Hip Osteoarthritis (OA)

Where is it painful for a patient with Hip OA?

Classical patient features for Hip OA

Age: vast majority > 60 years old // each year the prevalence increases

Gender: female > male

Activity: highest prevalence with sedentary individuals

Sport: marathon runners have higher prevalence, no link with recreational runners // if anything reduced prevalence

Area of symptoms for Hip OA

- deep in the groin

- deep in the buttock

- can refer down the buttock and as low as the knee however commonly localised

Characteristics of symptoms for a client with Hip OA

- stiffness

- deep ache

- Patient reports: clicking, clunking, grinding, catching

Typical activity capability/restriction for Hip OA

- activities with large hip ranges or high levels of hip muscle recruitment become progressively more difficult including walking, running, bending, transferring, stairs, ramps

- patients have commonly made autonomous adaptations continue to perform activities of daily living

- common for patients to be deconditioned locally and remotely

Behaviour of symptoms for Hip OA

Aggs: walking, running, bending, transferring, stairs, ramps

Ease: Heat, exercise (whilst performing it), NSAIDs

24 hour: Morning stiffness < 30min, stiffness following activity

Typical history for a client with Hip OA

- Insidious onset

- progressive in nature

- may have other joint involvement (ask about knees)

Pathobiological mechanisms underlying Hip OA

- Plausible nociceptive mechanism on initial presentation

- Due to the insidious and progressive nature of symptoms patients likely have some nociplastic pain components

- Enquire about how the patient is coping especially with activities of daily living

- Understand patients beliefs about what the problem is and when they might need // some patients will have strong the surgical preferences for intervention competitively to rehab

Proposed pathology for Hip OA

Can have a pathogenic trigger

- could be in the form of mechanical stress or an abnormal biochemical environment

- Collagen matrix at the joint can become disorganized // cartilage degradation and then eventually subchondral bone degrades

- Osteophytes can develop in reaction to this

- reduction in joint space

- Reduced proteoglycans

- Reduced water content

- Increased inflammatory reaction

Physical impairments & associated structure/tissue sources (ie P/E findings)

Local

- restricted ROM (AROM and PROM) capsular pattern (IR and flexion will be first to show signs of deterioration)

- positive FABER

- reduced strength all hip muscles

- muscle wastage

- differentiation: pain with compression, relief with distraction

- position: pain in closed packed and rief in open packed

Remote

- look for involvement of other joints (ie knees)

- muscle wastage

- reduced balance/proprioception

General

- functional decline

- deconditioning

- falls history

Typical contributing factors for Hip OA

- Age // increased every year

- Hip dysplasia

- History of FAI

- Previous surgery at the hip

- Weight (likely metabolic influences)

- Genetics

- Diabetes (metabolic influences)

- History of inflammatory conditions (RA, AS)

- menopause

- diet

- previous hip dislocation

Relevant precautions/ contraindications to P/E and treatment

- questions regarding comorbidities needed to be asked prior

- if evidence for subchondral bone loss or neck of femur fracture indicated // send for imaging prior

- if the acute incident (especially if the patient has a fall) // send to hospital for further investigations

Relevant diagnostic imaging for Hip OA

- x-ray sufficient to observe joint changes

- note that levels of degradation and pain do not have a close association

- if less than 2mm joint space then send for surgical opinion // does not mean that surgery is indicated however

- MRI: due to increased detail will be better able to establish changes in the early onset

Typical prognosis for Hip OA

Surgical management (high-level evidence)

- favourable outcome in 77-93% of cases

Conservative (high-level evidence)

- exercise therapy + education reduced the risk of surgery by 44% in hip OP patients

- exercise pre-op improved pain, range, QOL

Management/treatment selection for Hip OA

Monitoring patients with hip OA (high-level evidence)

- hip dysfunction and OA outcome score (HOOS) has been validated

Symptom management

- Triage and referral for a surgical opinion if necessary

- unload through activity changes

- refer to Dr for review of medications (high-level evidence)

Exercise (high-level evidence)

- exercise in the initial phase can be used for pain relief

- increase the load as able

- Want to strengthen locally and then incorporate into full body

Joint mobilisation (high-level evidence)

- RCT with mobs + exercise vs exercise. No difference in outcome measures functionally however patients had higher satisfaction when MT was used for the patients

- Individualize for patient

- makes sense that the patient would get some benefit (especially longitudinal and laterally directed glides)

- note: clear serious pathology prior to mobilisation

Total hip replacement (high-level evidence)

- showed operation had significant benefit mid/long term

- Indications for surgical opinion: if less than 2mm joint space, failed conservative management and if the patient has high levels of pain and disability

Hip arthroscopy (low levels evidence)

- only shown to have small temporary benefits

- very high conversion rates ~90% to THR

NSAIDs (high-level evidence)

- effective for pain relief in 60% of patients

CSI (high-level evidence)

- 1-month significant increase in pain and function

- in mild cases more effective (75-90%) compared to severe cases (9-20%)

Hydrotherapy (high-level evidence)

Differential diagnosis for Hip OA

NOF // need a scan to rule out if trauma

FAI // subjective questioning and imaging as required

GT/ GT bursitis// palpation and dynamic assessment

Cancer // special questions

Infection // special questions

muscle strain (groin, hip flexor, hamstring, glutes) // dynamic assessment

labral pathology // special questions

Sciatica // positive neuropathic signs and neurological symptoms

Referral from lumbar spine // lumbar spine assessment

ligamentum teres // trauma, instability, avascular necrosis or vascular signs

References

Brukner P, Khan K. Clinical sports medicine (volume 1 injuries). 5th ed. Australia: McGraw-Hill Education; 2017.

French, H.P., Cusack, T., Brennan, A., Caffrey, A., Conroy, R., Cuddy, V., FitzGerald, O.M., Gilsenan, C., Kane, D., O'Connell, P.G. and White, B., 2013. Exercise and manual physiotherapy arthritis research trial (EMPART) for osteoarthritis of the hip: a multicenter randomized controlled trial. Archives of physical medicine and rehabilitation, 94(2), pp.302-314.

Lespasio, M.J., Sultan, A.A., Piuzzi, N.S., Khlopas, A., Husni, M.E., Muschler, G.F. and Mont, M.A., 2018. Hip osteoarthritis: a primer. The Permanente Journal, 22.

O'Connor, M.I., 2007. Sex differences in osteoarthritis of the hip and knee. JAAOS-Journal of the American Academy of Orthopaedic Surgeons, 15, pp.S22-S25.

Łyp, M., Kaczor, R., Cabak, A., Tederko, P., Włostowska, E., Stanisławska, I., Szypuła, J. and Tomaszewski, W., 2016. A water rehabilitation program in patients with hip osteoarthritis before and after total hip replacement. Medical science monitor: international medical journal of experimental and clinical research, 22, p.2635.

Svege, I., Nordsletten, L., Fernandes, L. and Risberg, M.A., 2015. Exercise therapy may postpone total hip replacement surgery in patients with hip osteoarthritis: a long-term follow-up of a randomised trial. Annals of the rheumatic diseases, 74(1), pp.164-169.

Teirlinck, C.H., Dorleijn, D.M.J., Bos, P.K., Rijkels-Otters, J.B.M., Bierma-Zeinstra, S.M.A. and Luijsterburg, P.A.J., 2019. Prognostic factors for progression of osteoarthritis of the hip: a systematic review. Arthritis research & therapy, 21(1), pp.1-19.