Osteoarthritis of the Hip

Rudy Handoyo

Department of Physical Medicine and Rehabilitation, Dr. Kariadi General Hospital,

Faculty of Medicine, University of Diponegoro, Semarang, Indonesia

rud_hand@hotmail.com

Keywords: Osteoarthritis, Hip, Degenerative Joint.

Abstract: Osteoarthritis (OA), often referred to as “wear-and-tear” arthritis, or degenerative joint disease, is the

most common form of joint disorder. The effects of OA on the large joints of the lower extremities,

including the hips, can result in reduced mobility and marked physical impairment that can lead to loss of

independence and to increased use of health care services such as dependency in walking, stair climbing,

and rising from a seated position. Disease initiation and progression are caused by a combination of local

factors and systemic factors that vary between individuals and its progression caused by a combination of

endogenous and environmental risk factors. The management of hip OA included: 1. Pharmacological

treatment: analgesic, NSAID, duloxetine, opioid, intra articular injection. 2. Rehabilitation management:

joint rest, physical modalities, exercise, appropriate joint use, weight control, assistive devices and

orthosis, ergonomic and environmental adaptation, education, psychological intervention. 3. Surgery.

Medical rehabilitation goal such as: decrease pain/symptoms, increase range of motion, maintain the

strength of muscle, increase aerobic capacity, optimize daily function and minimize disability. Exercise

therapy should be the mainstay therapy when possible, with physical modalities utilized as an adjunct.

Evaluate and correct for abnormal biomechanics, using assistive devices and orthosis as necessary.

1 INTRODUCTION

Osteoarthritis (OA), often referred to as “wear-and-

tear” arthritis, or degenerative joint disease, is the

most common form of joint disorder. As a

degenerative disorder, OA can involve any joint, and

it primarily affects the articular cartilage and

surrounding tissues. The hip joint is one of the

body’s largest weight-bearing joints and is

commonly affected by OA. The OA process

involves progressive loss of articular cartilage,

subchondral cysts, osteophyte formation,

periarticular ligamentous laxity, muscle weakness,

and possible synovial inflammation (Lespasio et al.,

2018). The effects of OA on the large joints of the

lower extremities, including the hips, can result in

reduced mobility and marked physical impairment

that can lead to loss of independence and to

increased use of health care services such as

dependency in walking, stair climbing, and rising

from a seated position (Lespasio et al., 2018).

2 DISCUSSION

The reported prevalence of hip osteoarthritis varies

greatly due to differences in the definition of

osteoarthritis used (radiographic, symptomatic, or self-

reported) and the characteristics of the sample (Bennell,

2013). The prevalence rates varied from 0.9% to 45%.

Men and women showed similar overall prevalence:

11.5% for men and 11.6% for women. In contrast to

prevalence, information on the incidence of hip

osteoarthritis is limited, reflecting greater methodological

challenges. Cumulative incidence rates varying from

3.8% over 10 years to 33% over 8 years (Bennell, 2013).

The lifetime risk for symptomatic hip OA is 19% for

men and 29% for women (Suri et al., 2012).

2.1 Etiology and Risk Factors

Disease initiation and progression are caused by a

combination of local factors and systemic factors

that vary between individuals (figure 1 and 2) and its

progression caused by a combination of endogenous

Handoyo, R.

Osteoarthritis of the Hip.

DOI: 10.5220/0009061900370043

In Proceedings of the 11th National Congress and the 18th Annual Scientiﬁc Meeting of Indonesian Physical Medicine and Rehabilitation Association (KONAS XI and PIT XVIII PERDOSRI

2019), pages 37-43

ISBN: 978-989-758-409-1

and environmental risk factors (Lohmander et al.,

2017).

Figure 1: Etiology and risk factor for hip osteoarthritis.

Figure 2: Risk factors for osteoarthritis and related disability.

