Hip osteoarthritis: symptoms, treatment and hip replacement

The hip is a ball-and-socket joint: the rounded top of the thigh bone sits in a cup in the pelvis. Both surfaces are covered in smooth cartilage so that the bones glide without friction. Arthritis UK explains that in osteoarthritis the cartilage becomes thinner and the surfaces rougher, which can produce swelling, pain and stiffness, although not everyone with these changes has symptoms.

The NHS describes osteoarthritis as the most common type of arthritis in the UK and says the protective cartilage on the ends of bones breaks down. NICE Clinical Knowledge Summaries adds that it is a whole-joint condition, with bone remodelling, bony outgrowths and mild inflammation of the joint lining alongside the cartilage loss.

Being told you have hip osteoarthritis does not mean it will inevitably worsen. Arthritis UK stresses that many people improve their symptoms with the measures below, and the NHS says the condition does not necessarily get worse over time.

Arthritis UK says the pain comes on gradually, though a recent injury can trigger it, and that it often varies from day to day. The painful areas are usually the lower back, buttocks and groin, and some people feel it from the top of the thigh down to the knee or even the ankle. Because hip pain is often felt away from the hip itself, it is easy to blame the back or the knee.

• Pain that is worse after activity and at the end of the day.

• Stiffness, but morning stiffness that lasts less than about 30 minutes.

• Difficulty with standing up, walking or bending, which can become suddenly harder when the hip is badly affected.

• The hip occasionally locking for a few moments (Arthritis UK).

• Weakening and shrinking of the muscles round the hip in advanced disease, which loads the joint further.

• Low mood and disturbed sleep, which Arthritis UK notes can accompany the pain.

The exact cause is often unknown. The NHS lists joint injury, other conditions such as rheumatoid arthritis or gout, age, family history, obesity and being a woman as factors thought to raise the risk, and says weight-bearing joints such as the hips and knees take the extra strain in obesity. Arthritis UK cites the genes inherited from your parents.

The NHS hip pain page is useful for sorting causes. It gives osteoarthritis as the likely cause when someone is over 45 and has pain that is worse when walking with stiffness after moving, and compares that with rheumatoid arthritis (pain and stiffness worse after not moving, for example on waking), bursitis (pain that may spread to the thigh and feel worse lying on that side), a sprain or tendon problem after intense exercise, a hip fracture after a fall, and joint infection when the hip is hot and swollen with a temperature.

NICE guideline NG226 says osteoarthritis should be diagnosed clinically, without imaging, in people aged 45 or over who have activity-related joint pain and either no morning stiffness or morning stiffness lasting no more than 30 minutes. Imaging is not used routinely unless there are atypical features or features suggesting another diagnosis. NICE lists atypical features as recent trauma, prolonged morning stiffness, rapid worsening, a hot swollen joint, or concern about infection or malignancy.

When an X-ray is requested it is usually to rule out another cause or to plan surgery rather than to grade the pain. NICE also advises against using imaging routinely to follow up or to guide non-surgical management. A hip X-ray report that mentions wear can be reassuring or worrying, but it does not on its own predict how much pain a person has.

Arthritis UK says exercise should be a core part of treatment whatever your fitness level, because it strengthens the muscles supporting the hip, improves posture and helps with weight. It highlights swimming and cycling, which reduce load on the joint, and water-based exercise, where the water takes the body's weight. Strengthening exercises are advised on at least two days a week, alongside range-of-movement work and aerobic activity. NICE recommends offering tailored therapeutic exercise to everyone with osteoarthritis and considering supervised sessions.

Day-to-day measures include pacing, supportive shoes with thick soles, using a stick in the hand opposite the sore hip, not carrying loads on the affected side, using the handrail on stairs, sitting on firm chairs high enough that the hip is slightly above the knee, and avoiding crossing the legs. NICE says to consider walking aids for lower-limb osteoarthritis.

On medicines, NICE says to use them alongside exercise at the lowest effective dose for the shortest time. Topical NSAIDs are most clearly recommended for the knee; for other joints NICE says to consider them, and an oral NSAID can be considered with stomach protection if topical treatment is ineffective or unsuitable. It advises against routinely using paracetamol or weak opioids and against glucosamine and strong opioids. NICE suggests manual therapy for hip or knee osteoarthritis only alongside exercise, and not acupuncture or electrotherapy such as TENS.

NICE advises that intra-articular corticosteroid injections can be considered when other medicines are ineffective or unsuitable, or to support exercise, and that they give relief for only 2 to 10 weeks. Arthritis UK describes steroid injections for the hip as typically limited to about three a year. Hyaluronic acid injections are not recommended by NICE and, according to Arthritis UK, are not available on the NHS.

NICE says to consider referring people with hip, knee or shoulder osteoarthritis for joint replacement when symptoms substantially affect quality of life and non-surgical management has been ineffective or unsuitable. The decision should rest on clinical assessment rather than a numerical score, and age, sex, smoking, other conditions or a high BMI should not by themselves exclude someone from referral, though the risks can vary with them.

Arthritis UK calls total hip replacement one of the most commonly performed and successful operations in the world, with pain relief and better movement, and says most hip replacements now last at least 15 years. Hip resurfacing, which replaces only the damaged surfaces, is less popular because of concerns about metal surfaces affecting the soft tissues around the hip. Your surgeon will explain which approach suits you, usually through a shared decision-making process.

The NHS hip pain page says to call 999 or go to A&E for severe hip pain after a fall or injury, being unable to walk or put weight on the leg, or tingling or loss of feeling after an injury. It advises an urgent GP appointment or NHS 111 for severe hip pain that began suddenly without a fall, a swollen and hot hip, skin colour change, or hip pain with a high temperature or feeling generally unwell.

For ordinary persistent pain the NHS says to see a GP if it stops normal activities or affects sleep, keeps coming back or has not improved after two weeks of home care, and notes that in many areas you can refer yourself to a community musculoskeletal service for physiotherapy. People who prefer to see a private physiotherapist or orthopaedic surgeon can do so, but the same thresholds for surgery apply. Facilities and waiting times differ between providers.