Your hip joint is involved in almost every activity you do. A diseased or injured hip can limit your ability to move and work. These types of injuries can affect millions of Americans in the United States.
The anatomy of the hip starts first with the bones around the hip: your pelvis; the acetabulum or the socket; the femoral head or ball; and the femur, the thigh bone.
When you compare a normal hip to an arthritic hip, the arthritic hip loses the cartilage, starts to develop bone spurs and bone cysts and may cause you to become slightly shorter. Arthritis is one of the most common conditions that I see and it’s one of the most common causes of disability in adults.
There are multiple reasons why your hip may hurt. Some questions we may consider include:
- Is it potentially related to the nerves or your spine referring pain to your hip?
- Do you have hip impingement due to an injury to your labrum?
- Do you have arthritis with injuries to your cartilage?
- Do you have bursitis which affects the outer portion of your hip?
Muscles can also cause hip pain. The most common muscles that I see involved in injuries around the hip are your piriformis and your psoas muscle.
Common Causes of Hip Pain
Osteoarthritis
Osteoarthritis is a process of degeneration that starts with one or more joints, typically later in life. It can affect all of the joints in the hands and may affect one or both sides of a hip or knee joint.
Treatments can involve non-surgical treatment to reduce the pain and inflammation and surgical treatment to remove osteoarthritis.
Rheumatoid Arthritis
Rheumatoid arthritis is an inflammatory arthritis where the body’s immune system will attack the hip joint, which can result in an inflamed or swollen joint. It affects multiple joints, including your hands, and it typically starts earlier in life.
In the last 10 years, patients have needed less surgery over time because the medical treatment has been so good. If the medical treatment does not work, surgery is then a last resort.
Post-Traumatic Arthritis
Post-traumatic arthritis is where somebody has had a broken bone or an injury to their hip, the injury is fixed, and then arthritis develops later. It is another common condition that results in somebody who may need a surgery for their hip.
Femoroacetabular Impingement (FAI)
Femoroacetabular impingement (FAI) is less known but is very common in the United States. It can result in hip pain that’s developed slowly over the past few months. The hip hurts when you’re bending, lifting or sitting, you play or you’re very active. Your x-rays otherwise are normal and you don’t have arthritis. You may need an MRI to check for labral injuries or injuries to the cartilage.
Deformities in your hip joint can cause a labral injury over time. FAI is a different type of hip injury that needs a specific type of procedure, ultimately, if non-surgical treatment fails to improve. Treatments can involve range of motion exercises to reduce impingement and you may need surgery if they do not help.
Muscle or Tendon Injury
Muscle and tendon injuries are often after an acute injury like a fall or after exercise. You have pain typically over a specific area. That muscle may be really soft or painful to touch. You may notice cramping, spasms or tightness around the muscle. You won’t have a broken bone or arthritis on your x-rays. You may need an ultrasound or an MRI to find the specific muscle that’s been injured so that we can guide treatment for that muscle. Typically, the basics help with these muscle injuries: rest, ice, compression, and elevation, or RICE treatment. Then you may ultimately need some physical therapy to return that muscle back to normal function so you can get back to your activity or sports.
Nerve Compression Injuries
If you have a back condition like lumbar arthritis, nerve impingement or sciatica, these conditions can refer pain to the hip. Nerve compression pain typically results in shooting or radiating pain. You may experience burning, numbness or tingling. It’s often worse when you’re standing or sitting and it may improve as you walk. On x-rays you may find arthritis in the back but there is typically no hip arthritis. There may be an MRI to see if there’s impingement on the nerves in the lower back. Medications can reduce inflammation of the nerves that are irritated. Physical therapy can also help increase mobility and strength of the back and hip to reduce that inflammation.
Non-Surgical Treatments for Hip Conditions
- Walking aids. Canes and walkers help you take pressure away from the affected joint and can help it during recovery.
- Heat or cold therapy. After an acute muscle injury I recommend cold therapy first. In the subsequent days, muscle responds well to heat so it will loosen up and be less likely to spasm.
- Physical therapy.PT can improve your posture, hip mobility and range of motion so you don’t become stiff, which is often a side effect of injuries.
- Medications.Anti-inflammatory medications, steroid medications and potentially injections may also help with a specific hip condition. The most common conditions that an injection may help are things like bursitis, hip arthritis and potentially nerve impingement.
Surgical Treatments for Hip Conditions
Arthroscopy
Arthroscopy is a common surgical treatment for tendon injuries, labral injuries or impingement. If there is significant cartilage damage or arthritis in the hip joint, arthroscopy may not be the best thing to get because you may ultimately still need a hip replacement. It’s important to evaluate the cartilage, the structure of the bone and the injury that you have in determining the right procedure for you. If you’re a young patient and you want to get back to sports and high-level activity, then an arthroscopy may be better suited for you for your injury.
Joint Replacement
Hip replacement is a very reliable and durable operation. Most patients never need a second surgery. Is hip pain affecting your ability to get a good night’s sleep? Have you had to give up activities because of your hip pain? Are you constantly taking more medications because of your hip pain? And is that hip pain affecting your ability to do simple things like walking upstairs, walking on uneven ground or walking even short distances?
In a total hip replacement, the surgery itself involves removing the injured portion of the hip: the arthritic socket and arthritic ball (femoral head). We replace them with prosthetic implants, typically made of titanium. They’re porous-coated, meaning they have a surface where your bone can grow into it.
I use a robotic assisted tool for hip replacement surgery which allows for better accuracy, reduces hip instability or dislocation and has good short-term patient-reported outcomes. It has a very high forgotten joint score, which means that a year or two beyond surgery, patients can hardly tell the difference of which hip has been replaced.
