- A structured program of exercises and physiotherapy can significantly reduce your hip pain and improve daily function.
- Groin pain, often radiating to your thigh or knee, is a characteristic symptom of hip osteoarthritis.
- Managing your weight and modifying high-impact activities can help protect your hip joints from further degeneration.
- Hip osteoarthritis, a common condition causing pain and stiffness, can be effectively managed with targeted physiotherapy.
Table of Contents
Hip osteoarthritis (coxarthrosis)
Hip osteoarthritis (or coxarthrosis) is one of the most common and debilitating forms of osteoarthritis, characterized by the progressive deterioration of the cartilage lining the femoral head and the acetabular cavity of the pelvis. It affects approximately 10% of the population over 60 and is the leading cause of hip replacement surgery in Italy.
Coxarthrosis causes groin and thigh pain, joint stiffness, and progressive limitation of ambulation, significantly compromising quality of life. However, a structured program of exercises and physiotherapy can reduce pain by 30-50%, improve function, and delay or avoid surgery.
Table of Contents
- Anatomy of the Hip Joint
- Causes and Types of Coxarthrosis
- Symptoms
- Diagnosis
- Conservative Treatment
- Exercises for Coxarthrosis
- When is a Hip Replacement Necessary?
- Timeline and Prognosis
- Prevention
- Frequently Asked Questions (FAQ)
- Frequently Asked Questions
- Sources and Scientific References
Anatomy of the Hip Joint
The hip is a spheroidal joint (enarthrosis) formed by:
- Femoral head: the “ball”, covered with articular cartilage
- Acetabulum: the “socket”, a deep cavity in the iliac bone that accommodates the femoral head
- Acetabular labrum: a ring of fibrocartilage that deepens the socket and improves stability
- Joint capsule: a fibrous covering reinforced by powerful ligaments
The hip is a weight-bearing joint: it supports body weight during standing and walking. During walking, the hip bears a load equal to 3-4 times body weight; during running, up to 5-6 times. This explains why hip cartilage is particularly vulnerable to degeneration.
Causes and Types of Coxarthrosis
Primary Coxarthrosis (Idiopathic)
This is the most common form, linked to aging and progressive cartilage degeneration without a specific identifiable cause. It typically affects individuals after 55-60 years of age, with a higher prevalence in females.
Secondary Coxarthrosis
It results from a pre-existing condition that has altered hip biomechanics:
- Congenital hip dysplasia: an abnormal conformation of the acetabulum that predisposes to early degeneration
- Femoroacetabular impingement (FAI): an incongruence between the shape of the femoral head and the acetabulum that causes abnormal contact — one of the emerging causes of coxarthrosis in young adults
- Avascular necrosis of the femoral head: the death of bone tissue due to insufficient blood supply
- Post-traumatic: after fractures of the acetabulum or femoral head
- Rheumatoid arthritis: rheumatoid disease can affect the hip
- Perthes disease: necrosis of the femoral head in childhood
Risk Factors
- Age: the most important factor — rare before 45, frequent after 60
- Overweight and obesity: every extra kg increases the load on the hip by 3-4 kg during walking
- High-impact sports activities: long-distance running, soccer, rugby (in the long term)
- Heavy labor: lifting loads, prolonged postures (agriculture, construction)
- Postural alterations: limb length discrepancy, pelvic alterations
- Genetics: documented family predisposition
Symptoms
Pain
- Typical location: groin pain — this is the most characteristic symptom. Pain can radiate to the front of the thigh down to the knee
- Lateral pain: pain can also be localized on the lateral aspect of the hip (trochanteric region), but in this case, it must be distinguished from trochanteritis
- Character: dull, deep, worsening with activity and improving with rest
- Start-up pain: pain in the first steps after sitting for a long time (“gelling” phenomenon), which improves after a few minutes of walking
- Progression: initially, pain occurs only after intense exertion, then becomes present even with light activities, and finally at rest and at night
Stiffness
- Morning stiffness: lasts less than 30 minutes (unlike rheumatoid arthritis)
- Limited mobility: internal rotation is the first movement limited, followed by flexion, abduction, and external rotation
- Functional difficulties: tying shoes, putting on socks, getting in and out of the car, climbing stairs, trimming toenails
Limp
In advanced stages, pain and stiffness cause an antalgic gait: the stride is shorter on the affected side, and the patient tends to lean the torso towards the painful hip to reduce the load.
