Conservative (Non-operative) Treatment of Hip Arthritis
Non-operative treatment is the preferred treatment for patients with mild to moderate hip osteoarthritis. Non-operative treatments often include a combination of life-style changes and medications. These can be very therapeutic if an individual adheres to the program. Treatment often requires a period of trial and error on the part of the patient. Ultimately the patient will be the best judge of which combination of conservative treatment options are most helpful. The goals of non-operative treatment are to improve the symptoms associated with hip arthritis, slow disease progression, and delay or avoid surgical treatment. Conservative treatment options for hip osteoarthritis that may be beneficial include:
- Activity Modification
- Weight Loss
- Physical Therapy and Exercise Programs
Avoiding or changing the nature of activities to reduce excessive stress on the hip joint is an important first step in non-operative treatment. This will not only help with symptomatic relief but will also reduce further wear on the articulating surfaces of the joint. Some activities to avoid include running, jumping and any other repetitive high impact movement. It is important to replace high impact activities with lower impact exercises to maintain strength, balance and cardiovascular fitness. Lower impact activities include swimming, cycling and resistance exercises.
Another component of activity modification is the use of proper footwear. Good shoes are important for symptom reduction. Footwear can affect the way load is distributed through the legs while walking. A supportive sneaker/tennis shoe with a hard sole and soft insert will help to more appropriately distribute the impact caused by walking.
Assistive devices to offload the hip and add stability can significantly decrease the load the affected hip joint. One such assistive device is a cane used in the opposite hand from the symptomatic hip. This can help to offload stress placed on the hip with walking. A walker can also be used for the same purpose.
More information on the proper way to use canes and walkers can be found here:
Excess weight has long been known to aggravated the pain associated with both hip and knee osteoarthritis. It may also be a risk factor for the development of arthritis. This is because excess weight causes increased force through the hip joint with activity, leading to joint wear and pain. There may also be systemic (whole body) effects associated with obesity that contribute to disease progression.
As such, weight loss in overweight individuals can have a positive effect on symptom reduction, quality of life, and physical function. Although weight loss can be hard to achieve, even modest weight loss through a combination of light to moderate intensity exercise and dietary modifications can have a significant impact on symptoms of hip osteoarthritis.
Physical Therapy and Exercise Programs
The importance of regular exercise cannot be overstated when it comes to managing hip osteoarthritis. Exercise serves to reduce symptoms and preserve joint function at or above its current level. A strictly followed exercise program can delay or even prevent disability associated with osteoarthritis. In terms of which exercises are superior for the management of hip osteoarthritis, there is no universal consensus, although exercises that build the muscles around the hip joint and low back are likely to be beneficial. In addition, any exercise that exacerbates pain in the hip joint should be avoided. Exercises should be tailored to the needs of the individual, taking into account their lifestyle, baseline activity level and access to fitness spaces.
Individuals with hip osteoarthritis may be prescribed physical therapy as part of a conservative treatment protocol. The physical therapist will teach and supervise appropriate exercises for joint health. These exercises will be focused on improving strength, balance, and flexibility. The movements may begin with passive exercises, meaning the physical therapist is moving the joint for you. Later in treatment, the movements will become active, meaning you are performing them yourself with guidance. Activities will target specific muscle groups responsible for hip flexion, extension, internal rotation and external rotation. More information about these muscles can be found on the Hip Anatomy page.
Once the appropriate exercise techniques are learned, exercises can be integrated into a home exercise program and should be performed with regularity. Although it can sometimes be hard to adhere to a regular exercise program, the benefits will only be achieved with consistent performance. In particularly motivated individuals, hip exercises can also be learned without guidance from a physical therapist.
Example exercises for hip osteoarthritis may include the following:
In addition to exercises, the physical therapist can also use alternate treatment modalities to help alleviate symptoms. These include taping, ultrasound, massage and electrical stimulation.
Medications can be added to a conservative treatment program to help decrease they symptoms of pain and discomfort associated with hip arthritis. Symptomatic improvement with medication has the added benefit of making it easier to exercise and thus maintain joint function. There are a few common medications that may be considered, the most common of which are Non-steroidal anti-inflammatory drugs (NSAIDs). Notably, opioids are not recommended for the treatment of hip osteoarthritis due to the high incidence of addiction.
