Hip osteoarthritis assessment and treatment

01OverviewDefinition, clinical context and the essential points that orientate the chapter.

Hip osteoarthritis presents most often as activity-related groin pain, but buttock, thigh or isolated knee pain can dominate. Ask about walking distance, stairs, sleep, footwear, washing, work, caring and meaningful activities rather than a generic pain score alone. Establish stiffness duration, sudden change, trauma, systemic symptoms, childhood hip disease, steroid and alcohol exposure and inflammatory history. Clarify what treatment success means to the person and which risks or recovery demands they can accept.

NICE allows clinical diagnosis without imaging when the person is at least 45, pain is activity related and morning stiffness is absent or lasts no longer than 30 minutes. Examine gait, leg length, hip flexion and especially internal rotation, abductor strength and a functional movement such as rising from a chair. Examine the lumbar spine, knee and greater trochanter when symptoms are referred or lateral. Neurovascular findings and true limb shortening require their own explanation.

Do not order radiographs simply to confirm every typical case. Obtain weight-bearing pelvic and hip views when symptoms are atypical, rapidly changing, post-traumatic or being evaluated for surgery. Radiographs may show non-uniform joint-space loss, osteophytes, sclerosis and cysts, but symptom burden can be severe with modest change and vice versa. MRI is not routine for established osteoarthritis; use it to answer a specific alternative such as occult fracture, osteonecrosis, tumour or early inflammatory disease.

Therapeutic exercise is a core treatment even when it initially increases discomfort. Prescribe progressive strengthening, aerobic activity and range work matched to pain, comorbidity and access, with supervised sessions when they improve technique or adherence. Explain that regularity matters more than a named exercise brand. Walking aids can unload the joint; a stick is generally held contralaterally. Occupational changes, pacing, footwear and home adaptations preserve independence without framing avoidance as treatment.

For people who are overweight or obese, explain that any weight loss is likely to help and that around 10% is likely to provide more benefit than 5%, while agreeing achievable goals without making care conditional on weight. Address sleep, mood and social barriers. Manual therapy is considered only alongside exercise. NICE does not recommend acupuncture or dry needling for osteoarthritis. Electrotherapy and devices should not displace active care unless a specific functional assessment supports them.

Medication supports activity rather than replacing it. Consider a topical NSAID for non-knee joints after discussing practical application and evidence, then an oral NSAID if topical treatment is ineffective or unsuitable. Review gastrointestinal, renal, hepatic and cardiovascular toxicity, pregnancy, anticoagulants and concurrent medicines and add gastroprotection such as a proton-pump inhibitor. Use the lowest effective dose for the shortest time and provide stopping advice during dehydration or acute kidney risk.

NICE advises against routine paracetamol or weak opioids except infrequent short-term use when other options are contraindicated, not tolerated or ineffective, and against strong opioids. Do not offer glucosamine. Image-guided intra-articular corticosteroid can be considered for temporary relief, explicitly explaining the approximate two-to-ten-week benefit and using the window to advance exercise. Repeated injection carries infection, glucose and tissue considerations and is not a substitute for surgical referral when quality of life remains poor.

Refer for arthroplasty when symptoms substantially impair quality of life and evidence-based non-operative options are ineffective or unsuitable. Referral should not be withheld solely because of age, sex, smoking, comorbidity or overweight or obesity; instead optimise modifiable risk and discuss how it affects individual complications. Surgical assessment integrates symptoms, examination, radiographs and goals. During waiting, continue exercise, walking aids, analgesic safety review and escalation for acute change rather than leaving the person in passive deterioration.