Crepitus
Cracking and crepitus during hip movement are frequent in advanced stages.
Diagnosis
Clinical Examination
- Passive hip mobility: internal rotation is typically the first to decrease and the most painful. Flexion, abduction, and external rotation progressively decrease
- Patrick’s test (FABER): hip flexion, abduction, and external rotation — positive if it reproduces groin pain
- Gait assessment: analysis of walking, presence of limp
- Lower limb length: coxarthrosis can cause limb shortening
- Muscle strength: assessment of glutes and iliopsoas
Imaging Diagnostics
- Pelvic X-ray: the first-choice examination. It shows the classic signs of osteoarthritis: joint space narrowing, osteophytes, subchondral sclerosis, subchondral cysts
- MRI: indicated in doubtful cases, to evaluate labral lesions or osteonecrosis
- CT scan: for surgical planning (hip replacement)
Radiographic Classification (Kellgren-Lawrence)
| Grade | Description |
|---|---|
| 0 | Normal |
| 1 | Doubtful: possible osteophytes |
| 2 | Mild: definite osteophytes, possible joint space narrowing |
| 3 | Moderate: marked joint space narrowing, multiple osteophytes, sclerosis |
| 4 | Severe: complete loss of joint space, large osteophytes, deformity |
Conservative Treatment
International guidelines recommend conservative treatment as the first approach for all grades of coxarthrosis, before considering surgery.
The Three Pillars of Treatment
- Physical exercise: the most effective treatment — specific exercises + aerobic activity
- Weight management: losing even just 5-10% of body weight significantly reduces symptoms
- Education: understanding the disease, self-management strategies, and when to seek help
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Medications
- Paracetamol: first-choice pain reliever
- NSAIDs (ibuprofen, naproxen): for flare-ups, for limited periods
- Topical NSAIDs: gel applied to the hip, less effective than for the knee due to the depth of the joint
- Corticosteroid injections: under ultrasound guidance, effective for controlling flare-ups
- Hyaluronic acid injections: less strong evidence compared to the knee, but used in some cases
Physiotherapy
- Therapeutic exercises: muscle strengthening, mobilization, stretching — the program should be personalized
- Manual therapy: joint mobilizations to maintain mobility
- Hydrotherapy: exercises in warm water — particularly effective for coxarthrosis because they reduce the load on the joint
- Therapeutic education: pain management, joint protection, adapted activities
- Assistive devices: walking sticks (used in the hand opposite the painful hip), long-handled shoehorns, toilet seat risers
Exercises for Coxarthrosis
The exercise program is the treatment with the best scientific evidence for coxarthrosis. It should be performed at least 3 times a week, ideally daily. Your doctor or physical therapist will adapt the program.
Mobilization
Supine hip flexion (knee to chest)
Supine hip rotation (windshield wiper)
Supine hip circles
Stretching
Iliopsoas stretch
Piriformis stretch
Adductor stretch
Strengthening
Glute bridge
Supine hip abduction (clamshell)
Wall mini squat
Step-up (stair climbing)
Aerobic Activity
Regular aerobic activity is recommended for coxarthrosis:
- Walking: 30 minutes, 5 times a week — the most accessible activity
- Cycling/stationary bike: reduces hip load while maintaining mobility
- Swimming and aquagym: water supports body weight and allows pain-free movement
- Adapted Pilates and yoga: improve flexibility, strength, and balance
When is a Hip Replacement Necessary?
Hip replacement surgery is indicated when:
- Pain is severe and does not respond to at least 3-6 months of adequate conservative treatment
- Functional limitation significantly compromises quality of life
- Night pain is intractable
- X-ray shows advanced osteoarthritis (Kellgren-Lawrence grade 3-4)
Total hip replacement is one of the procedures with the highest satisfaction rates in orthopedic surgery (> 95%). The average lifespan of a modern prosthesis is 15-25 years.
The post-hip replacement rehabilitation pathway is crucial for the final outcome.
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Timeline and Prognosis
Coxarthrosis is a chronic and progressive condition, but the rate of progression is highly variable. Some patients remain stable for years, while others progress rapidly.
| Expectation | |
|---|---|
| Exercise benefit | Noticeable after 6-8 weeks of regular practice |
| Long-term management | Continuous exercise program + aerobic activity |
| Slowing progression | Healthy weight + exercise + joint protection |
| When to operate | When quality of life is compromised despite treatment |
Prevention
- Maintain a healthy weight: overweight is the most important modifiable risk factor
- Regular physical activity: exercise keeps cartilage nourished and muscles toned
- Muscle strengthening: strong glutes protect the hip joint
- Avoid excessive impact: alternate running with low-impact activities (swimming, cycling)
- Treat structural abnormalities: early diagnosis of femoroacetabular impingement and dysplasia can prevent secondary osteoarthritis
For more information, consult the Complete Guide to Hip Pain.
