Hip Osteoarthritis

Have you ever experienced hip pain, stiffness in the morning, or difficulty with tasks like putting on shoes or walking after you’ve been sitting for a while?

You may be experiencing the symptoms of hip osteoarthritis.

Unfortunately, there are a lot of negative connotations associated with osteoarthritis. Many people are told that their hip is “worn out” or “bone on bone” or “degenerative”. When someone with hip pain is told by a health professional that their pain is the result of ‘wear and tear’ from a sport or activity they used to do, they are probably going to have a hard time understanding that exercise will help their symptoms, and they may even think that the only way forward would be to replace that joint. 

At Be Mobile Physiotherapy, one of the missions we take very seriously is reducing the barriers to exercise… So, this article will attempt to help you understand what hip osteoarthritis is, what causes it, and most importantly… what you can do about it.

What is hip osteoarthritis?

The word osteoarthritis can be split into three to help understand what it means:

• Osteo - from the Greek ostéon, meaning bone. (Dictionary.com)
• Arthritis - from the Greek arthro-, meaning joint and -itis, meaning inflammation. (Shen et al. 2020).

So the term osteoarthritis refers to inflammation of the joints between bones. This definition is important because it highlights the fact that osteoarthritis affects the whole joint, including the bones, ligaments, joint capsule and cartilage. It’s valuable to our understanding of the condition to point out that whilst cartilage can change in osteoarthritis (usually becoming thinner), it is only one piece of the puzzle.

What factors increase our risk of developing these joint changes?

There are numerous factors that increase your risk of hip osteoarthritis. Some we can modify, and some are out of our control. Let’s take a look:

Radiographic vs. Symptomatic Hip Osteoarthritis

With all that in mind, it would be safe to assume that if you had an X-ray of your hip, and the report looked something like this...

• Joint space narrowing
• Subchondral sclerosis
• Osteophytes
• Subchondral cysts
• Labral tear

WRONG!

Imaging findings do not correlate closely with the symptoms of osteoarthritis. One study of asymptomatic (no symptoms) people aged between 15 and 66 showed that a whopping 73% had abnormalities on imaging, and 69% had a labral tear (Register et al. 2012).

Another review of the scientific literature concluded that whilst imaging findings were more prevalent in people with symptoms, abnormalities are so frequently found in people with no hip symptoms that we cannot say there is a clear relationship between imaging findings and pain (Heerey et al. 2017).

We also know that the prevalence of hip abnormalities on imaging gets higher as you get older (Register et al. 2012). This tells us that changes like cartilage thinning and labral tears are normal age-related changes. We wouldn’t call skin wrinkles ‘degenerative skin changes’ so why would we label changes in the joint ‘degenerative’. Whilst these findings can play a role in someone’s pain, they are just one factor.

This is good news for anyone that has had an X-ray, CT or MRI scan showing abnormalities in their hip. If someone with no symptoms can have signs of osteoarthritis, then someone with symptoms can reasonably expect to improve, even if their imaging doesn’t change! Basically, there are other factors that contribute to our symptoms that we can modify!

Factors that contribute to hip osteoarthritis symptoms

Pain is a complex phenomenon that is the result of an imbalance of danger and safety messages that are interpreted by our brain (Moseley & Butler 2017). It is not as simple as pain = damage. A full discussion about pain is beyond the scope of this article, so if you would like to read more I highly recommend our pain article which you can find here. A classic proof of this definition of pain can be seen in phantom limb pain - the phenomenon whereby an amputee still feels pain in a limb which they no longer have. Clearly, tissue damage cannot be present, and hopefully you can see that there must be other factors contributing.

With that in mind let’s consider some of the danger and safety messages that might lead the brain to create pain in the hip.

These are just some examples of danger and safety messages. Some might sound silly to you, whilst others you might resonate with. The important thing is to recognise that there are lots of factors that contribute to why your hip is painful.

