The Short Version
Hip arthritis happens when the smooth cartilage inside the hip joint becomes damaged and wears down. It commonly causes groin pain, stiffness, and difficulty with activities such as walking, stairs, getting in and out of a car, or putting on shoes and socks.
The X-ray is important, but it is only part of the picture. Treatment should be based on how your hip feels, how it functions, what the examination shows, and what matters to you — not simply on how bad an X-ray looks.
The Basics
What is hip arthritis?
The hip is a ball-and-socket joint. The ball is the top of the thighbone, called the femoral head. It sits inside a socket in the pelvis called the acetabulum.
In a healthy hip, both surfaces are covered by smooth cartilage. That cartilage allows the joint to move with very little friction.
With osteoarthritis, that cartilage gradually becomes damaged and wears away. As the joint changes, the space between the ball and socket becomes narrower. The bone underneath the cartilage can become denser, bone spurs may form, and cysts can sometimes develop within the bone.
In advanced arthritis, much of the normal cartilage may be gone. This is what people are usually describing when they use the phrase “bone-on-bone.”
Arthritis does not always progress at the same rate, and an arthritic hip does not automatically need surgery. The goal is to treat the symptoms and limitations the arthritis is causing — not simply the appearance of the joint on an X-ray.
Symptoms
Where does hip arthritis usually hurt?
This is one of the most useful questions we can ask because not every pain around the hip actually comes from the hip joint.
Arthritis inside the hip commonly causes pain in the groin or front of the hip. Some patients feel it in the upper thigh or buttock, and hip pain can sometimes travel toward the knee.
You may also notice:
- Stiffness after sitting or resting
- Difficulty getting up from a low chair
- Pain getting in or out of a car
- Difficulty putting on shoes or socks
- Trouble crossing your legs
- Pain or fatigue with longer walks
- A limp that becomes more noticeable with activity
- Loss of hip motion
- Pain that begins interfering with sleep or daily life
What if my pain is on the outside of my hip?
Pain directly over the outside of the hip is often different. It can come from the gluteal tendons and other tissues around the greater trochanter rather than from arthritis inside the joint.
That distinction matters because the treatments are different. A patient can also have arthritis on an X-ray and still have most of their symptoms coming from somewhere else.
If your pain is primarily on the outside of the hip, you may also want to read Lateral Hip Pain & Gluteal Tendinopathy.
Can back problems feel like hip problems?
Yes. Problems in the lower back can sometimes cause pain in the buttock, thigh, or leg. Nerve irritation may also cause numbness, tingling, burning, or pain that travels farther down the leg.
Hip and back problems can also exist at the same time. Part of the evaluation is determining how much of your pain is really coming from the hip joint.
Evaluation
How do we know if the hip is the problem?
Most of the time, diagnosing hip arthritis does not require an MRI. A good history, physical examination, and the right X-rays usually tell us a great deal.
Your symptoms
I want to know where the pain is, when it occurs, what makes it worse, and what it is keeping you from doing.
The question is not simply, “Does your hip hurt?” It is also:
- How far can you comfortably walk?
- Can you manage stairs?
- Can you put on your shoes and socks?
- Are you having trouble getting into a car?
- Are you giving up activities you enjoy?
- Is the pain affecting work or family life?
- Is the hip beginning to affect your sleep?
The examination
During the examination, I look at how you walk and how the hip moves. Arthritis often causes loss of motion, particularly rotation of the hip. Certain movements may reproduce the familiar pain in the groin.
I also examine the surrounding areas when necessary. Tenderness over the outside of the hip, significant back symptoms, weakness, or nerve findings may suggest that something other than arthritis is contributing to the problem.
Do I need an MRI?
Usually not for straightforward hip arthritis. X-rays are generally more useful for showing the degree and pattern of arthritis.
MRI can be helpful when the diagnosis is unclear, the X-rays do not explain the symptoms, or we are looking for another problem.
Imaging
What do my hip X-rays actually mean?
A normal hip has visible space between the ball and socket on an X-ray. That space represents the cartilage that normally separates the two bones, even though the cartilage itself does not show up directly on a standard X-ray.
As arthritis progresses, we may see:
- Joint-space narrowing as cartilage is lost
- Bone spurs around the edges of the joint
- Subchondral sclerosis, meaning the bone beneath the cartilage becomes denser
- Subchondral cysts, which can develop within the bone
- Changes in the shape of the femoral head or socket in more advanced disease
How I Think About It
We treat the patient, not the X-ray.
I see patients with severe-looking arthritis who are still functioning reasonably well. I also see patients whose hip has become a major limitation in nearly everything they do.
An X-ray helps confirm what is happening structurally, but it does not tell me by itself whether you need a hip replacement.
The most useful question is whether the symptoms, examination, X-rays, and impact on your life all tell the same story.
Treatment
What can I do about hip arthritis?
There is no single treatment plan that is right for every arthritic hip. If your symptoms are manageable, there is no requirement to rush into surgery.
Nonsurgical treatment is usually aimed at keeping you active, improving function, and controlling symptoms for as long as those treatments are helping.
Activity and exercise
Staying active is generally better than becoming completely sedentary. The goal is to find activities that keep you moving without repeatedly causing a major flare in symptoms.
