How should hip osteoarthritis be managed non‑surgically?

Treatment of Hip Osteoarthritis

Begin immediately with the triad of structured exercise programs, patient education, and weight loss (if overweight/obese), supplemented by topical NSAIDs for initial pain control, as this combination addresses both symptom relief and disease modification. 1, 2, 3

Core Non-Pharmacological Interventions (Start These First)

Structured Exercise Programs

• Implement land-based strengthening, aerobic exercise, and aquatic therapy as the foundation of all treatment plans 1, 2, 4
• Prescribe a minimum of 12 supervised physical therapy sessions, as this demonstrates superior outcomes compared to fewer sessions 3
• Exercise reduces pain, improves function, and addresses the bilateral muscle weakness and atrophy characteristic of hip OA (affecting hip flexors, extensors, abductors, knee flexors/extensors, gluteus maximus, gluteus minimus, hamstrings, quadriceps, and adductors) 5
• Continue exercise indefinitely even after symptom improvement to prevent progression 2

Weight Loss (Mandatory for BMI ≥25)

• Target structured weight reduction of 4-7 kg through weekly supervised sessions 3
• Weight loss improves pain, physical function, mobility, and quality of life by reducing cumulative joint loading 1, 2
• Evidence for hip OA weight loss benefits is more limited than for knee OA, but the intervention remains recommended 1

Patient Education

• Provide structured education about disease process, prognosis, and treatment expectations to improve self-efficacy and adherence 2
• Implement formal self-management programs teaching symptom monitoring and activity adjustment 2

Assistive Devices

• Prescribe canes when disease impacts ambulation 3

Pharmacological Management (Sequential Approach)

First-Line: Topical Agents

• Insufficient evidence exists for topical NSAIDs specifically for hip OA (evidence is strong for knee OA only) 1
• Insufficient evidence for topical capsaicin for hip OA 1

Second-Line: Oral Medications

• Offer acetaminophen and/or oral NSAIDs (such as naproxen 500 mg twice daily or celecoxib 100-200 mg daily) for hip pain 1, 3, 6, 7
• Oral NSAIDs demonstrate superiority to acetaminophen in moderate-to-severe OA pain 3
• Celecoxib 100 mg twice daily or 200 mg once daily provides equivalent effectiveness for OA 6
• Naproxen causes statistically significantly less gastric bleeding than aspirin 7

Third-Line: Duloxetine

• Add duloxetine 60 mg daily as alternative or adjunctive therapy when acetaminophen/NSAIDs are inadequate or contraindicated 1, 3, 8
• Provides significant reductions in pain and improvements in physical function 3

Avoid Opioids

• Do not initiate opioids (including tramadol) for hip OA pain 1, 3
• For patients already on long-term opioids, refer to opioid management guidelines 1
• Tramadol may provide short-term pain relief but is not recommended for initiation 9

Intra-Articular Injections

Corticosteroid Injections

• Offer intra-articular corticosteroid injections for persistent hip pain inadequately relieved by oral medications and physical therapy 1, 3, 9
• Hip injections require image guidance (unlike knee injections) 3
• Avoid injections within 3 months preceding joint replacement surgery 3
• Provides short-term pain relief 8

Hyaluronic Acid (Viscosupplementation)

• Most societies recommend against viscosupplementation for hip OA 9

Platelet-Rich Plasma

• Has potential benefits but evidence of effectiveness remains incomplete 9

Avoid These Interventions

• Do not use glucosamine 9
• Do not routinely obtain MRI for diagnosis (plain radiographs with weight-bearing views are sufficient) 1
• Do not use typical opioids 9

Treatment Sequencing Algorithm

1. Initiate immediately: Education + structured exercise (minimum 12 supervised sessions) + weight loss if BMI ≥25 2, 3

2. Add at 0-2 weeks: Oral NSAIDs or acetaminophen for symptomatic relief 3

3. If inadequate response after 4-6 weeks: Add duloxetine OR intra-articular corticosteroid injection (image-guided) 3

4. Reassess every 4-6 weeks during initial treatment phase 2

Surgical Referral Criteria

Consider surgical consultation when:

• End-stage OA with minimal/no joint space on weight-bearing radiographs 3
• Inability to cope with pain after exhausting all appropriate conservative options 3
• Obtain weight-bearing plain radiographs before surgical referral 3

Evidence for Surgery vs. Conservative Treatment

• Total hip replacement results in clinically important, superior reduction in hip pain (mean Oxford Hip Score improvement of 15.9 points vs. 4.5 points with resistance training at 6 months, difference 11.4 points, P<0.001) in patients ≥50 years with severe hip OA and surgical indication 10
• At 6 months, 21% of patients assigned to resistance training crossed over to total hip replacement 10

Complementary Interventions

Mind-Body Therapies

• Tai chi is strongly recommended for hip OA, combining meditation with gentle movements, breathing exercises, and relaxation 3
• Insufficient evidence for yoga specifically for hip OA (evidence exists for knee OA only) 3
• Cognitive behavioral therapy may reduce pain and improve coping 3

Other Modalities

• Insufficient evidence for acupuncture, massage, or transcutaneous electrical nerve stimulation for hip OA 1

Critical Pitfalls to Avoid

• Do not delay core interventions (exercise, weight loss, education) while pursuing pharmacological management—these must start simultaneously 2
• Do not perform hip injections without image guidance—unlike knee injections, hip anatomy requires imaging 3
• Do not continue ineffective treatments—reassess every 4-6 weeks and escalate therapy 2
• Do not use MRI routinely for diagnosis—it adds no diagnostic value over plain radiographs for OA 1