muscle fatigue leads to loss of technique, such as running and walking. Exercises that have controlled movement regardless of fatigue, such as cycling, aren’t as prone to flare ups from overload.

Note that the level of exercise deemed “too much” is specific to the individual. For some, too much is a 60 minute walk. For others, a 20km run is still within normal levels. It’s all relative to your level of training and experience.

What are the 4 stages of osteoarthritis?

Osteoarthritis is divided up into four “stages”, but these aren’t really distinct progressions. You don’t suddenly move from a stage 1 to a stage 2 overnight.

The stages relate to the presence of 4 signs of hip osteoarthritis on imaging – loss of joint space, bony spur formation (called osteophytes), small divots forming under the cartilage (called subchondral cysts) and breakdown of the bone under the cartilage (called sclerosis).

The “stage” of osteoarthritis is defined as the number of changes present on X-ray – if you have bone spurs and a loss of joint height, but no cysts or sclerosis, you have stage 2 or grade 2 OA.

It’s definitely worth highlighting that the stage of OA has no bearing on the clinical presentation (ie. the way you feel and move).

I’ve personally treated long distance runners with very mild symptoms that have stage 4 OA on X-ray.

What is considered severe osteoarthritis?

“Severe” hip osteoarthritis could be defined as having all four changes present on X-ray or it may be defined as having severe symptoms.

What are the early signs of hip arthritis?

Remember that osteoarthritis is a very gradual process – you don’t wake up one day and you’ve got it.

So the earliest signs of hip osteoarthritis tend to identified retrospectively. Once you know that your symptoms are hip OA, you can often look back and think “I wonder if that hip thing I had two years ago was actually the first signs of OA?”

Early symptoms include morning stiffness after a more active day of exercise or activity, when you’ll wake up and it takes a while for you to comfortably reach your shoelaces.

You’ll also notice pain after rest particularly if you’ve been sitting in the same position for a long period of time, like a plane flight or car drive.

How do I know if I have osteoarthritis in my hip?

The only way to confirm hip osteoarthritis is with an X-ray, CT or MRI scan of the hip.

It’ll show some of the signs we identified above and confirm the extent of the changes within the hip joint cartilage and surrounds.

How serious is osteoarthritis of the hip?

You’ll often hear the line from doctors that “you’ll eventually need a hip replacement”.

Technically we’ll all need a joint replacement if we live to 200, but this doom and gloom phrase doesn’t take into account all the effective strategies that can manage hip osteoarthritis.

For most people, the non-surgical approaches work really well. And as we age and the hip osteoarthritis gradually progresses, the demands on the hip reduce so the symptoms remain manageable.

What are the symptoms of severe hip arthritis?

In its most severe form, hip osteoarthritis has a combination of severe morning stiffness, reduced range of motion and significant pain.

The cycle of symptoms tends to be that the pain limits activity, the lack of activity limits range and the reduce range worsens the stiffness. More stiffness causes more pain, and so the story goes.

The key to breaking that cycle is in disrupting one or more of those steps. If you can improve range or reduce pain and stiffness, that downwards spiral becomes an upwards trend.

In a small number of cases, breaking the cycle isn’t successful and surgery becomes the best option.

For those considering surgery, here are the most common questions we get asked (and our answers).

“What is end stage osteoarthritis hip?”

End stage OA is based on imaging findings. It doesn’t directly relate to symptoms but end stage OA tends to be more symptomatic and more prone to flare ups.

“Can bone on bone hip arthritis be reversed?”

The phrase “bone on bone” can be quite misleading and rather dramatic.

The ends of the bone are covered in a durable layer of hard cartilage (called osteochondral cartilage). In severe OA, a portion of that surface is compromised so that the underlying bone is exposed.

In most OA, the degeneration affects one side of the joint more than the other.

So a more accurate phrase might be “I’ve got a small patch of bone on cartilage”, but that doesn’t sound nearly dramatic enough, right?

“What is the life expectancy of a person with osteoarthritis?”

This one is an understandable concern given that severe hip osteoarthritis tends to affect the elderly most.

While osteoarthritis doesn’t directly shorten life expectancy, it can reduce daily levels of activity if it’s not effective treated and that can have serious health consequences.

How fast does osteoarthritis of the hip progress?

The rate of progression of hip osteoarthritis depends on the presence of a number of risk factors.

Despite the presence of multiple risk factors, it’s still a very slow progression. It usually takes a decade or more to see evidence of more changes on imaging.

From the first appearance of hip osteoarthritis on scans to stage 4 hip OA, it often takes 25-30 years.

What can make osteoarthritis worse?

Risk factors for early hip osteoarthritis include heavier body types and reduced leg strength. There’s also a sedentary lifestyle and sporadic levels of activity (eg. run a marathon, then have a few months of nothing, then run another marathon).

How quickly does osteoarthritis spread?

Once hip osteoarthritis is evident on one part of the joint surface, it can gradually progress in both depth (into the cartilage) and coverage (across the cartilage).

Abnormal movement patterns due to flare ups of the hip OA symptoms often causes additional wear on other aspects of the joint and accelerates the spread of OA.

Reducing the number and duration of episodes is the key to minimising the spread of OA.

What helps with osteoarthritis in the hip?

A short course of anti inflammatory meds can help you overcome the symptoms to get started on a strength program. Medication shouldn’t be used in isolation as it works much more effectively when used in conjunction with exercise.

For any medication, particularly anti-inflammatory use for prolonged periods, we recommend speaking to your doctor or pharmacist.

Reducing body weight makes a huge difference. With up to 8x your body weight impacting your joint during some activities, every 1kg of bodyweight lost takes 8kg of pressure off the joint.

There are also support organisations to help with everything from advice on management to sharing your experiences with hip osteoarthritis with others.

Is walking good for osteoarthritis of the hip?

Walking is one of the best activities for hip osteoarthritis. It’s gentle but helps maintain joint movement and cartilage health, along with numerous other benefits.

Which exercise is best for the hip with osteoarthritis?

The number 1 question we get asked is “What is the best exercise for osteoarthritis?”

The simple answer is to aim for a little more than what you can do now and find a form of exercise that you can continue doing, even during a flare up. For example, hiking is great and you can always use hiking poles if the hip OA becomes symptomatic.

You also MUST MUST MUST focus on strength. When it comes to the most proven, effective management approach to hip osteoathritis, leg strength is King!

Getting stronger improves control of the hip and reduces the adverse loading patterns that are irritating the joint cartilage.

Is running bad for arthritis?

Running doesn’t wear away your joints quicker. It’s been studied and proven countless times.

In fact, your joint quality is better with running if you’ve always been a runner (those who start later in life don’t get the same benefits) and your running load is consistent (ie. no long breaks and sudden increases in volume).

Running is great for joint and bone health and for maintaining range of motion of the hip.

What happens if hip arthritis is left untreated?

This really depends on your lifestyle. Generally speaking, untreated hip osteoarthritis leads to faster degeneration of joint cartilage and worsening symptoms with each episode. The episodes tend to last longer as well.

If you’ve got an active lifestyle, such as a tradesperson or gym user, the symptoms will subside as you ease back into a consistent level of activity.

If you’ve got a sedentary lifestyle, such as an office job, the episodes last much longer and often result in ongoing restrictions to range of motion and function.

As a rule of thumb, it’s OK to wait a few weeks to see if the hip symptoms will ease on their own. After that, if you’ve still got symptoms, make a booking and get some professional advice.

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