Walking, cycling, swimming, water exercise, and strengthening can all be reasonable depending on your symptoms and overall health.
Physical therapy
Physical therapy or a structured home exercise program can improve pain and function for some patients, particularly with mild to moderate hip arthritis.
Therapy cannot regrow the cartilage that has been lost, but it may improve strength, mobility, balance, and the way you move.
Anti-inflammatory medication
Nonsteroidal anti-inflammatory medications — commonly called NSAIDs — can reduce pain and improve function in symptomatic hip arthritis when they are medically safe for you.
They are not appropriate for everyone. Kidney disease, stomach ulcers, blood thinners, cardiovascular disease, and other medical conditions may affect whether these medications are a good choice. That decision should be individualized.
Using a cane or other walking aid
A cane can decrease the load on a painful hip and sometimes makes a surprisingly large difference. If you use one, it is generally held in the hand opposite the painful hip.
Corticosteroid injections
A corticosteroid injection into the hip joint can provide short-term pain relief for some patients.
Because the hip joint is deep beneath the skin, these injections are typically performed with imaging guidance to make sure the medication reaches the joint.
An injection does not reverse the arthritis. I think of it as one possible tool for controlling symptoms rather than a cure.
What about gel injections?
Hyaluronic-acid injections — sometimes called “gel” injections — are used in some arthritic joints, particularly knees. Current evidence does not support their routine use for symptomatic hip osteoarthritis.
Nonsurgical treatments are tools, not boxes that every patient has to check. Which treatments make sense depends on the severity of your arthritis, your symptoms, your health, and what you are trying to get back to doing.
For a broader discussion, see Non-Surgical Treatment Options.
Making the Decision
When is it time to consider hip replacement?
There is not a single X-ray finding, pain score, or age that tells everyone when it is time for a hip replacement.
I usually start thinking seriously about replacement when several things come together:
- The symptoms fit with pain coming from the arthritic hip
- X-rays show arthritis that helps explain those symptoms
- Pain or stiffness is meaningfully limiting daily life
- Walking, exercise, work, sleep, or important activities are becoming increasingly difficult
- Reasonable nonsurgical treatments are no longer providing enough relief
- You feel that the limitations of living with the hip have become greater than your desire to continue managing it without surgery
You do not need to wait until you can barely walk.
I do not think the goal should be to prove how long you can tolerate a bad hip. At the same time, an arthritic X-ray alone is not a reason to have surgery.
Hip replacement becomes reasonable when the arthritis is clearly affecting your quality of life, the diagnosis makes sense, other reasonable options are no longer giving you what you need, and you are ready to do something more definitive about it.
A Useful Question
How much of your life are you changing because of your hip?
Patients sometimes tell me their pain is “not that bad,” but then explain that they stopped walking for exercise, avoid stairs, no longer travel the way they want to, cannot put on a shoe comfortably, and plan their day around avoiding painful activities.
That loss of function matters. The decision is not based only on how you rate your pain from zero to ten.
If you are beginning to ask whether you are at that point, read When Is It Time for Joint Replacement?.
If Surgery Becomes the Plan
What does hip replacement actually do?
A total hip replacement removes the damaged surfaces of the arthritic ball-and-socket joint and replaces them with artificial components.
The goal is not simply to make an X-ray look different. The goal is to relieve arthritic pain and help you return to a more comfortable, functional life.
If you would like to understand the operation in more detail, continue to Understanding Hip Replacement.
Common Questions
Frequently asked questions
Does bone-on-bone arthritis mean I need surgery?
No. It tells us that the arthritis is advanced, but the decision to have surgery should also consider your symptoms, function, examination, overall health, and goals.
Can hip arthritis get better on its own?
The structural cartilage loss of osteoarthritis does not usually reverse. Symptoms, however, can change. Some patients can manage their arthritis for a long time with activity changes, exercise, medication, injections, or other nonsurgical measures.
Can physical therapy cure hip arthritis?
No. Therapy cannot restore cartilage that has been lost, but it can improve strength, movement, and function and may reduce pain in appropriately selected patients.
Do I need an MRI before seeing a hip replacement surgeon?
Usually not. For typical osteoarthritis, a history, examination, and appropriate X-rays are often enough to make the diagnosis. MRI is more useful when the diagnosis remains uncertain or another condition is suspected.
Why does my hip arthritis sometimes hurt near my knee?
Pain from the hip joint can be felt farther down the thigh and sometimes near the knee. This is one reason examining the hip can be important even when a patient initially notices pain somewhere else.
Am I too young or too old for hip replacement?
Age is only one part of the decision. The severity of the arthritis, your symptoms, health, activity level, goals, and the expected benefits and risks of surgery all matter.
Key Takeaways
What I want you to remember
- Hip arthritis commonly causes groin pain, stiffness, and progressive difficulty with everyday activities.
- Not every pain around the hip comes from arthritis inside the hip joint.
- X-rays are important, but we treat the patient — not the X-ray.
- Exercise, physical therapy, medications, walking aids, and selected injections can help some patients manage symptoms.
- Hip replacement becomes an option when arthritis is meaningfully affecting your life and nonsurgical treatment is no longer giving you enough relief.