NSAIDs (non-steroidal anti-inflammatory drugs)
NSAIDs work by inhibiting enzymes called cyclooxygenases (COX). These enzymes normally produce substances that promote the cycle of pain and inflammation in the body. Common NSAIDs that may be used to treat osteoarthritic pain include ibuprofen, naproxen, celecoxib (Celebrex), and diclofenac.
NSAIDs can either be taken orally or applied locally to the hip joint as a gel (topical Voltaren gel). The advantage of local application is that the drug does not pass through the stomach, preventing some of its adverse effects.
Although NSAIDs are generally safe when used as prescribed, they are not without risk. Some of these risks include increased bleeding, ulcer formation, kidney damage and overdose. Given the significance of these risk factors, it is recommended to take the lowest effective dose of NSAIDs for only a short duration to treat symptoms. It is also recommended that NSAIDs be taken with food to minimize the risk of irritating the stomach.
Acetaminophen (brand name: Tylenol) works via a different mechanism than NSAIDs. The mechanism of action is not known for certain, but it is thought to activate descending serotonin inhibitory pathways that dampen pain. As such, Acetaminophen can safely be given at the same time as NSAIDs in most cases.
Some risks associated with acetaminophen use include overdose as with most other medications, as well as potential allergy to a component of the drug.
Glucosamine is a substance produced by chondrocytes (cartilage-forming cells) that acts in the cartilage production pathway. Chondroitin is a substance normally present in the cartilage that maintains its structure. Glucosamine and chondroitin have been taken together in supplement form for many years with the goal of improving joint function and slowing progression of osteoarthritis. Unfortunately, the use of glucosamine-chondroitin has not been shown to be beneficial when compared to placebos in well done research studies (that studied knee osteoarthritis).
Nevertheless, some patients report subjective improvement in their symptoms when they take glucosamine and/or chondroitin sulfate. Some of the perceived benefits of glucosamine-chondroitin may stem from the placebo effect. This means the act of taking the supplement has a psychological effect, conferring some symptomatic improvement. The AAOS (American Academy of Orthopedic Surgeons) guidelines about glucosamine-chondroitin state that it does not perform better than placebo for improving symptoms and joint function in people with hip osteoarthritis. Although glucosamine-chondroitin is a supplement and thus not regulated by the Food and Drug Administration (FDA), research on the effects of glucosamine-chondroitin suggests it is generally safe to take.
The local injection of corticosteroids (cortisone) into the hip joint can reduce inflammation and pain associated with arthritis for a variable period of time, sometimes lasting months. This symptom relief can make it easier to exercise and perform activities of daily living. Injections into the hip joint require precise placement of a needle, guided by a special type of x-ray called fluoroscopy. Because the joint space is relatively deep in the body, the needle must be long and requires skill to be placed precisely.
The injection will contain a short-acting numbing medication that can relieve symptoms almost immediately. However, the short-term effect wears off quickly, and disruption to tissue caused by the procedure may increase pain for a few days before significant symptomatic improvement is felt.
Repeat cortisone injections into the hip should be given at least 3 months apart. Additionally, there may be a limit to the number of injections that can be safely given. Long term use may cause damage to the joint cartilage. Other potential side effects of cortisone injections are rare, but can include local bone death (osteonecrosis), joint infection, nerve damage, temporary blood sugar increase, facial flushing and local bone thinning (osteoporosis).
Hyaluronic Acid Injections
Hyaluronic acid is a critical component of synovial fluid, which is a protective fluid located in the joint space. Injection of hyaluronic acid into the joint space is thought to protect cartilage, delaying the progression of osteoarthritis and potentially improving joint function. Hyaluronic acid must be injected using the same technique as cortisone injections, including the use of fluoroscopy.
The use of hyaluronic acid to treat hip osteoarthritis is much less common than knee osteoarthritis. In fact, the American Academy of Orthopedic Surgeons (AAOS) does not recommend its use to treat hip osteoarthritis at this time. This is because there has been no substantial research indicating that it works to relieve symptoms or improve joint function.