Hip arthrosis (coxarthrosis)

Photo from gymnastics group

In hip osteoarthritis, the protective cartilage layer of the bones in the hip joint becomes thinner. This increases the pressure on the bones, and over time the mobility of the joint decreases. The first sign of hip osteoarthritis is often pain in the hip and groin area when moving – especially if you are over 45 years old.

Hip osteoarthritis can progress in very different ways. Many people have only mild ailments for a long time, with which they cope well. Sometimes, however, the disease progresses rapidly and can significantly affect the quality of life.

The main treatments for hip osteoarthritis are exercise and physical therapy , anti-inflammatory painkillers and – if the patient is severely overweight – weight loss.

If hip osteoarthritis progresses and leads to more severe and more frequent pain, sleep problems and restrictions in everyday life, joint replacement is also a possibility.

The complaints and the personal situation are decisive for the choice of treatment. X-rays, on the other hand, have only limited significance in hip osteoarthritis – and can even be misleading.

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Hip osteoarthritis usually begins insidiously – over several months, often even years. At first, the joint usually hurts only when weight is placed on it or at the end of a strenuous day. Pain is typical when walking and climbing stairs, as well as when moving the thigh inward – for example, when crossing the legs. The pain may also radiate to the buttocks, the inner thigh or, rarely, even to the knee.

After prolonged rest, the hip joint may feel somewhat stiff for up to 30 minutes, for example in the morning. Prolonged morning stiffness is more indicative of another condition, such as rheumatoid arthritis . If the hip also hurts at rest or at night, the arthrosis is usually already advanced.

Changes to the bone and deformities of the femoral head can limit mobility and make it difficult, for example, to put on stockings or care for your feet. As osteoarthritis progresses, it can cause severe limitations in work and home activities, recreational activities, and social life. The consequences for everyday life are often the greatest burden in the case of hip arthrosis.

Some people with hip osteoarthritis also experience acute flare-ups with sudden more severe pain and joint stiffness. Pain tends to feel sharp, pulsating or burning during an acute episode. In most cases, however, the symptoms subside again within a few days.

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The hip joint consists of the femoral head on the thigh bone and the socket on the pelvic bone. Both are covered with cartilage. Hip osteoarthritis occurs when the joint cartilage softens, cracks, and loses substance.

If the cartilage becomes thinner and the joint space narrower, the bones are no longer so well protected against pressure loads. They react to this by forming new bone substance, which then becomes visible as new bone formations in the X-ray image (so-called bone spars or osteophytes ).

Colloquially, osteoarthritis is often called "wear and tear of the joint. This term is misleading, however, because the joint is not "consumed" by use – on the contrary, the cartilage depends on movement to be supplied with nutrients. Types of exercise such as walking or cycling are beneficial for cartilage and joints. Sports like handball or soccer, on the other hand, can overload and contribute to osteoarthritis. This also applies to heavy physical work or severe overweight.

When overloaded, the metabolic processes in the joint can become unbalanced. Build-up and degradation processes take place continuously in the joint. Osteoarthritis occurs when too many substances and enzymes are produced that promote inflammation and lead to tissue breakdown – and too few that counteract it.

Graph: healthy hip joint on the left, with advanced osteoarthritis on the right

Healthy hip joint on the left, advanced arthrosis on the right

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Hip osteoarthritis can be promoted by several factors, including:

  • familial predisposition
  • severe overweight
  • congenital hip diseases or malpositions
  • heavy physical work, for example in construction
  • permanent stress due to intensive training, in sports with strong impact loads such as soccer or handball
  • inflammatory joint diseases such as rheumatoid arthritis
  • previous hip injuries, for example bone fractures in the area of the hip joint, or a dislocated hip joint
  • Hip impingement: Bony outgrowths on the joint lead to narrowing between the femoral head and the socket.

In most cases, several factors play a role in the development of hip osteoarthritis.

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An estimated 5% of adults in Germany have hip osteoarthritis with noticeable symptoms. Women are affected slightly more often than men.

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How hip osteoarthritis progresses cannot be predicted with certainty. Often the symptoms remain more or less the same for many years. In a large Dutch study, people with hip osteoarthritis were followed regularly for five years to monitor the progression of the disease. Of them had about

  • 40% mild pain, roughly consistent over the five years;
  • 20% moderate pain, also about constant;
  • 25 % moderately severe pain that became more severe over the course of five years, and
  • 15 % persistent severe pain.

A follow-up examination after ten years has confirmed the study results. 12 out of 100 persons decided to have a joint replacement in this period.

Osteoarthritis pain can fluctuate somewhat from day to day: phases of more severe symptoms alternate with symptom-free or symptom-free phases.

Not only biological factors play a role in osteoarthritis, but also personal attitudes, social and work life, lifestyle, and psychological factors such as anxiety, worry, and stress. They can all affect how the discomfort feels, how severe it is, and how you deal with it.

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Often, the doctor can diagnose hip osteoarthritis based on the typical symptoms. To do this, she or he asks how long the pain has existed, how it feels, and when it occurs – for example, only during movement or also at rest. Typical is the so-called start-up pain, which occurs after longer pauses in movement and quickly disappears through movement. Information about other complaints such as morning stiffness or previous injuries also helps with the diagnosis .