KONAS XI and PIT XVIII PERDOSRI 2019 - The 11th National Congress and The 18th Annual Scientiﬁc Meeting of Indonesian Physical

Medicine and Rehabilitation Association

2.2 Signs And Symptoms

 Pain:

o Progressively increasing

o Aggravated - movement; when hip is

loaded wrong or too long; cold weather

o Eased with continuous movement

o Commonly in groin/thigh, radiating to

buttocks or knee

o End-stage: Constant pain, night pain



Stiffness:

o Morning stiffness with end-stage

osteoarthritis, usually eased with movement

(<1 hour)

 “Locking" of hip movement

 Decreased range of motion - leading to joint

contractures and muscle atrophy

 Crepitation with movement

 Gait abnormalities - short limb gait, antalgic

gait, trendelenburg gait

 Leg length discrepancy



Local inflammation

2.3 Criteria OA of The Hip

Table 1: Clinical (history, physical examination, laboratory) classification criteria for osteoarthritis of the hip, classification

tree format.

Hip pain

And

Hip internal rotation < 15°

And

ESR ≤ 45 mm/hour

(If ESR not available, substitute hip flexion ≤ 115°)

Hip internal rotation ≥ 15°

And

Pain on hip internal rotation

And

Morning stiffness of the hip ≤ 60 minutes

And

Ages > 50 years

Hip pain

And

At least 2 of the following 3 features

ESR < 20 mm/hour

Radiographic femoral or acetabular osteophytes

Radiographic joint space narrowing (superior, axial, and/or medial)

Figure 3: Combined Clinical (history, physical examination, laboratory) and radiographic classification criteria for

osteoarthritis of the hip, traditional format.

2.4 Diagnosis

 History

 Physical examination



X-ray



CT scan



MRI

2.5 Management and The Goal

 Pharmacological treatment:

o Analgesic: paracetamol

o NSAID

o Duloxetine

o Opioid: Tramadol

o Intra articular injection: corticosteroid

 Rehabilitation management:

(Marks, 2015 ; Stemberger and Kerschan, 2013)

Osteoarthritis of the Hip

o Joint rest

o Physical modalities

o Exercise

o Appropriate joint use

o Weight control

o Assistive devices and orthosis

o Ergonomic and environmental adaptation

o Education

o Psychological intervention

o Surgery: Total Hip Replacement

Table 2: Combined clinical (history, physical examination, laboratory) and radiographic classification criteria for

osteoarthritis of the hip, classification tree format.

Hip pain

And

Femoral and/or acetabular osteophytes on radiograph

ESR ≤ 20 mm/hour

And

Axial joint space narrowing on radiograph

The goal of Medical Rehabilitation are to decrease

pain/symptoms, Maintain and increase range of

motion, Maintain the strength of muscle, Increase

aerobic capacity, Optimize daily function, and

Minimize disability (Talmage and Lemke, 2001;

Hanada, 2003)

2.5.1 Joint Rest

In hip pain patients automatically tend to rest more,

but it will be better to advise patients with this

condition to get rest periods of 20 - 60 minutes

duration. Such rest periods allow the cartilage to

rehydrate. Although there is little scientific

evidence that rest or joint unloading might be

effective in preserving or improving the mobility

and work capacity of persons with osteoarthritis,

relief of pain is usually said to be proportional to the

amount of protection from weight bearing (Marks,

2015).

Muscles around a painful joint are thought to

fatigue more readily than muscles of a healthy pain

free joint, and can work more effectively if they are

not fatigued, protection from weight bearing appear

to influence the work capacity of individuals with

hip osteoarthritis. Rest can reduce or minimize joint

inflammation and protect an inflamed osteoarthritic

joint from further damage. Patients are advised to

make appropriate planning of activities and

avoidance of prolonged or repetitive activities

(Marks, 2015).

2.5.2 Physical Modality

To relieve pain transiently and to aid muscle

relaxation particularly during an acute flare of the

disease, and to treat associated inflammatory

conditions ice therapy or transcutaneous electrical

nerve stimulation can be considered. In mild sub-

acute or chronic disease phases, such modalities:

short wave diathermy and ultrasound applications,

may help to facilitate joint mobilization and

stretching procedures needed to maintain or increase

hip joint range of motion (Marks, 2015).

