Quick answer: Hip osteoarthritis usually announces itself in the groin, not on the outside of the hip. The most consistent early sign is loss of internal rotation — turning the leg inward. Exercise is still the recommended first-line treatment, but a July 2026 Cochrane review found the average pain benefit is smaller than most articles claim. For people with severe hip OA and a surgical indication, hip replacement outperformed supervised strength training in a head-to-head trial, and modern implants are now estimated to survive far longer than the figures most patients have been quoted.
When to See a Doctor Urgently
Most hip pain is not an emergency, but a few patterns need same-day assessment rather than an exercise programme:
- A hot, swollen, exquisitely painful hip with fever or feeling unwell — a joint infection is possible and is treated as an emergency.
- Inability to bear weight after a fall, or sudden severe hip or groin pain in an older adult after minor trauma — a fracture must be excluded.
- Pain that is worse at night, unrelenting at rest, or accompanied by unexplained weight loss.
- Numbness, weakness, or loss of bladder or bowel control alongside back and leg pain.
Hip osteoarthritis develops over months and years. Anything that appears suddenly and severely deserves a different explanation.
Where the Pain Is Tells You a Lot
The single most useful thing to know about hip OA is that the joint refers pain away from itself. The hip joint sits deep and towards the front, so the pain surfaces in the groin, the front of the thigh, and often the inner knee. People routinely arrive at a clinic convinced they have a knee problem or a back problem.
Location is the fastest rough filter:
- Groin, front of thigh, or inner knee — most consistent with the hip joint itself. Pain that travels down to the knee but no further, and gets worse the longer you walk, points at the joint.
- Outer hip, over the bony point, painful to lie on at night — usually not osteoarthritis. This pattern typically comes from the gluteal tendons and the tissue over the greater trochanter, and it is managed very differently: loading the tendon, not mobilising the joint.
- Buttock with pain travelling below the knee, with pins and needles or numbness — more likely to be coming from the lumbar spine.
- Deep groin pain with catching or clicking in a younger, active person — raises hip impingement or a labral tear rather than established OA.
These overlap, and people can have two at once. But if your pain is on the outside of the hip, the odds that hip OA is the whole story drop sharply — and that is the mistake that sends people to the wrong exercises for months.
The Internal Rotation Test Clinicians Actually Use
Hip OA restricts internal rotation before it restricts anything else. The classification criteria published by the American College of Rheumatology use exactly this: hip pain together with internal rotation under 15 degrees and hip flexion of 115 degrees or less; or hip pain with internal rotation of 15 degrees or more that is painful, morning stiffness lasting an hour or less, and age over 50. Those criteria carry a sensitivity of 86% and specificity of 75% without any imaging at all.
You can get a rough sense of this at home. Sit on a firm chair with both knees together and bent at a right angle. Keeping the knees still, swing one foot outward, away from the midline — that movement rotates the hip inward. Compare sides. If one hip moves noticeably less than the other, or the movement reproduces groin pain, that asymmetry is worth showing your doctor.
This is a prompt for a proper examination, not a diagnosis. But it is a specific, checkable observation you can take to an appointment, and it is far more useful than reporting “my hip hurts”.
What Causes Hip Osteoarthritis
Hip OA is joint degeneration involving cartilage, underlying bone, the joint lining, and surrounding muscle. Contributing factors include age, family history, previous hip fracture or dislocation, childhood hip conditions including developmental dysplasia, hip impingement morphology, and occupations involving years of heavy lifting or prolonged standing. Higher body weight is a recognised risk factor for developing hip OA, though as the next section explains, the treatment evidence for weight loss in hip OA is weaker than most people assume.
In many cases no single cause is identifiable, and searching for one is less productive than managing the symptoms.
Diagnosis: What an X-Ray Does and Does Not Tell You
Hip OA is graded on X-ray using the Kellgren-Lawrence scale:
- Grade I: possible small bone spurs, minimal joint space narrowing.
- Grade II: definite bone spurs, mild narrowing.
- Grade III: multiple bone spurs, moderate narrowing, some hardening of the bone beneath the cartilage.
- Grade IV: large bone spurs, severe narrowing or loss of joint space, bone contacting bone.
X-ray grade correlates poorly with how much pain someone has. People with Grade III changes can have modest symptoms; people with Grade I changes can be significantly limited. This is not a quirk — it is a consistent finding, and it is why guidelines direct treatment decisions from symptoms and function rather than from the picture. If a scan report frightens you more than your actual hip does, that gap is normal.
Exercise: What the 2026 Evidence Actually Shows
Exercise is recommended as first-line treatment for hip OA in every major guideline, and that recommendation still stands. What has changed is the honest size of the effect.