 It can be a good idea to write down some of the positive and negative things going on in your life whenever your hip is particularly sore. This can be a helpful way to identify what factors increase your symptoms and vice versa. 

 Now that you have a good grasp of some of the factors influencing pain with hip osteoarthritis, let’s discuss what you can do about your symptoms…

Evidence based treatment for hip osteoarthritis

There are many treatments available for people with hip osteoarthritis, but not all are appropriate for everyone at every stage - see the figure below:

Whilst surgery can be an effective strategy for a few people. It comes with significant risks, costs and is not a guaranteed solution to the symptoms (remember that hip osteoarthritis is not only about the joint changes!). Some people will benefit from using analgesia to manage their symptoms in consultation with their doctor. But all people with hip osteoarthritis should at the very least trial an extended period of exercise, weight management and education.

Education

Seeing as you are already hip-deep in this strategy I’ll be brief (pardon the pun). Understanding hip osteoarthritis means you can have a more positive attitude towards the condition and are more empowered to self manage your symptoms. The benefit of educating yourself is that exercise and movement becomes a safety, rather than a danger message!

Weight Management

Maintaining a healthy weight is a cornerstone of good health. You don’t need me to convince you, but keeping a healthy weight reduces your risk of a wide variety of diseases including cardiovascular disease, diabetes and certain types of cancer. But keeping in the healthy weight range can also have a big impact on osteoarthritis symptoms. In fact there is a dose-response relationship between weight loss and improvements in osteoarthritis symptoms and function (Riddle & Stratford 2017; Bliddall et al. 2014). In other words, if you are overweight and you lose even a small amount of bodyweight, you should notice that your hip starts to feel better, in addition to all the other huge benefits! Weight loss is a challenging feat, and requires a combination of manipulating the diet and engaging in exercise. The topic of eating to lose weight is once again beyond the scope of this article, so let’s focus on the latter.

Exercise

Exercise has so many positive effects on our health. There are so many that it would be impossible to list them all here. It really is a magic pill. Here is a brief list of the direct benefits that exercise has on hip osteoarthritis:

• Helps with managing weight
• Improves the strength of the muscles around the hip
• Increases the hip joint’s ability to tolerate load - meaning you can handle more before the onset of symptoms
• Makes difficult daily tasks easier - like getting out of a chair, putting on socks and shoes, and getting down to the floor
• Provides an analgesic effect - exercise causes the release of ‘feel good’ chemicals in your brain that make you feel better, and can also lessen pain

But what if it really hurts to exercise?

It can be incredibly frustrating when you start a well-intentioned exercise regime, and pain stops you in your tracks. It’s good to remember though that hurt does not equal harm. There are obvious exceptions to this rule - such as a broken bone, but in the case of a persistent issue like hip osteoarthritis, pain during exercise is simply an alert that you are loading a sensitive joint. Joints, like other tissues in our body, are adaptable. So as you become more accustomed to the exercise, and your hip gets used to the loading and movement, your symptoms should slowly decrease. The key is finding the appropriate starting point. This simply means finding a level of exercise that you can tolerate, both at the time, and in the 24-48 hours following the activity.

What type of exercise?

The best form of exercise is the one that gets done. The Australian Government Minimum Physical Activity Guidelines are a great starting point. Though these minimums may be far too much for some people to handle, they will still get drastic benefits, starting with a smaller amount.

Aerobic Exercise

Aerobic exercise, also known as cardiovascular exercise can take many forms. These include walking, cycling, swimming, dancing or playing sports like tennis. If you haven’t been active for a while, it’s best to start with something you can handle easily, and slowly build up. Here is an example walking progression to meet the physical activity guidelines when you have painful hips.

In the table, notice the gradual progress over the weeks in terms of frequency, duration and intensity. To gauge intensity, you can rate how hard you are working out of 10 - if 10 is the hardest exercise you can imagine. A score of 6 would correlate with being able to hold a conversation, but not sing a song.