2.5.3 Exercise

Exercise is designed to reduce or prevent muscle

weakness and atrophy, maintain joint range of

motion, and improve endurance. The

implementation of exercises should not be stressful

or injurious to the joints. Since joint stiffness, pain,

disability and muscle weakness are related in

patients with hip osteoarthritis a series of carefully

graded non-weight bearing isometric strengthening

exercises carried out on a daily basis to improve hip

abductor and hip extensor muscle strength and

endurance. Once muscle spasm and any evidence of

joint inflammation have subsided, these exercises

might be progressed to pain free isotonic exercises

performed thrice weekly. Progressing too rapidly

could worsen pain, likely discouraging patients to

continue training. On the other hand, too light

exercise may remain ineffective (Uusi et al., 2017).

Well designed non-weight bearing or partial

weight bearing low-impact walking and conditioning

exercises performed within the limits of pain and

motion on a stationary bicycle, or in a warm pool

(temperature 30˚C -34˚C) and swimming exercises

in water, have all been shown to promote

functioning in those with no signs of acute

KONAS XI and PIT XVIII PERDOSRI 2019 - The 11th National Congress and The 18th Annual Scientiﬁc Meeting of Indonesian Physical

Medicine and Rehabilitation Association

inflammation. The re-education of postural control

and balance is important to prevent fall (Marks,

2015), because falls, which can cause further

traumatic hip joint damage, are so common in

people with hip osteoarthritis.

Safety of an intervention is an important point.

In general, exercise is safe and well tolerated by

most patients with lower limb OA. However, the

patient has to be informed that disease activity can

vary from day-to-day, and that signs of excessive

exercise stress include joint pain during activity,

pain lasting more than 1–2 hour after exercise,

swelling, fatigue, and weakness (Stemberger et al.,

2013).

2.5.4 Appropriate Joint Use

Patients should be advised to avoid prolonged static

activities, contact sports, repetitive high impact

loading or over-exercising. Patients also should try

to carry out activities as ease and comfortable as

possible, and avoid rapid walking or needless stair

climbing. Hip joint stresses may also be lessened by

limiting the weight of loads carried (Marks, 2015).

2.5.5 Weight Control

The maintenance of an optimal body weight or the

implementation of a weight reduction program for

overweight or obese patients may reduce

unwarranted stresses on an osteoarthritic hip joint.

Another potential problem related to obesity that

could destroy articular cartilage, or cause greater

axial loading than the hip joint can accommodate

(Marks, 2015).

2.5.6 Assistive Device and Orthosis

It has been widely reported that people with hip

osteoarthritis who have unsteady gait or advanced

disease, may improve their functional capacity and

acquire some protection from untoward mechanical

perturbations of the affected joint through the use of

crutches, canes, walkers, or braces. It is further

believed that footwear designed to absorb shock,

shoes that give good support, shoes that have thin

non-slip soles, or the use of corrective foot orthotics

such as a heel lift in one shoe—if leg lengths are

unequal—may prove beneficial, while dress aids,

such as a long shoe horn or stocking stretcher, may

help to facilitate those daily activities that require

bending and reaching (Marks, 2015).

2.5.7 Ergonomic and Environmental

Adaptations

Adaptations to the home environment may further

relieve some unwarranted hip joint stresses that

could otherwise hasten hip joint damage. Joint

protection during functional activities may also be

enhanced by the use of raised toilet seats, grab bars

next to toilets and in tubs or shower facilities and

using adapted aid to do the activity of daily living

(Talmage and Lemke., 2001). Arm rests on chairs

and higher chairs may also prove beneficial for

people with end stage hip osteoarthritis who are not

candidates for surgery (Marks, 2015).

2.5.8 Education

For people with hip osteoarthritis, education about

their condition, and their role in its management, is a

vital first step towards lessening their level of

functional disability and decreasing their pain. They

may experience an overall improvement in life

quality when compared to those receiving no form

of education (Marks, 2015).

