Hip osteoarthritis (OA)?

The hip joint is a ‘ball and socket’ joint and is surrounded by a joint capsule and ligaments. Osteoarthritis mainly affects the cartilage at the ends of the bone (see image below). This cartilage is called hyaline cartilage and can be found on the end of the femur (ball) and the acetabulum (socket). The cartilage provides smooth, friction-free movement between the bones and acts as a shock absorber.

Osteoarthritis causes the articular cartilage to become thinner and starts to break down (see image above). This eventually exposes the bone underneath the cartilage and causes friction between the two bones. This causes inflammation and swelling (known as an effusion) in the joint. This inflammation causes a restriction of movement and significant pain.

The joint lining, called the synovium, also becomes inflamed and this is known as synovitis. Synovitis is very painful and can cause you to limp and can affect normal everyday activities such as going up and down the stairs or getting in and out of a car.

The restriction in hip movement and the associated pain can also significantly limit your ability to carry out your hobbies such as gardening, going on long walks, cycling and jogging.

How do you know if you have hip osteoarthritis?

Hip osteoarthritis is normally a progressive disease that gets worse over weeks or months, often creeping up slowly over a prolonged period of time. On occasion, what appears to be an innocuous incident at the time can trigger the pain. For example, tripping up, twisting or missing a step.

You will start to notice your hip getting stiff and painful when completing tasks such as putting your shoes and socks on or getting out of the car. The pain is normally located in the groin and around the side of the hip but can also refer down the front and side of the thigh to the knee. Classically, arthritic symptoms are worse in the morning or with inactivity and ease up as you start moving and carrying out normal activities.

Arthritic pain normally occurs episodically and you will experience good days and bad days. Acute flare-ups can last for a few weeks but will often settle down with relative rest and medication.

As hip osteoarthritis progresses you may notice a more significant loss in range of movement of the joint and more morning stiffness. You may also start to limp and get pain at night.

How is osteoarthritis of the hip diagnosed?

Getting the right diagnosis is essential to ensuring you embark on the right treatment plan for you.

Hip osteoarthritis is diagnosed on an X-ray (see image below). All GP’s will be able to send you for an X-ray. The waiting time for an X-ray is normally short on the NHS. Your GP may also refer you for blood tests to rule out any other systemic reasons for your pain such as rheumatoid arthritis.

An X-ray will also assess the stage of the arthritis; be it mild, moderate or severe. But it is very important to remember the amount of osteoarthritis you have on an X-ray does not always correlate with how much pain and dysfunction you are experiencing. It is not unusual that a patient has severe pain but minimal arthritic changes on an X-ray. It is also known that many patients over 40 years old have osteoarthritic changes on X-ray but do not experience pain.

This is why it is essential that the results of your X-ray are combined with a full clinical assessment by one of our expert physiotherapists. This includes an assessment of your joint range of movement, muscle length and muscle strength. We will also assess your biomechanics and function.

At Complete many physiotherapists are also highly experienced sonographers who will carry out a diagnostic ultrasound of your hip and surrounding soft tissues at your appointment. This is a very useful investigation for hip pain as it allows visualisation not only the bones and joint, but also the surrounding muscles, tendons and joints. We can also assess how much inflammation and swelling there is in the joint and surrounding structures.

A diagnostic ultrasound is excellent at differentiating between other local reasons for your hip pain which an X-ray will not show, such as:

• Hip flexor and gluteal tendinopathy
• Bursitis
• Muscle tear
• ‘Groin’ strain also known as adductor tendinopathy

Research has shown that ultrasound imaging is highly sensitive at picking up early joint changes such as synovitis which can be responsible for the pain associated with osteoarthritis (Wakefield et al, 2000. Gurjit et al, 2020).

How do we treat osteoarthritis in the hip?

It is not possible to reverse the structural changes that occur with hip osteoarthritis.
Physiotherapy plays a key role in the management of osteoarthritis of all joints and the hip is no exception. Research suggests that maintaining good flexibility and strength around the joint can help to slow disease progression (Hunter et al, 2009).

It is not uncommon that you get associated muscle weakness with this condition. Muscles are one of the key shock absorbers around the hip so it is important to strengthen your gluteal muscles and hip flexors to reduce compression on the joint.

Hip osteoarthritis can respond well to physiotherapy. This may include soft tissue techniques, joint mobilisations, acupuncture and a progressive home exercise program.

Here are a few top tips you may also like to try yourself:

• Try to lose weight – this can make a significant impact on your pain and function
• Rest or modify the activities that aggravate your pain
• Begin a gentle strengthening programme
• Take simple painkillers such as paracetamol or ibuprofen.
• Try using a topical anti-inflammatory such as Voltarol Gel.

Before using any medication always speak to a pharmacist or GP.

What if conservative treatment does not work?

If you are still getting pain and all conservative options have been unsuccessful there are a few other treatment modalities available to you.
Ultrasound-guided injections are one of these options and should be considered if the pain is:

• Waking you up at night
• Stopping you from engaging in everyday activities such as walking
• Preventing you from engaging in a course of physiotherapy

At Complete all of our injections are carried out using real-time ultrasound guidance. This ensures the accuracy of the injection into the joint. A hip joint injection should not be carried out without needle guidance.
Injections aim to reduce your pain, improve your range of movement and delay surgery. Following injection, we would always advise that you commence a course of physiotherapy to maximise the pain relief.

At Complete we normally inject either steroid or hyaluronic acid. On occasion, we will inject both at the same time. On occasion, we may suggest Platelet Rich Plasma (PRP) injections as an alternative option. This would only be considered for younger patients with mild to moderate osteoarthritis of the hip.

Steroid Injections
A majority of the hip injections we carry out are steroid injections. We always carry out the procedure with ultrasound guidance and use local anaesthetic to reduce any discomfort from the injection itself.
Steroid is a strong anti-inflammatory and can provide rapid pain relief. The duration of the pain relief from a steroid injection varies considerably and it is not possible to predict how long an injection will last. Broadly speaking the less severe the arthritis the longer they last. Patients with severe arthritis and those who are overweight do not respond for long periods of time.

Hyaluronic Acid
Hyaluronic Acid is a naturally occurring substance within the body. It has anti-inflammatory properties and also acts to lubricate the joint. There is a growing body of evidence that hyaluronic acid can provide pain relief in active patients, who are not overweight. This will be injected under ultrasound guidance, along with local anaesthetic, as a safe alternative to steroid.

How many injections can you have?

Patients often ask how many injections we recommend. The Arthritis Research Council (ARC) suggest no more than three steroid injections per year, with a minimum of 3 months between each injection. At Complete we try to limit the number of steroid injections to a minimum.

Before any injection is carried out we will always carry out a full assessment including an ultrasound scan (at no extra charge) and discuss all your available options.

What if an injection does not work?

If there is significant arthritis in the hip and the injection does not work, we may refer you to an orthopaedic consultant to discuss potential surgical options.

For more information or to book an appointment please call 020 7482 3875 or email injections@complete-physio.co.uk

Other hip conditions

Iliopsoas Tendinopathy/Bursitis
Greater trochanteric pain syndrome
Proximal hamstring tendinopathy
Femoroacetabular hip impingement (FAI)