A Cochrane review updated in July 2026 pooled 18 randomised trials covering 1,368 people with hip osteoarthritis. Compared with no treatment or usual care, land-based exercise reduced pain by around seven points on a 100-point scale. Researchers generally treat a 12-point improvement as the threshold at which a patient notices a real difference in daily life — so the average benefit landed below that mark. Physical function improved by a similar modest margin, and there was little evidence of improvement in quality of life. The certainty of the evidence was downgraded because many trials were small and relied on self-reported outcomes.
The review’s authors were explicit that this is not an argument against exercising. It is an argument for setting honest expectations: exercise is low cost, unlikely to cause harm, carries well-established benefits for the rest of your health, and people are clearly worse off when they stop moving. But if you have been told exercise will resolve hip OA pain and it has not, the evidence says that is a common outcome, not a personal failure.
One further caveat worth knowing: much of what is assumed about osteoarthritis comes from knee research, and hip OA behaves differently. Treatments do not automatically transfer between the two joints.
Weight Loss: The Hip Is Not the Knee
Hip joint contact forces during walking are estimated at roughly two to three times body weight, so reducing load has clear biomechanical logic. For knee osteoarthritis, weight loss has demonstrated benefit.
For the hip, the direct trial evidence does not show the same thing. A randomised trial published in the Annals of Internal Medicine in 2025 gave 101 adults with hip OA and overweight or obesity either a home exercise programme alone, or the same programme plus a supervised very-low-calorie diet. The diet group lost substantially more weight — around 8.5% more — yet showed no significant advantage in hip pain at six months.
This does not mean weight is irrelevant, and it does not mean weight management has no value: several secondary measures did improve, and the general health case is unchanged. It means the specific promise that losing weight will fix hip OA pain is not supported by the hip evidence, and anyone making major dietary changes should do so with their doctor or a dietitian rather than on the strength of a health article.
Five Exercises for Hip Osteoarthritis
These are standard physiotherapy movements targeting the muscles that most often weaken around an arthritic hip. Build up gradually. Mild discomfort during and shortly after is expected; sharp pain, or pain that is clearly worse the following day, means reduce the range or the repetitions and get the programme checked.
1. Side-lying hip abduction (clam)
Lie on your side with knees bent to about 45 degrees. Keeping the feet together, lift the top knee like a clamshell opening. Hold two seconds, lower slowly. Work towards three sets of 15 each side. Targets gluteus medius, commonly the weakest muscle in hip OA.
2. Standing hip extension
Stand facing a wall for support. Keeping the leg straight, take it slowly backwards 20 to 30 degrees without arching the low back. Hold two seconds. Three sets of 12 each side. Strengthens gluteus maximus, which drives walking and stairs.
3. Hip circumduction
Stand on one leg with a hand on the wall. Move the other leg in a slow circle, ten in each direction. Gentle mobilisation that maintains range without loading the joint.
4. Seated hip flexion
Sit in a chair. Lift one knee towards your chest, hold three seconds, lower. Alternate. Two sets of 12. Maintains hip flexor function, which often declines in more advanced OA.
5. Figure-four stretch
Sitting, cross one ankle over the opposite knee and lean gently forward until you feel a stretch in the outer hip. Hold 30 seconds each side. Skip this one if it produces groin pain rather than a stretch.
Medication and Injections
Pain relief is a discussion for your prescriber, particularly if you take blood thinners or have kidney, heart, or stomach conditions, since anti-inflammatories carry real risk in those situations. Topical and oral options are typically layered onto exercise rather than replacing it.
Injections into the hip are a different proposition from injections into the knee. The hip joint is deep, so accurate injection requires ultrasound or X-ray guidance rather than landmarks alone, and the evidence base built around the knee does not transfer automatically. If you are weighing up an injection, our reviews of the evidence for hyaluronic acid injections and PRP therapy cover how these treatments are actually assessed — with the caveat that both examine the knee.
When Hip Replacement Is Worth It
Total hip replacement is typically considered when significant pain and disability persist despite several months of appropriate conservative treatment, when imaging confirms advanced changes, when daily life and sleep are meaningfully affected, and when you are well enough for surgery.
Until recently that recommendation rested on observational data rather than trials. The PROHIP trial, published in the New England Journal of Medicine in 2024, addressed that directly: 109 patients aged 50 and over with severe hip OA and an indication for surgery were randomly assigned to hip replacement or a supervised progressive resistance training programme. At six months, the surgery group improved by 15.9 points on the Oxford Hip Score against 4.5 points for resistance training — a difference of 11.4 points, both statistically and clinically significant. Serious adverse events were similar between groups. Notably, 21% of those assigned to resistance training had gone ahead with surgery within the six months anyway.
That is a clear result for people who already meet the criteria for surgery. It says nothing about people with mild or moderate hip OA, who were not studied.