After the consultation, the doctor palpates the joint and examines hip mobility while the patient is lying down. This involves moving the leg in a stretched position with the knee bent in different directions. She or he also looks at the gait and checks to see if the pelvis is crooked or the legs are a different length.

Imaging examinations such as X-rays, ultrasound, computer tomography or magnetic resonance imaging are often not very informative in the case of osteoarthritis. For example, there are people with severe changes in the joint who have hardly any complaints, and others with severe complaints whose joint looks healthy. Studies show that only a quarter of all people with osteoarthritis visible on X-ray have pain. Other abnormalities such as cracks on the joint lip are also common – but usually without medical significance. A joint lip is a cushioning layer of fibrous tissue that lines the articular surface of the acetabulum.

The results of imaging examinations are therefore often not helpful and may, on the contrary, be misleading. Treatment should be based on symptoms and personal situation anyway.

Imaging examinations or blood tests are useful if another disease is suspected, such as rheumatoid arthritis or gout – or if a bone fracture is to be ruled out after a fall or accident.

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There is no cure for hip osteoarthritis. However, various treatments can alleviate the symptoms. First and foremost, there is much you can do yourself to strengthen the joint.

Recommended treatments include:

  • well cushioned, supportive and comfortable shoes without heels
  • Exercise therapies such as physiotherapy with exercises to strengthen the thigh and hip muscles, rehabilitation sports, functional training, water gymnastics and Tai Chi
  • anti-inflammatory painkillers ( NSAR ) to take
  • Weight loss if the patient is severely overweight

Moving and doing sports despite pain is difficult for some people to imagine. Some fear that this will cause additional damage to their joints. But this is not the case; on the contrary, studies show that exercise therapy can improve joint function. Sometimes they can even delay hip surgery.

Another option for treating hip osteoarthritis is cortisone injections. According to previous studies, they can alleviate the symptoms for a few weeks. Cortisone injections are considered more useful when

  • only one joint is affected by osteoarthritis,
  • the hip joint is acutely inflamed or severely painful,
  • other treatments are not sufficient or there are medical reasons for not doing so.

However, cortisone injections are not a long-term solution. On the one hand, they can have side effects and, rarely, lead to serious complications. On the other hand, repeated injections could weaken the joint cartilage in the long term. It is also not proven that they can help in the long run.

Because only a few studies have investigated the effectiveness of cortisone injections for hip osteoarthritis, there are different recommendations for use. If cortisone injections are used, it is important that the doctor has experience with them and ensures adequate hygiene. For example, he or she should use an ultrasound device to place the injection correctly so that it can work optimally and, if possible, no nerves, vessels or other structures are injured.

If osteoarthritis is advanced, severely affects daily life and quality of life, and other treatments are not sufficient, an artificial hip joint may be considered. It can significantly improve symptoms in over 90% of people with advanced osteoarthritis. After surgery, active rehabilitation is important – and a little patience. It may take several weeks or months to get used to the new joint and for the body to recover from the procedure.

Other treatments have not been shown to help with hip osteoarthritis – these include:

  • Painkillers to apply to the hip
  • Paracetamol
  • Duloxetine
  • Hyaluronic acid injections
  • X-ray stimulation radiation (also called orthovoltage therapy): This involves treating the joint with low-level X-rays 6 to 12 times over several weeks.
  • Smoothing of the cartilage during hip arthroscopy
  • Dietary supplements , for example, with chondroitin, glucosamine, or vitamins
  • Herbal preparations, for example based on devil’s claw or nettles
  • homeopathic remedies
  • Food or food extracts based on soy or avocado, for example
  • therapeutic ultrasound, laser treatments, TENS treatments or special heat treatments (diathermy)
  • Gold implantation

More knowledge

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People with osteoarthritis are sometimes given the impression that it’s an unstoppable disease that can’t be helped – or a normal sign of aging that must be accepted. However, this is not the case, so one should not be unsettled by such statements. Even though osteoarthritis cannot be cured, there are many things that can be done for the joints and against the symptoms.

It is important to become active oneself and, together with one’s doctors and therapists, to find treatments and ways of dealing with the disease that suit one’s own situation.

Even though osteoarthritis can limit quality of life, it pays to maintain a positive attitude. Because one’s own feelings, thoughts and behavior also influence how burdensome the pain is.

People with osteoarthritis are offered many therapies without benefit and some are advertised with unrealistic promises. Here a healthy skepticism is appropriate, because a miracle weapon against arthrosis does not exist. A good strategy is to develop realistic expectations, learn to live well with the condition, and focus on treatments that have been shown to be beneficial.

When hip osteoarthritis progresses, it can affect many areas of life. However, many people learn over time to cope with everyday life despite their condition – for example, they take more time to do chores and adjust their physical activities.

Walking aids such as walking sticks, walking frames and rollators can relieve the strain on the joints and make it easier to get around inside and outside the home. How to properly adjust and use assistive devices can be shown by physical or occupational therapists and physicians from various specialties such as orthopedics, rheumatology and geriatrics.

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