Hip Osteoarthritis
Hip osteoarthritis is a gradual change in the whole hip joint, including the cartilage and the bone beneath it. It usually starts as a deep ache in the groin or front of the thigh after walking, with morning stiffness that eases with movement. How much it hurts and how the X-ray looks can differ a lot.
Key points
- What usually helps
- Exercise and education are the first treatment. In severe arthritis, a hip replacement gives larger gains.
- What you can do now
- Walk in shorter bouts through the day. Ease morning stiffness with heat and movement.
- How long it takes
- Many people see meaningful change within 6 to 12 weeks, and keeping it up matters over the long term.
- When to see a doctor first
- Some signs need medical care the same day. Check the list before you start treatment.
Symptoms
Does this sound like you?
- Deep, aching groin pain (most commonly felt in the groin or front of thigh)
- Morning stiffness that usually eases within about 30 minutes of gentle movement
- Pain with activities on your feet (walking, standing for long periods, climbing stairs)
- Less ability to turn the hip inward (internal rotation), often the first and biggest movement lost
- Less movement overall (difficulty bringing the knee towards the chest or moving the leg out to the side)
- Pain may refer to buttock or even the knee (which can be misleading)
Often alongside it
- Grinding sensation (crepitus) with hip movements, though not always present
- More pain at the end of the day (a sign that load plays a part)
- Stiffness after periods of rest
- Low back pain from moving differently to protect the hip
- Changes in the way you walk, and in how the back, hip, knee and ankle share the load
- Trouble with everyday tasks (putting on shoes and socks, getting out of low chairs)
- Doing less of the activities you enjoy because of the pain that follows
It usually starts gradually, as a deep ache in the groin after a long walk that is easy to mistake for a muscle strain. Morning stiffness follows, so putting on socks and shoes becomes harder. Over months or years the ache becomes more persistent. Many people tell me they have slowly given up activities like hiking, gardening or playing with grandchildren. The typical picture is someone over about 45 with activity-related groin pain, morning stiffness that eases with movement, and reduced inward rotation of the hip on examination.
Before using this comparison, check when these symptoms need a doctor first.
When to see a doctor first
Get seen today
A hot, swollen or suddenly very painful hip, a fever, or feeling unwell
Possible joint infection. Get medical assessment today, or go to emergency if you feel unwell. Infection is possible even without a fever
You cannot put weight on the leg after a fall, or hip pain that comes on or worsens quickly without a clear reason
Possible fracture or loss of blood supply to the bone (avascular necrosis). Same-day medical assessment; go to emergency after a fall
Check with your doctor
Severe pain at night or at rest, constant pain, or unexplained weight loss
Not typical of osteoarthritis. See your family doctor promptly to look for other causes
Treatment
How it is treated
Main approach. Exercise and education are the recommended first treatment, and they can improve pain and function over several months. In severe osteoarthritis, a hip replacement gives larger gains than exercise.
Alongside it. Learning how load relates to what your hip can handle, and how to adjust your activities, lets you manage the condition yourself. It also reduces the habit of avoiding movement out of fear (fear-avoidance), which adds to disability.
Managing it over time. Keeping up a strengthening and activity routine helps hold on to the gains, and for some people it helps put off the need for a joint replacement.
A typical rehabilitation progression
Three phases, from settling symptoms to returning to full activity.
Recovery from hip osteoarthritis is usually staged: calm the symptoms first, then rebuild the strength and capacity of the area, then return to your full activities. The phases below show how that can progress.
Phase 1Calming the Joint and Restoring Tolerance (Weeks 1 to 4)
The 2025 update of the clinical guideline for hip (Koc, Cibulka and colleagues) strongly recommends patient education and exercise tailored to you (individualised exercise) as the first treatment. The early weeks are about removing friction, not chasing strength. I help you find an amount of walking, standing and stair work you can tolerate, add movement that does not press the joint surfaces hard together (low-compression) to help lubricate the joint, and pair it with a short daily warm-up for morning stiffness.