Key points

NICE supports a clinical diagnosis in people aged 45 or over with activity-related joint pain and no morning stiffness or stiffness lasting no longer than 30 minutes; routine imaging is unnecessary in a typical presentation.
Localise groin, buttock and referred knee pain, test gait, flexion and internal rotation, examine both hips and distinguish spine, trochanteric and knee sources.
Image when the presentation is atypical, rapidly progressive, traumatic, inflammatory or uncertain, or when radiographs are needed for surgical planning; severity on film does not equal symptom severity.
Core treatment is tailored therapeutic exercise plus support for weight loss when overweight or obese, delivered with education and sustained behaviour change rather than rest.
Consider a topical NSAID and, if ineffective or unsuitable, an oral NSAID at the lowest effective dose for the shortest time with gastrointestinal, renal, liver and cardiovascular risk review and gastroprotection.
Do not routinely offer paracetamol or weak opioids except infrequently for short-term relief when other medicines are contraindicated, not tolerated or ineffective; do not offer strong opioids.
An intra-articular corticosteroid injection may offer short-term relief for about 2 to 10 weeks when other pharmacological options are unsuitable or to support exercise; do not offer hyaluronan injections.
Refer for joint replacement when pain, stiffness or reduced function substantially affects quality of life and non-surgical care is ineffective or unsuitable; use clinical judgement, not a numerical severity score or arbitrary BMI barrier.

02AetiologyUnderlying causes, associations and risk factors, with why each one matters.

Age-related joint failure

Cartilage, subchondral bone, synovium and periarticular muscle change together, with risk rising through later adulthood rather than from simple cartilage wear alone.

Abnormal hip morphology

Developmental dysplasia, femoroacetabular shape and childhood disorders alter load distribution and can produce symptomatic disease at a younger age.

Previous structural injury

Fracture, infection, slipped epiphysis, Perthes disease or surgery can leave lasting incongruity and accelerate symptomatic secondary osteoarthritis.

Systemic and load factors

Higher body weight, physically demanding exposure, genetic susceptibility and reduced muscle capacity influence symptoms and structural progression in combination.

03PathophysiologyThe causal sequence from the underlying abnormality to symptoms and harm.

1
Cartilage matrix failure
Mechanical and inflammatory signalling reduces cartilage resilience, narrows the joint space and exposes subchondral bone to increasing contact stress.
2
Subchondral remodelling
Sclerosis, cysts and altered trabecular load transmission contribute to deep activity pain and loss of joint compliance.
3
Osteophyte and capsular change
Marginal bone formation and capsular thickening restrict internal rotation and flexion and can create impingement during daily activity.
4
Synovial pain amplification
Intermittent low-grade synovitis and effusion add pain variability and stiffness that correlate imperfectly with radiographic structural severity.
5
Muscle and gait adaptation
Hip-abductor weakness and an antalgic gait reduce stability, increase energy cost and transfer load to the spine, knee and opposite hip.

04Clinical features and red flagsSymptoms, examination findings, patterns of presentation and time-critical warnings.

Typical clinical pattern

Age at least 45, activity-related groin or thigh pain and absent or brief morning stiffness supports clinical diagnosis without routine imaging.

Restricted internal rotation

Painful loss of hip internal rotation and flexion with an antalgic gait is a characteristic examination pattern.

Referred knee pain

Hip disease may present as anterior thigh or knee pain, so a normal knee examination should prompt assessment above.

Atypical inflammatory pattern

Prolonged morning stiffness, systemic symptoms or several active joints should redirect assessment toward inflammatory disease.

Rapid destructive pattern

Sudden load failure, severe night pain or quickly collapsing radiographs requires fracture, osteonecrosis, infection and malignancy exclusion.

Replacement-level impact

Sleep loss, curtailed walking, inability to dress or work and failure of reasonable non-operative care indicate referral based on quality of life.

Red flags requiring action

Fever, systemic illness, intense passive-movement pain or a recent bacteraemic source raises concern for septic arthritis and requires urgent aspiration and source-control assessment.
Inability to bear weight after a fall, shortened or externally rotated limb, or focal bony tenderness requires urgent fracture imaging even if previous radiographs showed osteoarthritis.
Night pain unrelated to movement, weight loss, mass, previous cancer or destructive radiographic change requires malignancy investigation rather than escalation of analgesia alone.
Rapid onset in a younger adult, steroid or alcohol exposure, sickle-cell disease or transplant history raises concern for femoral-head osteonecrosis and supports early MRI when radiographs are non-diagnostic.

05InvestigationsWhat to request, why it matters and how to interpret it.