2.5.9 Psychological Intervention

Hip osteoarthritis can become a chronic pain and

make the patients get depression condition and need

psychological support to face the pain.

11,12

One study

found that patients whose spouses were involved in

their program had less pain and psychological

disability compared with patients whose spouses did

not participate (Talmage and Lemke., 2001).

2.5.10 Evidence Based and

Recommendation

Most frequently recommended for exercise is

aquatic exercise and biking because provide

cardiovascular training without putting undue stress

on the joint of lower extremity, so to prevent the

inflammation and increasing the pain (Talmage and

Lemke, 2001). The benefits such as increased

aerobic capacity, increased endurance, increased

muscular strength, assistance with weight loss,

psychological benefit: decreased stress, depression

and give socialization for that activity. Cochrane T

at al. (2005) reported: Group-based exercise in water

over 1 year can produce significant reduction in pain

and improvement in physical function in older adults

with lower limb OA, and may be a useful adjunct in

the management of hip and/or knee OA (Cochrane et

al., 2005). Fransen M et al. (2014) reported the

Osteoarthritis of the Hip

conclusions: Pooling the results of 10 RCTs

demonstrated that land-based therapeutic exercise

programs can reduce pain and improve physical

function among people with symptomatic hip OA

(Fransen et al., 2014). Larmer PJ (2014) conclude

that exercise and education is important thing in the

management of OA hip (Larmer et al., 2014).

Fernades L et al (EULAR - 2013) give 11

recommendation for the non pharmacological

management of knee and hip osteoarthritis such as

biopsychosocial approach, education, exercise,

weight loss, life style changes, walking aid

(Fernandes, 2013).

Table 3: Pharmacological recommendation for the initial management of hip OA.

We conditionally recommend that patients with hip OA should use one of the following:

Acetaminophen

Oral NSAIDs

Tramadol

Intra articular corticosteroid injections

We conditionally recommend that patients with hip OA should not use one of the following:

Chondroitin sulfat

Glucosamine

We have no recommendation regarding the use of the following:

Topical NSAIDs

Intra articular hyaluronate injection

Duloxetine

Opioid analgesics

*No strong recommendation were made for the initial pharmacologic management of hip osteoarthritis (OA). For

patients who have an inadequate response to initial pharmacologic management see the Results for alternative

strategies. NSAIDs: non steroidal anti inflammatory drug

Table 4: Non Pharmacological recommendations for the management of hip OA

We strongly recommend that patients with hip OA should do the following:

Participate in cardiovascular and /or resistance land based exercise

Participate in aquatic exercise

Lose weight (for persons who are overweight)

We conditionally recommend that patients with hip OA should do the following:

Participate in self-management programs

Receive manual therapy in combination with supervised exercise

Receive psychological intervention

Be instructed in the use of thermal agents

Receive walking aids, as needed

We have no recommendation regarding the following:

Participation in balance exercises, either alone or in combination with strengthening exercise

Participation in Tai Chi

Receive manual therapy alone

Table 5: Recommendations for hip OA: non pharmacological therapies.

Land-based exercise

Aquatic exercise

Lose Weight

Self-management program

Manual therapy and physiotherapy

Psychological intervention

Thermal agents

Walking aids

Balance exercises

Tai Chi

Manual therapy alone

Electrotherapy

Therapeutic ultrasound

Pulsed magnetic field therapy

KONAS XI and PIT XVIII PERDOSRI 2019 - The 11th National Congress and The 18th Annual Scientiﬁc Meeting of Indonesian Physical

Medicine and Rehabilitation Association

Acupuncture

Ergotherapy

Manual massage

Mudpacks

Manual LD

Strong. B Moderate. C Unable to recommend. X not mentioned

3 CONCLUSIONS

Practice points Rehabilitation of musculoskeletal

degenerative conditions should be patient-centered

and active participation should be emphasized

(Stemberger et al., 2013). Exercise therapy should

be the mainstay therapy when possible, with

physical modalities utilized as an adjunct. Evaluate

and correct for abnormal biomechanics, using

assistive devices and orthosis as necessary. Pain-

related fear will trigger avoidance of specific

movements and physical activity in general, called

fear of movement, which in turn will lead to

deconditioning. In other words, the muscles are

getting weaker, cardiovascular capacity will

decrease and as a result, not only is pain aggravated

(Hanada, 2003), but disability, lower quality of life

and depression are also observed (Marks, 2015 ;

Stemberger et al., 2013).