Example exercises
- Lying on your back, turning the hip in and out (internal and external rotation) through a comfortable range, 2 sets of 10 slow repetitions, morning and evening, to shorten start-up stiffness
- Stationary bike with a high seat and easy resistance, 8 to 12 minutes, as a low-impact way to move the hip (the Cochrane review of exercise for hip osteoarthritis, Fransen and colleagues 2014, supports exercise in general for pain and function)
- Lying on your back or sitting, pressing the leg outward against a belt or a wall and holding still ( ), 4 sets of 30 seconds, to start loading the muscles on the side of the hip (abductors) without flaring the joint
- Walking in short bouts you can tolerate, split across the day rather than one long walk, each short enough that you finish with an ache below 3 out of 10
- Heat before movement, small hip rotation circles before getting out of bed, and pacing tips for stairs and getting into the car
Possible progression milestones
Morning stiffness down to under 20 minutes on most days, a 20 to 30 minute walk without stopping and without a flare the next day, and being able to explain in your own words how load relates to what the hip can handle.
Phase 2Strengthening the Muscles Around the Hip (Weeks 5 to 12)
This mirrors the structured exercise on land, rather than in water, that the 2019 guideline from the Osteoarthritis Research Society International (OARSI, Bannuru and colleagues) lists as a core treatment for hip osteoarthritis. The goal here is building strength around the hip, particularly in the muscles that move the leg out to the side and back (abductors and extensors), so everyday tasks feel easier and more controlled. As an example, resistance might go up by about 10 percent a week when the hip stays settled over the following 24 hours. The right step depends on how your hip responds.
Example exercises
- Standing up from a chair and sitting back down (sit-to-stand), at a chair height that keeps pain below 3 out of 10, 3 sets of 8 to 12 reps, moving to a lower chair over this phase
- Hip hinge (bending forward from the hips with a straight back) to a chair or bench, first with body weight and then holding a weight at the chest (goblet hold), 3 sets of 10, to practise bending and lifting with the muscles at the back of the hips and thighs (posterior chain)
- Supported split squat (a squat with one foot forward and one back), hands on a bench, shallow depth at first, 3 sets of 8 per side
- Standing with a band around the legs, moving one leg out to the side (hip abduction) while keeping the pelvis level, 3 sets of 12 per side
- Stationary bike or walking in a pool, 20 to 30 minutes without stopping, 3 times a week, for fitness (aerobic capacity) and to keep the joint lubricated
Possible progression milestones
Rising from a standard dining chair without pushing off the thighs, walking 30 to 45 minutes without stopping and without a flare the next day, and managing 3 sets of 10 hip hinges holding 8 to 12 kilograms.
Phase 3Loading for Real-World Activity (Months 3 to 6 and beyond)
At this point the hip handles moderate loads and the aim is getting your activities back, whether that is hiking, gardening for an afternoon, playing with grandchildren, or getting back to yoga or pickleball. Loading moves on to single-leg work, hills and the demands of your own activities. This fits the 2025 hip osteoarthritis guideline's recommendations for training everyday tasks (functional training), walking (gait training) and balance.
Example exercises
- Step-ups to a 15 to 20 centimetre step with a focus on driving through the whole foot, 3 sets of 8 per side
- Squat to a box holding a weight at the chest (goblet squat), lowering the box gradually over this phase as range and confidence improve, 3 sets of 8
- Single-leg Romanian deadlift (standing on one leg and hinging forward at the hip) with a light touch on a chair or wall, 3 sets of 6 per side, for control of the muscles at the back of the hips and thighs
- Hill walking built up step by step, or carrying weights (loaded carries), for people whose goals include hiking or travelling with luggage
- Return to chosen recreation with a week-by-week exposure plan rather than an all-or-nothing comeback
Possible progression milestones
Back to the activities that mattered to you at the start and keeping them up, confidence on stairs and single-leg tasks, morning stiffness brief or gone, and a maintenance program you are willing to keep doing twice a week.
What you can do now
- Walk in shorter bouts through the day. Several shorter walks spread across the day, rather than one long one, keep you active without a sudden jump in load on the hip. Keep each walk short enough that you finish with an ache below 3 out of 10.If the hip is worse the next day, shorten the walks rather than stopping altogether.
