Hip Osteoarthritis

Hip arthritis is often diagnosed late, for two reasons. It is felt in places people do not associate with the hip, and it overlaps with back pain in the same age group. This page is about telling it apart, and about what the evidence says helps.

What it is

The hip is a ball and socket, lined on both sides with cartilage a few millimetres thick. Osteoarthritis is the loss of that lining. As it thins, the joint space narrows, the bone underneath thickens, small spurs form at the edges, and the joint becomes stiff as well as painful.

It is not simply the result of use. Shape matters: a socket that is shallow or mildly misshapen from childhood loads the cartilage unevenly for decades, and a proportion of hips that wear out early do so for that reason.

Where it is felt, and where it is not

This is the part worth reading carefully.

• The groin. The most typical location, and the most reliable pointer to the joint itself.
• The front of the thigh, and the knee. Hip pain refers along this route routinely. A worn hip can present as knee pain with a knee that examines normally, and people are sometimes investigated for a knee problem for months first.
• The buttock. Common, and it overlaps with pain coming from the spine.
• The outer side, over the bony point. Usually not the joint. That is more often the tendons and the bursa on the outside of the hip, which is a different problem with different treatment.

Movement tells you more than the location does. A worn hip loses rotation early, so difficulty with socks, shoes, and turning in bed often appears before walking distance drops.

Hip or back?

Both are common after fifty, both cause pain around the buttock and thigh, and plenty of people have both. A short guide:

	More like the hip joint	More like the spine
Where	Groin, front of thigh	Buttock, back of leg
How far down	Rarely below the knee	Often below the knee, into the foot
Sensation	Ache, deep	Pins and needles, numbness, burning
Worse with	Weight bearing, rotating the leg	Certain back positions, standing or walking distance
On examination	Movement restricted when someone else moves your leg	Hip movement usually free

An examination usually settles it. Where it does not, an injection into the hip joint can be used to answer the question directly: if the pain goes, the joint was the source.

What the imaging is for

A weight-bearing X-ray of the pelvis and hips is the starting point, and usually all that is needed. It shows joint space, bone changes, the shape of the socket, and any difference in leg length.

Films taken lying down understate joint space loss, exactly as they do at the knee. If your X-ray was taken lying down, that is worth knowing before any conclusion is drawn from it.

An MRI is not routine for straightforward arthritis. It is useful when the diagnosis is uncertain, when the X-ray looks better than the symptoms, or when something other than wear is suspected.

What actually helps

Here the hip differs from the knee, and it is worth being straight about it.

For the knee, a structured strengthening programme is one of the better returns available. For the hip, the measured benefit is smaller.¹ A 2026 Cochrane review found that exercise probably improves pain and function in hip osteoarthritis only slightly against usual care, by around 8 and 7 points on a 0 to 100 scale, which sits below the difference patients generally notice.

That is not a reason to skip it. Exercise is low risk, it maintains the muscle you will need if you do have surgery, it slightly reduced adverse events in that review, and it is good for you for reasons unrelated to your hip. It is a reason not to spend three years on physiotherapy for a hip that is worn through.

The realistic list, roughly in order of what it delivers for a hip:

• Weight reduction where relevant. The load through the hip in walking is a multiple of body weight.
• Activity modification. Cycling and swimming rather than stopping.
• A walking stick, used in the opposite hand. Unpopular and effective; it takes a meaningful share of the load off the joint.
• Simple analgesia, used sensibly and reviewed rather than repeated indefinitely.
• Exercise and physiotherapy, for the reasons above.
• A guided corticosteroid injection for a flare, or to confirm the joint is the source.
• Hip replacement when the joint is worn out and quality of life is the issue.

When replacement becomes the sensible option

Not at a particular grade on an X-ray. The questions that matter:

• Is the pain there at rest, or waking you at night?
• Is your walking distance shrinking month by month?
• Have you given up things that matter to you?
• Has non-surgical treatment had a real trial, rather than a mention?

If the answers point one way and the imaging agrees, replacement is a reasonable operation with a long track record. If they do not, it is not, and a surgeon who tells you so is being useful rather than unhelpful.

What to bring to a consultation

• Weight-bearing X-rays of the pelvis and both hips, and the written reports
• Any spine imaging, if back pain is part of the picture
• A list of what you can no longer do, and what you want back
• What you have already tried, for how long, and what it changed
• Your medications, including anything for pain

Common questions

Where is hip arthritis actually felt?

Most often in the groin, and often referred down the front of the thigh towards the knee. That referral catches people out: a worn hip can present as knee pain with a knee that examines normally, and some patients are investigated for a knee problem for months. Pain on the outer side of the hip, right over the bony point, is more often the tendons and bursa there than the joint itself.

How do I know whether it is my hip or my back?

They overlap and both are common in the same age group, so it is a genuine diagnostic question rather than an obvious one. Broadly, hip joint pain is felt in the groin, is worse on weight bearing and on rotating the leg, and comes with restricted movement when someone else moves your leg for you. Nerve pain from the spine tends to go below the knee, can include pins and needles or numbness, and is often worse with certain back positions. An examination usually separates them; sometimes an injection is used to settle the question.

Does exercise help hip arthritis?

Less than most people are told, and this is one of the clearer differences between the hip and the knee. A 2026 Cochrane review found that exercise probably improves pain and function in hip osteoarthritis only slightly, by around 8 and 7 points on a 0 to 100 scale against usual care, which sits below the difference patients generally recognise as meaningful. It is still worth doing, it is low risk, and it slightly reduced adverse events in that review. It is just not the answer for a hip that a strengthening programme often is for a knee.

Will an injection help?

A corticosteroid injection into the hip joint can settle a flare and is sometimes used to confirm that the joint is the source of the pain, which is genuinely useful when the hip and the spine are both candidates. It is short-term relief and a diagnostic tool rather than a treatment strategy. Injections into the hip are usually done under imaging guidance, because the joint is deep and blind injections are unreliable.

How do I know when it is time for a replacement?

There is no threshold on an X-ray that decides it. The useful questions are whether the pain is present at rest or disturbing sleep, whether your walking distance keeps shrinking, whether you have stopped doing things that matter to you, and whether non-surgical treatment has had a real trial. A hip that is worn through on imaging and taking over your life is a reasonable hip to replace. A hip with mild changes and manageable symptoms is not.

Does waiting make surgery harder?

It can. Waiting a long time with a badly worn hip tends to mean lost muscle, weight gain, stiffness that takes longer to recover, and sometimes progressive shortening of the leg. None of that makes surgery impossible, but it can make the recovery slower. That is an argument against drifting for years without a plan, not an argument for operating early.

References

1. Hall M, Lawford BJ, Hinman RS, Dobson F, Spiers L, Kimp A, French HP, Reichenbach S, Hernandez-Molina G, Bennell KL. Exercise for osteoarthritis of the hip. Cochrane Database of Systematic Reviews, 2026 (CD007912)
2. Evans JT et al. How long does a hip replacement last? A systematic review and meta-analysis. Lancet 2019;393(10172):647-654

Related reading

Total Hip Replacement

What a hip replacement involves, who it suits, how long modern hips last, what robotic assistance changes, and why no published Malaysian price benchmark exists.

Knee Osteoarthritis

What knee osteoarthritis is, how it is assessed and graded, what actually helps at each stage, and when a joint replacement becomes the sensible option.

Will Insurance Cover Your Knee Replacement in Malaysia?

How medical cards, guarantee letters, annual limits and pre-existing clauses work for knee surgery in Malaysia, and what to ask before admission.