REFERENCES

Lespasio MJ, Sultan AA, Piuzzi NS, et al. 2018. Hip

osteoarthritis: A primer. Perm J, 22:17-084. DOI:

https://doi.org/10.7812/TPP/17-084

Bennell K.2013. Physiotherapy management of hip

osteoarthritis. Journal of Physiotherapy, 59: 145-57.

Suri P, Morgenroth DC, Hunter DJ. 2012. Epidemiology

of osteoarthritis and associated comorbidities. Physical

Medicine and Rehabilitation, 4: S10-S19

Lohmander LS, Englund PM, Dahl LL, Roos EM. 2007.

The long-term consequence of anterior cruciate

Ligament and meniscus injuries: osteoarthritis.

American Journal of Sports Medicine, 35: 1756-79

Marks R. 2015. Non-operative management of hip

osteoarthritis. Pain Studies and Treatment, 3: 7-22.

http://dx.doi.org/10.4236/pst.2015.32002

Stemberger R, Kerschan-Schindl K. 2013. Osteoarthritis:

physical medicine and rehabilitation –

nonpharmacological management. Wien Med

Wochenschr, 163:228–235. DOI 10.1007/s10354-013-

0181-9

Talmage DM, Lemke CL. 2001. Common conditions of

the lower extremity. In: Bougie JD, Morgenthal AP,

eds. The aging body. Conservative management of

common neuromusculoskeletal conditions. New York:

McGraw-Hill Companies, 205-42

Hanada EY. 2003. Efficacy of rehabilitative therapy in

regional musculoskeletal condition. Best Practice &

Research Clinical Rheumatology, 17: 151-66

Uusi_Rasi K., et al., 2017. Exercise training in treatment

and rehabilitation of hip osteoarthritis: a 12-week pilot

trial. Journal of Osteoporosis, 1-7

Talmage DM, Lemke CL. 2001. Common conditions of

the lower extremity. In: Bougie JD, Morgenthal AP,

eds. The aging body. Conservative management of

common neuromusculoskeletal conditions. New York:

McGraw-Hill Companies, 205-42

Nadler SF. 2004. Non pharmacologic management of pain.

JAOA, 11(8): 6-12

Cochrane T, Davey RC, Matthes Edwards SM. 2005.

Randomised controlled trial of the cost-effectiveness

of water-based therapy for lower limb osteoarthritis.

Health Technol Assess, 9(31):iii-1v, 1x-xi,1-114

Fransen M, McConnell S, Hernandez-Molina G,

Reichenbach S. 2014. Exercise for osteoarthritis of the

hip. Cochrane Database of Systematic Reviews, Issue

4. Art. No.: CD007912. DOI:

10.1002/14651858.CD007912.pub2.

Larmer PJ., et al., 2014. Systematic review of guidelines

for the physical management of osteoarthritis.

Archives of Physical Medicine and Rehabilitation,

95:375-89

Fernandes L. 2013. EULAR recommendations for the

non-pharmacological core management of hip and

knee osteoarthritis. Ann Rheum Dis, 72:1125–1135.

doi:10.1136/annrheumdis-2012-202745

Hochberg MC., et al., 2012. American college of

rheumatology 2012 recommendations for the use of

nonpharmacologic and pharmacologic therapies in

osteoarthritis of the hand, hip, and knee. Arthritis Care

& Research, 64: 465-74

Osteoarthritis of the Hip