- Ease morning stiffness with heat and movement. Morning stiffness usually eases with movement, and heat can help before you get going. Make small hip circles before getting out of bed, then, lying on your back, slowly turn the hip in and out through a comfortable range, 2 sets of 10, morning and evening.Use heat before activity, not during a sudden flare. If the hip is hot, swollen or suddenly very painful, or you feel unwell, see the warning signs on this page.
- Strengthen the hip regularly, building gradually. Exercise at a sensible dose can ease pain and improve function, and research found no sign that it harms the hip. Flares tend to follow a sudden jump in what you ask of the hip, so build up gradually and aim for regular sessions rather than hard ones.Start in a range that does not hurt. Painless grinding or clicking is not a reason to stop. If clicking comes with sharp pain, the hip giving way or truly locking, get it examined.
- If you run, ease off trails and downhills. Running is not the cause of hip osteoarthritis in most people, and in many cases you can keep running at a reduced amount. Cut back trail and downhill running first, then rebuild distance gradually, guided by how the hip feels over the next 24 hours.
What I use in clinic
- Therapeutic Exercise. The clinical guideline for hip osteoarthritis (2017, revised 2025) strongly recommends exercise tailored to the person (individualised exercise). It can improve pain and function, though in severe osteoarthritis hip replacement gives larger gains.
- Manual Therapy Combined with Exercise. Hands-on joint mobilization and soft tissue work give short-term relief and make exercise easier to tolerate.
- Patient Education. Understanding why it hurts and what to expect reduces fear and improves outcomes.
Recovery
How long it takes
Managing a long-term condition like hip osteoarthritis is an ongoing project, not a quick fix. Many people see meaningful improvements in pain and function within 6 to 12 weeks of consistent effort, but the real benefits come from building these habits into your life for good. There will be good days and bad days. Realistic markers of progress include: Can you walk for 5 minutes longer than last month? Do you feel more confident going up and down stairs? Is the morning stiffness lasting 15 minutes instead of 30? Did you get back to gardening for an hour without a major flare-up?
The changes in the joint's structure progress over time, but symptoms go up and down a lot. Many people keep excellent function with the right management. Pain does not directly match what imaging shows: your pain is real, but it is not decided by how the X-ray looks. Living with long-lasting pain can lead to fear of movement, anxiety and a feeling of fragility, but gentle movement built up gradually can help the nervous system become less sensitive (recalibrate).
What changes the timeline
- How severe the symptoms are, not what imaging shows (many people with severe changes on imaging have few symptoms)
- How active and motivated you are at the start
- Body weight and metabolic health
- Ways of moving that protect the hip but strain other areas (compensatory patterns)
- Keeping up with the exercise program and with managing load
- Understanding how pain works, and how load relates to what the hip can handle
- Fear that leads you to avoid movement, and expecting the worst (catastrophizing)
How I track it. I track how much the pain gets in the way of the tasks that matter to you, how well you move when I test those tasks in clinic, and how confident you feel in daily activities
Similar conditions
Conditions that can feel similar
- Greater Trochanteric Pain Syndrome (Gluteal Tendinopathy)
- Tenderness in one spot on the bony point of the outer hip (the greater trochanter) rather than groin pain, and severe pain lying on that side at night. When the examiner turns the hip inward (passive internal rotation), it still moves normally, unlike in hip OA.
- Femoroacetabular Impingement Syndrome
- Sharp pain at the front of the groin when the hip bends deeply and turns inward, in a younger, active person. A test that bends, crosses and turns the hip inward (FADIR) brings on the pain, and there may be catching during squats or getting out of a low car. Morning stiffness is usually brief compared with OA.
- Lumbar Spine Referral (Facet or Radicular Pain)
- Pain changes when you move your lower back rather than your hip, the hip moves fully and equally on both sides when the examiner moves it, and pain may travel below the knee. Hip rotation is normal on the examination table.
- Inflammatory Arthropathy (Ankylosing Spondylitis or Rheumatoid)
- Prolonged morning stiffness, night pain, symptoms that ease with movement and exercise, other painful or swollen joints, or features such as fatigue or rashes can suggest an inflammatory arthritis and warrant medical assessment. These are clues rather than a diagnosis, and normal blood tests do not rule it out.