Investigation order

Read from the initial assessment onwards. Tests may run in parallel in urgent care; first-line, preferred, confirmatory, definitive and gold-standard labels appear only when the chapter explicitly states them.

01
First-line clinical assessmentFirst stepFirst line
Why
Diagnose a typical presentation and measure functional impact.
Interpretation and limitations
Age, activity-related pain and brief stiffness can establish diagnosis; document gait, range, strength and alternative pain sources.
02
Plain radiographs when indicated
Why
Assess atypical disease or plan surgery.
Interpretation and limitations
Weight-bearing views show structural change but correlate imperfectly with pain and should not be used as a referral gate alone.
03
Blood tests only for an alternative
Why
Investigate infection, inflammation or malignancy when suggested.
Interpretation and limitations
CRP, FBC and other tests are not routine for typical osteoarthritis; normal values cannot clear an acutely septic joint.
04
MRI for a specific differential
Why
Detect occult fracture, osteonecrosis, tumour or unexplained soft-tissue disease.
Interpretation and limitations
Avoid routine MRI for radiographic osteoarthritis; incidental labral and cartilage changes may not explain symptoms.
05
Diagnostic injection selectively
Why
Clarify whether pain arises from the hip when spine and regional disease coexist.
Interpretation and limitations
Temporary response can support localisation but does not quantify structural severity or guarantee replacement outcome.
06
Preoperative assessment
Why
Define anatomy, anaesthetic risk and modifiable factors after referral.
Interpretation and limitations
Use standardised radiographs and patient-centred optimisation without converting comorbidity into an automatic exclusion.

06Differential diagnosisRealistic alternatives and the features that help distinguish them.

Greater-trochanteric pain

Lateral tenderness and pain lying on that side with relatively preserved passive hip movement suggests gluteal tendon or bursal disease.

Lumbar referred pain

Back pain, neurological symptoms and pain below the knee suggest radicular or spinal origin, although hip and spine disease frequently coexist.

Avascular necrosis

Risk exposure and rapid deep groin pain may precede radiographic collapse; MRI detects earlier femoral-head disease.

Inflammatory arthritis

Prolonged morning stiffness, several swollen joints and systemic features support inflammatory disease rather than isolated mechanical hip symptoms.

Occult fracture or malignancy

Acute load failure or unremitting constitutional pain requires urgent imaging and must not be attributed to known degenerative change.

07ManagementImmediate care, first-line treatment, alternatives and escalation.

01TypicalDiagnose clinically and begin core careFirst stepThe person is 45 or older with activity-related pain and absent or brief morning stiffness and no red flags.

1Explain the diagnosis and variable relationship between symptoms and structural change without ordering routine imaging.
2Prescribe tailored strengthening, aerobic and range exercise and address weight, gait aids and functional barriers.
3Use medication only to enable activity, beginning with the safest suitable local or short systemic option.
4Set a review against walking, sleep and personal goals rather than pain score alone.

02AtypicalInvestigate the alternativeAlternativeAge, tempo, stiffness, examination or systemic findings do not fit routine osteoarthritis.

1Use urgent fracture or infection pathways when weight bearing, physiology or passive movement is severely abnormal.
2Obtain targeted radiographs, blood tests or MRI for the specific competing diagnosis.
3Refer inflammatory, oncological or osteonecrosis patterns to the appropriate specialist pathway.
4Do not let pre-existing osteoarthritis on imaging explain a new red-flag syndrome.

03EscalationRefer for replacement from impactEscalationPain, stiffness and function substantially impair quality of life despite effective or unsuitable non-surgical care.

1Discuss replacement benefits, complications, recovery, alternatives and the person's desired functional outcome.
2Refer using clinical judgement without numerical-score or arbitrary age, smoking, comorbidity or BMI exclusion.
3Optimise anaemia, smoking, weight, diabetes, medicines and support while preserving timely surgical assessment.
4Continue active treatment and safety review during waiting and reassess any sudden deterioration.

Key medicines and prescribing safety2 treatments · regimens, roles and cautions

Reduces nociceptive and inflammatory pain sufficiently to support exercise, sleep and function.