How long a modern hip replacement lasts
The widely quoted figure — that around 58% of hip replacements survive 25 years — comes from a 2019 Lancet analysis that included bearing materials no longer in routine use. A much larger 2026 Lancet study looked only at contemporary bearing surfaces across roughly 1.9 million procedures from eight national joint registries. It reported 93.6% implant survival at 20 years, with extrapolated estimates of 92.8% at 25 years and 92.1% at 30 years.
Those are population figures, not personal guarantees — age, bone quality, general health, and surgical technique all matter. But for a younger patient who has been advised to delay surgery purely on the grounds that the implant will wear out, the calculation has genuinely changed.
Claims We Corrected on This Page
This article previously carried statements we could not support, and we have removed them rather than softening them:
- A medical reviewer credit that was not real. The page carried a “medically reviewed by” line attributing review to a named specialist. No clinician reviewed this article. The line is gone, and our sourcing policy explains what we do and do not do.
- “Exercise reduced hip OA pain by 29%.” This figure did not match the review it was attributed to, and the current Cochrane evidence points to a considerably smaller average effect. Replaced with the July 2026 figures.
- “Exercise is the single most evidence-based treatment, above all medications and injections.” Overstated, and directly contradicted by the PROHIP trial in people with a surgical indication.
- “Over 95% patient satisfaction at 10 years.” Unsupported as written, and it conflated patient satisfaction with implant survival. Reported satisfaction figures after hip replacement are high but lower than that, and implant survival is a separate measure, now given above.
- “A 5 kg weight loss reduces hip loading by 15 kg per step.” A derived number presented as a finding. Removed in favour of the trial evidence on weight loss and hip pain.
Frequently Asked Questions
Why does my knee hurt if the problem is my hip?
The hip joint refers pain along shared nerve pathways to the front of the thigh and the inner knee. Referred knee pain from the hip typically stops at or above the knee and comes with restricted hip movement. If your knee examination is normal but your hip rotation is limited, the hip is the likely source.
Is walking good or bad for hip osteoarthritis?
Walking is generally beneficial and is not damaging the joint further. Many people find shorter, more frequent walks more tolerable than one long one. If walking consistently leaves you worse the next day, that is a signal to adjust distance and pacing, not to stop moving.
Does cracking or clicking in the hip mean it is getting worse?
Painless clicking is common and not an indicator of damage. Clicking accompanied by catching, locking, or sharp groin pain is worth investigating, particularly in younger people, where it can suggest a labral problem rather than OA.
Can hip osteoarthritis be reversed?
No treatment currently regrows hip cartilage or reverses established osteoarthritis. Treatment aims at pain, function, and keeping you active. Anything sold as a cure for osteoarthritis is being sold to you rather than proven to you. Our guide to how osteoarthritis progresses covers what does and does not influence the course.
Should I use a stick or a cane?
A stick held in the hand opposite the painful hip reduces load through that joint and can meaningfully improve walking distance. It is a practical aid, not a sign of giving up, and using one earlier often keeps people more active for longer.
How is hip OA different from knee OA?
Different pain location, different early movement restriction, and a different evidence base. Weight loss has clearer benefit for the knee than the hip, and knee injection evidence does not transfer. Our knee osteoarthritis guide covers that joint in full, along with knee treatment options and knee exercises.
What about cartilage damage in the hip from other causes?
Cartilage loss in the hip is not always osteoarthritis. Rapid cartilage breakdown after surgery, infection, or injury is a distinct condition — see our guide to chondrolysis of the hip.
Sources
- Hall M, Lawford BJ, et al. Exercise for osteoarthritis of the hip. Cochrane Database of Systematic Reviews, 2026.
- Frydendal T, Christensen R, Mechlenburg I, et al. Total Hip Replacement or Resistance Training for Severe Hip Osteoarthritis. New England Journal of Medicine, 2024;391:1610-1620.
- Efficacy of a Very-Low-Calorie Weight Loss Diet Plus Exercise Compared With Exercise Alone on Hip Osteoarthritis Pain: A Randomized Controlled Trial. Annals of Internal Medicine, 2025;178(9).
- Pentland V, Thompson Z, Dayimu A, et al. Survivorship of modern total hip replacement to 30 years. The Lancet, 2026;407:855-866.
- Evans JT, Evans JP, Walker RW, et al. How long does a hip replacement last? The Lancet, 2019;393:647-654.
- Altman R, Alarcón G, Appelrouth D, et al. The American College of Rheumatology criteria for the classification and reporting of osteoarthritis of the hip. Arthritis & Rheumatism, 1991;34:505-514.
Last updated: August 2026.
This article is for general information and is not a substitute for individual medical advice. It has not been reviewed by a licensed clinician. If you have hip pain, discuss diagnosis and treatment with your doctor or a physiotherapist, particularly before starting a new exercise programme or changing medication.