- Hip Labral Tear
- Clicking or catching when twisting on the leg, pain the person shows by cupping a hand in a C shape from the groin round to the side of the hip (the C-sign), and catching that stands out more than morning stiffness. In younger patients it often goes with the bone shape seen in hip impingement (FAI morphology).
- Stress Fracture of the Femoral Neck
- Groin pain that gets worse rather than better with activity, marked pain when hopping or standing on that leg, a recent sharp increase in running or military-style training, and warning signs in your hormonal or nutritional history.
Commonly confused with
Side-by-side comparisons for patterns that often get mistaken for hip osteoarthritis.
Questions
What patients ask me most
Do I need an X-ray before starting physiotherapy for hip osteoarthritis?
Usually no. The 2025 JOSPT Hip OA Clinical Practice Guideline and OARSI 2019 both describe hip OA as diagnosed from age, symptom pattern and examination findings. An X-ray can confirm the picture when it is unclear or when surgery is being considered, but how bad the X-ray looks matches pain and function poorly. I have seen patients with minimal changes on imaging who are in significant pain, and others with severe changes who walk for an hour without symptoms.
Will exercise make my hip arthritis worse?
Not when it is dosed sensibly. The Cochrane review of exercise for hip OA (Fransen et al., 2014) found small-to-moderate reductions in pain and improvements in function, with no sign of harm. The 2025 JOSPT clinical practice guideline strongly recommends individualised strengthening, flexibility and endurance programs. Flares tend to follow a sudden jump beyond what the hip currently tolerates, rather than loading itself, so getting the dose right matters more than avoidance.
Can physiotherapy help me avoid a hip replacement?
For many people, yes, at least for years. Strong exercise evidence backs meaningful improvement in symptoms and function. That said, I will not oversell it. The Bennell JAMA 2014 trial specifically found that a structured physiotherapy program combining several treatments did not do better than a placebo (sham) treatment over 36 weeks, which has been debated widely since. My read of the broader literature, including the 2025 JOSPT revision, is that consistent long-term loading, weight management and education can meaningfully change the course for many patients, and surgery remains a reasonable option when non-surgical care has stopped making progress and pain is dominating daily life.
Why does my hip hurt in the groin rather than the side?
The hip joint sits deeper and further forward than most people expect, so pain from the joint is often felt in the groin or front of the thigh and can travel to the knee. Several tissues in and around the joint can contribute, so where the pain sits is only one part of the assessment. Pain over the outer hip bone more often points to the buttock tendons (gluteal tendons) than to the joint itself. This is why I examine hip rotation carefully: losing the ability to turn the hip inward (internal rotation) is one of the more useful examination findings in hip OA.
Is it safe to keep running with hip osteoarthritis?
In many cases, yes, with adjustments. Running is not the cause of hip OA in most people. Total distance, terrain, recovery and overall hip strength matter more than the act of running itself. I usually keep runners with symptoms running at a reduced dose guided by symptoms, while they build strength in the muscles that move the leg out to the side and back (abductors and extensors). Then they rebuild distance gradually, guided by how the hip feels over the following 24 hours. Trail running and downhill running are the two I temporarily reduce first.
What about glucosamine, collagen, and supplements?
OARSI 2019 issued conditional recommendations against glucosamine and chondroitin for hip OA, citing inconsistent evidence on pain and function. Collagen and turmeric data are mixed. I do not discourage patients from trying low-risk options, but I do not want supplements displacing the treatments with the strongest evidence: exercise, education, and weight management where relevant. A physician or pharmacist can discuss whether an oral anti-inflammatory medicine is suitable for flare days, taking your other conditions and medicines into account.
How long until I feel a real difference?
Most patients notice meaningful change in morning stiffness and how far they can walk within 4 to 6 weeks of consistent loading. Strength gains and bigger improvements in daily function come closer to the 3-month mark. The 2025 JOSPT clinical practice guideline and OARSI 2019 both describe hip OA management as an ongoing project rather than a short course of treatment. My goal is to get you to a program you will actually keep doing twice a week for the long term.
Does cracking or grinding in the hip mean it is getting worse?
No. This grinding (crepitus) is common and does not match joint damage or outcomes well. A quiet hip is not necessarily a healthier hip. If clicking comes with sharp pain, giving way, or the hip truly locking, that changes the conversation, and I examine for an injury to the labrum (the rim of cartilage around the socket). Painless noise on its own is not a reason to stop exercise.