Oral NSAID with gastroprotection when appropriate

If a topical NSAID is ineffective or unsuitable, prescribe one oral NSAID at the lowest effective licensed adult dose for the shortest necessary period and co-prescribe a proton-pump inhibitor such as omeprazole 20 mg orally once daily while NSAID treatment continues when appropriate.

Review ulcer or bleed history, renal and liver function, cardiovascular disease, blood pressure, frailty, pregnancy, anticoagulants, antiplatelets and other nephrotoxins; avoid combining NSAIDs and stop during significant dehydration or acute kidney injury.

Can temporarily reduce pain and enable rehabilitation or decision-making without implying structural modification.

Intra-articular corticosteroid

Use one image-guided intra-articular corticosteroid injection under the local hip-injection protocol when other pharmacological treatment is ineffective or unsuitable or a short analgesic window will support exercise; explain that benefit is usually short term, around 2 to 10 weeks.

Exclude infection, discuss transient hyperglycaemia, bleeding and rare joint infection, check anticoagulation and timing relative to planned arthroplasty, and avoid serial automatic injections without reassessing diagnosis and goals.

08ComplicationsImportant consequences, why they occur and why they matter clinically.

Mobility and independence loss

Pain and restricted flexion impair walking, stairs, footwear, washing and transfers and can increase care needs.

Falls and deconditioning

Weakness, reduced confidence and avoidance of activity lower cardiovascular fitness and increase fall and frailty risk.

Secondary regional pain

Altered gait can aggravate lumbar, contralateral hip and knee symptoms and obscure the principal pain generator.

Analgesic harm

Repeated oral NSAIDs or opioids can produce gastrointestinal, renal, cardiovascular, cognitive and dependence complications without improving joint mechanics.

Surgical complications

Replacement can relieve pain but carries infection, dislocation, thrombosis, fracture, nerve injury, leg-length change, wear and revision risks.

09Monitoring and follow-upTreatment response, safety checks and longer-term review.

Review walking distance, stairs, sleep, dressing, work and personal goals rather than radiographs alone.
Assess exercise progression, abductor strength, gait-aid technique and falls or deconditioning at each planned review.
Monitor NSAID gastrointestinal, renal, cardiovascular and blood-pressure effects and deprescribe when no functional benefit is evident.
Track weight support and metabolic health without withholding effective care as a punishment for incomplete weight loss.
Re-screen for sudden pain, fever, inability to bear weight, night symptoms or neurological change when the course alters.
During surgical waiting, maintain active management and update frailty, anaemia, diabetes, smoking and home support.

10Special situationsVariants, exceptions and circumstances that change the usual approach.

The knee can be the hip

Femoral and obturator referral means hip osteoarthritis may present as knee pain despite an unremarkable knee examination.

Imaging is not the diagnosis

Typical osteoarthritis can be diagnosed clinically, and radiographic severity should not replace symptom and function assessment.

Exercise pain can be acceptable

A short increase during progressive strengthening does not imply joint damage when the programme is graded and recovery is monitored.

Weight discussion must enable care

Weight loss can improve symptoms and risk, but it is a supported treatment rather than an arbitrary prerequisite for referral.

Injection benefit is deliberately temporary

The two-to-ten-week window should advance rehabilitation or clarify decisions rather than reset an endless injection cycle.

Comorbidity informs, not excludes

Individual risk discussion and optimisation are more equitable and clinically useful than blanket denial of arthroplasty.

11Common pitfallsFrequent interpretation and management errors.

01
Ordering routine imaging for every typical case and then treating the radiograph rather than the person's function.
02
Failing to examine the hip in unexplained knee pain or the spine in posterior or neurological pain.
03
Advising rest instead of progressive strengthening and aerobic activity.
04
Using repeated paracetamol, opioids or NSAIDs without demonstrating meaningful functional benefit and monitoring toxicity.
05
Presenting corticosteroid injection as disease-modifying or failing to exclude infection.
06
Withholding referral solely because of age, BMI, smoking or a numerical score.