Resistance Training

Strength based exercise or resistance training is any form of exercise where you are moving against a resistance. This could be lifting weights, lifting your bodyweight or using resistance bands. Similar to aerobic exercise, we want to start low and build up slowly over time. A good resistance training program will involve exercises that challenge all the major muscle groups and gradually progresses in the loads used for each exercise. Resistance training can cause hip symptoms, especially when starting out, so here are some modifications you can make if you cannot tolerate the exercises:

1. Weight - Reduce the weight or try no weight at all.
2. Range of motion - if a bodyweight movement, like a squat, is still intolerable, you can reduce the depth. Even a very shallow squat, whilst it may not feel like much, is still beneficial, and represents a perfect starting point for a lot of people.

Substitute a similar exercise - If a particular exercise just isn’t working for you, there’s almost always an alternative. For example, if you are having difficulties even doing shallow squats, a sit-to-stand from a comfortable height chair can be more tolerable for some people. And if even that is too sore, don’t worry! You can leave squats for the moment and try different exercises such as pick ups.

If you’re not familiar with resistance training you can try a strength workout when you sign up for a free account on our website!

Takeaways

1. Hip osteoarthritis is a condition affecting the whole joint and the symptoms are influenced by many factors.
2. There are several factors that increase your risk of hip osteoarthritis, but leading a healthy lifestyle can be preventative.
3. Symptoms can be exacerbated/reduced by factors such as your mental health, sleep quality and your beliefs.
4. The best evidence based treatments are education, weight management and exercise.
5. The best exercise is the one that gets done, and whilst it can be painful. There are always modifications you can make to get moving!

If you would like more information about hip osteoarthritis or would like to see some exercises that can help, make sure you check out our Hip Osteoarthritis Video! Or you can drop us a line at [email protected]

References

• Australian Government Department of Health. (2021). Retrieved 5 August 2021, from https://www.health.gov.au/health-topics/physical-activity-and-exercise/physical-activity-and-exercise-guidelines-for-all-australians/for-adults-18-to-64-years
• Bliddal, H., Leeds, A., & Christensen, R. (2014). Osteoarthritis, obesity and weight loss: evidence, hypotheses and horizons – a scoping review. Obesity Reviews, 15(7), 578-586. doi: 10.1111/obr.12173
• Definition of osteo- | Dictionary.com. (2021). Retrieved 5 August 2021, from https://www.dictionary.com/browse/osteo-
• Heerey, J., Kemp, J., Mosler, A., Jones, D., Pizzari, T., Souza, R., & Crossley, K. (2018). What is the prevalence of imaging-defined intra-articular hip pathologies in people with and without pain? A systematic review and meta-analysis. British Journal Of Sports Medicine, 52(9), 581-593. doi: 10.1136/bjsports-2017-098264
• Hip Labral Tears | Orthopaedics 360. (2021). Retrieved 5 August 2021, from https://orthopaedics360.com.au/hip/hip-labral-tears/
• Mosley, G., & Butler, D. (2017). Explain pain supercharged. South Australia: NOI.
• Register, B., Pennock, A., Ho, C., Strickland, C., Lawand, A., & Philippon, M. (2012). Prevalence of Abnormal Hip Findings in Asymptomatic Participants. The American Journal Of Sports Medicine, 40(12), 2720-2724. doi: 10.1177/0363546512462124
• Riddle, D., & Stratford, P. (2012). Body weight changes and corresponding changes in pain and function in persons with symptomatic knee osteoarthritis: A cohort study. Arthritis Care & Research, 65(1), 15-22. doi: 10.1002/acr.21692
• Samartzis, D. , Keller, . Thomas Christian and Shen, . Francis H. (2020, November 19). arthritis. Encyclopedia Britannica. https://www.britannica.com/science/arthritis
•  GLA:D AU. (2021). Retrieved 5 August 2021, from https://gladaustralia.com.au/treatment-for-osteoarthritis/