The science
The Science of Hip Osteoarthritis
Hip is an active process involving the whole joint, not simple "wear and tear", and it does not mean your active life is over. It involves breakdown of the articular cartilage (the smooth tissue covering the bone ends), changes in the bone underneath, ("bone spurs", bony lumps that grow at the joint margins) and narrowing of the joint space. Low-grade inflammation, changes in how the joint is loaded and weakness of the surrounding muscles are all part of the picture. Pain is not directly proportional to X-ray changes: I regularly see patients with "severe" OA on imaging who have minimal pain and excellent function, and vice versa. Your experience of pain is real, but it is not solely dictated by what an X-ray shows.
The hip does not work in isolation. When it becomes stiff and painful from OA, the body makes compensations. The most common is increased movement and strain on the and (SI) joint, which is why so many people with hip OA also develop low back pain. A stiff hip also changes the way you walk, which alters the forces passing through the knee and ankle. Living with persistent pain is tiring and can lead to fear of movement and anxiety. Over time the nervous system can become more sensitive, turning up the volume on pain signals. Gentle, graded movement can help recalibrate the nervous system. Hip osteoarthritis may coexist with other hip conditions such as greater pain syndrome or hip , and can develop secondary to previous conditions like femoroacetabular (FAI) or hip tears.
Contributing factors
Your hip joint carries substantial forces during daily activities. Research using instrumented hip implants (Bergmann and colleagues, Journal of , 2001) measured peak forces of about 238% of body weight when walking at about 4 km/h, which is why even modest weight gain adds noticeably to hip joint load.
In hip , the biomechanical picture changes substantially. Recent systematic reviews (2023-2024) reveal that individuals with mild-to-moderate hip OA experience less net hip joint loading over a reduced range of hip motion for a longer proportion of the gait cycle. This means you spread lower forces over longer periods through less movement, a compensation that reduces peak loads but tends to keep the hip stiff and the muscles weak.
Reduced hip motion also asks the lower back and to move more, and changes how forces pass through the knee.
Muscle function plays a critical role. The hip (particularly and minimus) normally stabilize your pelvis during single-leg stance. When these weaken in OA, a can develop: your pelvis drops on the unsupported side during walking, which increases compressive forces on the already compromised joint. This muscle weakness isn't just a consequence of pain avoidance; studies show actual neuromotor changes including muscle co-contraction patterns that increase joint loading while paradoxically reducing effective force production.
Modern research (2024) emphasizes that discrepancies exist between external joint moments (what can be measured) and internal joint loads (what your cartilage experiences) in people with OA due to altered neural patterns and muscle co-contraction. This helps explain why two people with similar X-ray changes can have very different pain and function: how their muscles control and load the joint differs.
Research
What the studies show
Clinical guideline for hip osteoarthritis, 2017 revision
The guideline strongly recommends exercise tailored to the person, and hands-on treatment (manual therapy) combined with exercise, to improve pain, movement and function in hip osteoarthritis.
Establishes non-surgical care, backed by evidence, as the first treatment to try.
Cibulka MT, Bloom NJ, Enseki KR, et al. (2017). Hip Pain and Mobility Deficits-Hip Osteoarthritis: Revision 2017. J Orthop Sports Phys Ther. PMID: 28566053.
Hip replacement or strength training for severe hip osteoarthritis (PROHIP trial)
In people with severe hip osteoarthritis, a total hip replacement led to more improvement in their own ratings of pain and function at 6 months than a strength training program (an average gain of about 15.9 points on a hip questionnaire, compared with about 4.5 points).
Shows that surgery can do better than exercise in severe osteoarthritis, while non-surgical care remains a reasonable first option when it is milder.
Frydendal T, Christensen R, Mechlenburg I, et al. (2024). Total Hip Replacement or Resistance Training for Severe Hip Osteoarthritis. N Engl J Med. PMID: 39476341.
Related Conditions
Conditions I commonly see alongside, or confused with, this one.
Getting back to it
Physiotherapy for hip osteoarthritis, built around the activity you want back.