Frequently asked questions
Are there upper or lower age limits on hip replacement?
Twenty or thirty years ago, we thought that if you were a young patient below the age of 40 or 50, hip replacement surgery would not be a good option for you because you would definitely need a second surgery. In hip replacements done in the last two decades, the materials used are lasting much, much longer. Part of the reason for the change is the implant allows the bone to grow into it, so it becomes solid after a certain number of weeks.
As we’ve tracked hip replacements done in the United States, the United Kingdom and Australia, we found that hip replacements at 30 years have about a 90-95% success rate, or patients who have not had any procedures after the first one. Five percent of patients may have a risk of having a second surgery, after 30 plus years, because the materials have become better and we focus on making sure the surgery is done correctly. We pay very close attention to restoring the patient’s anatomy and we think that the well-done hip replacement can last most patients’ lifetime.
How can you tell which reason is the cause of the hip pain?
My assessment in the office always starts with a really simple question: where does it hurt? Most patients will say my hip. I’ll go further and ask some specific questions. When does it hurt? Where specifically around the hip do you feel that the center point of that pain is? Is it in the very front? Is it on the side? Is it in the back? Does it go from one and spread to the other?
These types of questions home in on one of those potential causes of hip pain that we talked about. Based on those answers, we get x-rays, we may get ultrasound, we may get an MRI. These investigation studies then lead us further towards diagnosing correctly what the problem is so that we can give you the correct treatment plan.
Can a cortisone shot make hip pain worse in the long term?
Cortisone has been safe and used around the body for several years. It’s a very safe and good alternative for both the diagnostic and a therapeutic treatment plan. I recommend against an unlimited number of cortisone injections in the hip. Unlike the knee, where you can do injections for several years safely, the hip has had mixed results. For some reason, hip joints may become sensitive to long term injections and may weaken the bone quality of the hip. Typically, I don’t recommend more than two in a given 12-month period. If that second injection does not give the patient at least 75 to 80% relief of symptoms for greater than three months, I would not recommend further injections.
How soon after hip surgery can you walk upstairs?
My hip replacement patients are able to walk up the stairs on the day of surgery. You work with a physical therapist and you’re able to take slow single steps. There are no restrictions as to the number of stairs that you do.
If you have a different surgery and you’re not allowed to put full weight on your leg, you may have restrictions on stairs.
After a total hip replacement, are there restrictions on how you can sit, how long you can sit or what you can sit on?
There are differences between different surgeons and the different ways that patients have surgeries, whether it’s a first-time surgery or a revision surgery, and if the approach is from the front (anterior) or back (posterior). For most hip replacement surgeries done in the United States, there are no restrictions on how long you can sit or what you can sit on. Most patients feel comfortable in about a 90-degree position or in an elevated position.
Any restrictions are specific to the type of surgery you have. Some patients who have posterior surgery may be on specific types of precautions for a short number of weeks. Patients who have anterior surgery may be on different types of precautions for a different number of weeks. It depends on the type of surgery and the surgeon’s recovery protocols.
How can you tell the difference between osteoarthritis and inflammatory arthritis in the hips and does one cause or exacerbate the other one?
Osteoarthritis and inflammatory arthritis are typically two different entities. They almost never exist at the exact same time in causing joint problems.
A specific type of diagnosis has to be made for inflammatory arthritis, which typically requires blood work to check for inflammatory markers to confirm diagnosis of things like rheumatoid arthritis or psoriatic arthritis. If you have inflammatory arthritis, you may benefit from specific medications to prevent surgery altogether, whereas osteoarthritis doesn’t respond to those types of medications.
What is the recovery time after a hip replacement?
Hip replacement is quite predictable. Most patients in the first two weeks are staying around the house and are able to take care of themselves with the assistance of a family member or a friend. You have a walker or a cane at first, and some patients are able to get off of the cane within the first two weeks. By six weeks, most patients are able to be off of the assistive device that they were previously on and are able to drive and to do simple things like go to the grocery store.
Going back to work and activities depends on the activity and work type that you do. If you have a sitting job, you’re able to go back to that sooner than going out and working on your feet or lifting or carrying heavy objects.
What are some exercises to help relieve hip pain or where can patients find out that information?
One great place is the American Academy of Orthopaedic Surgeons (AAOS). It has a section for patients to look up conditions, hip problems and general hip conditioning exercises.
We also have great OrthoVirginia therapists that can see you, evaluate you and give you recommendations on exercises and techniques to relieve your hip problems.
Some simple things that you can do are staying active: going to the gym, walking, getting into a pool or riding a bicycle. Working on your hip, your back and your core can keep your whole pelvis and hip strong.
Is a hospital bed necessary after a hip replacement?
Not typically. Most patients can sleep in their own bed.
Is there a risk in waiting too long to get a hip replacement?
There’s no time limit, so to speak, with hip replacement surgery. The biggest thing that I see is patients who are continuing non-surgical treatment (such as mediations and injections) even though those treatments are not working. Ultimately, they may reach a point when they are not as active or fit and may not be medically safe to have surgery at a later time.
If non-surgical treatments are working, then there’s no rush to hip replacement. But if they aren’t working and if you’re otherwise healthy, it’s important to consider better long-term solutions.
Does bone-on-bone arthritis in the knee affect the hip and cause pain?
Yes, in two ways. One is that severe arthritis in a joint can change the way you walk, so you may be putting more pressure or more weight on a hip joint or the other knee joint. The other aspect is that if you have bone-on-bone arthritis in a knee, there is a chance that you may have a similar problem in the affected hip. The hip may also be experiencing arthritis due to genetics, injuries or time.