Frequently Asked Questions (FAQ)
Yes, most patients with mild-to-moderate coxarthrosis can be effectively managed with conservative treatment: exercises, physiotherapy, weight management, and medications. Hip replacement is reserved for advanced cases that do not respond to conservative treatment. Even in cases of radiographically severe osteoarthritis, if symptoms are manageable, surgery is not mandatory.
Walking is beneficial. Moderate walking (30 minutes, 5 times a week) is recommended for coxarthrosis: it maintains mobility, strengthens muscles, improves circulation, and helps control weight. It does not accelerate joint degeneration. If pain increases during walking, reduce the duration and speed and consult your doctor or physical therapist.
Coxarthrosis is osteoarthritis of the hip joint (groin pain), while trochanteritis is inflammation of the bursa and tendons on the lateral aspect of the hip (lateral pain). They are two different conditions with different treatments, but they can coexist. The location of the pain (groin vs. side) is the main distinguishing factor.
There is no absolute minimum or maximum age. Most hip replacements are implanted between 60 and 80 years of age, but in cases of severe early osteoarthritis (dysplasia, necrosis), surgery may be performed even at 40-50 years. The decision depends on the severity of symptoms, the compromise of quality of life, and the response to conservative treatment, and should be discussed with your doctor or physical therapist.
Yes, it is common. Pain from coxarthrosis can radiate from the groin region along the anterior thigh to the knee. This “referred pain” is due to the distribution of the obturator nerve and the femoral nerve. It is not uncommon for a patient to present complaining of knee pain when the actual problem is the hip.
Modern prostheses have an average lifespan of 15-25 years, with some studies reporting survival rates exceeding 90% at 20 years. The duration depends on many factors: type of prosthesis, patient activity, weight, bone quality. In case of wear, a revision surgery (replacement of the prosthesis) is possible.
Frequently Asked Questions
What are the common early symptoms of hip osteoarthritis?
Hip osteoarthritis typically presents with groin pain, which may radiate to the thigh or knee. This condition often leads to joint stiffness and a progressive limitation of ambulation, significantly impacting daily activities.
How does a physical therapist contribute to the management of hip osteoarthritis?
A physical therapist develops a structured program of exercises, including mobilization, stretching, and strengthening, to reduce pain and improve hip function. This targeted approach helps manage symptoms, enhance mobility, and can delay or potentially avoid the need for surgery.
What lifestyle modifications are beneficial for individuals with hip osteoarthritis?
Managing body weight is crucial, as it reduces stress on the hip joints and can slow disease progression. Modifying high-impact activities to lower-impact alternatives also helps protect the joints from further degeneration and alleviate discomfort.
When might surgical intervention be considered for hip osteoarthritis?
Surgical intervention, such as a hip replacement, is typically considered when conservative treatments no longer effectively manage pain or significantly improve function. It is often reserved for cases where the progressive deterioration of the hip joint severely compromises quality of life.
For a broader overview of related conditions, see our complete guide to hip pain.
Sources and Scientific References
- van Doormaal MCM et al. (2020). A clinical practice guideline for physical therapy in patients with hip or knee osteoarthritis. Musculoskeletal Care. 18:575-595. DOI | PubMed
- Kolasinski SL et al. (2020). 2019 American College of Rheumatology/Arthritis Foundation Guideline for the Management of Osteoarthritis of the Hand, Hip, and Knee. Arthritis Care Res (Hoboken). 72:149-162. DOI | PubMed
- Bartels EM et al. (2016). Aquatic exercise for the treatment of knee and hip osteoarthritis. Cochrane Database Syst Rev. 3:CD005523. DOI | PubMed
- Bennell K (2013). Physiotherapy management of hip osteoarthritis. J Physiother. 59:145-57. DOI | PubMed
- Moseng T et al. (2024). EULAR recommendations for the non-pharmacological core management of hip and knee osteoarthritis: 2023 update. Ann Rheum Dis. 83:730-740. DOI | PubMed