Hip osteoarthritis (coxarthrosis): osteoarthritis of the hip is one of the most common joint conditions after the age of fifty, and one of those about which the most untrue things are said. If you have just been handed a report with this word on it, the question in your head is probably just one: can something be done, or is it only a matter of waiting for the replacement? The honest answer lies in between, and it is less dramatic than it seems.
Let us start with what the research really says, because it is the point where most articles slip. No study shows that exercises rebuild the cartilage or make hip osteoarthritis go backwards. Anyone who promises you this is selling you something. What exercises do, and this is documented, is reduce pain, improve movement and, according to at least one study, push the moment of surgery further into the future. These are goals different from cure, but they concretely change the life of those who live with this problem.
⚠ Important: read this first
The exercises and advice in this article are general information and may not suit your situation. Every person has a unique clinical history: what works for others could be counterproductive for you.
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First of all: when hip pain should not be managed alone
Groin pain that gets worse when walking and improves with rest is the typical picture of hip osteoarthritis. But the same area can hurt for reasons that have nothing to do with cartilage wear, and some of these do not wait. See a doctor without delay, before starting any exercise programme, if you recognise one of these situations.
Pain that came on after a fall, with inability or great difficulty in bearing weight. In older people and in those with osteoporosis even a trivial trauma can fracture the proximal femur, and the fracture may not be obvious straight away.
Fever, chills, general malaise together with hip pain. An infected joint is an emergency: it is treated in hours, not in weeks.
Worsening groin pain in those who have taken cortisone for prolonged periods, who drink heavily, or who have a condition such as sickle cell anaemia. These are the classic risk factors for necrosis of the femoral head, a condition in which conservative treatment does not stop progression and in which reaching the diagnosis early changes the options available.
History of cancer, unexplained weight loss, pain that does not change in any position and gives no respite at night. Bone pain of tumour origin has exactly this characteristic: it is independent of movement.
Onset at a young age, or pain in a hip that has never been "normal". Dysplasia, femoroacetabular impingement and sequelae of childhood illnesses deserve specialist assessment, not a generic routine taken from the internet.
Outside these cases, mechanical hip pain from hip osteoarthritis can be started to be managed calmly and methodically. That is what the rest of this guide is about.
What hip osteoarthritis is
The hip is a spherical joint: the head of the femur, the "ball", fits into the acetabulum of the pelvis, the "cup". Both surfaces are covered with cartilage, a smooth and slippery tissue that allows movement to be fluid and silent.
In hip osteoarthritis this cartilage thins and frays, in some cases until the underlying bone is left exposed. The bone reacts by thickening and producing osteophytes, the bony spurs seen on X-ray. The joint stiffens and becomes painful. It is useful to know, however, that osteoarthritis is not a simple passive wear, like the pads of a brake: it is an active process involving cartilage, bone, capsule and muscles, and for this very reason it can respond to what we do.
Two forms are distinguished. The primary form appears without an identifiable structural cause and is the most common, linked to age and to a share of family predisposition. The secondary form arises in a hip that already had something wrong with it, such as congenital dysplasia, femoroacetabular impingement, the outcome of fracture or dislocation, or avascular necrosis, and for this reason it can also appear in young people.
What the research really says about exercise
This is where the most important part lies, so let us look at the numbers rather than the promises.
The Cochrane review dedicated to exercise in hip osteoarthritis pooled ten randomised studies comparing a ground-based exercise programme with a control group that did not train. With high-quality evidence, across nine of those studies and 549 participants in total, exercise reduced pain and improved physical function immediately after treatment. The size, translated into understandable language: starting from an estimated pain of 29 points on a scale of 0 to 100 in the control group, exercise lowered it by the equivalent of 8 points, and improved physical function by about 7 points. The "number needed to treat" was 6: that means six people must be treated for one more person to obtain a clinically relevant benefit.
Three things must be said clearly, because they are usually left out. The first: on quality of life measured with questionnaires, in three small studies, the benefit was not demonstrated. The second: the effect is modest, not miraculous. Anyone who tells you that exercises "solve" hip osteoarthritis is describing another planet. The third concerns the solidity of the data: only five of the ten studies enrolled exclusively people with hip osteoarthritis (419 participants), the others mixed hip and knee (130 participants), although between the two subgroups of studies the authors found no significant differences on pain and function. It should be added that in none of these studies was it possible to keep participants unaware of the treatment they received, and that pain, function and quality of life were all reported by the participants themselves. As for adverse effects, dropouts were slightly more frequent among those who trained (6% against 3%, difference not significant), and the few events reported were all increases in pain attributed to the programme.
That said, there is a finding that deserves attention. A Norwegian study followed 109 people with symptomatic and radiographic hip osteoarthritis for six years, divided between those receiving education plus therapeutic exercise and those receiving education alone. At six years the natural hip was still in place in 41% of the first group against 25% of the second, with a median time to replacement of 5.4 years against 3.5. The authors speak of a 44% reduction in the need for surgery, and they frame it as a hypothesis suggested by the data, not as an established result. One point must be stated in full: those who had trained reported better hip function before surgery or at the end of the study, but on pain and stiffness no significant differences emerged between the two groups. It is a single study, on small numbers, and hip survival at six years was not the main outcome of the original trial, which measured pain at 16 months, but it says something that no cream and no supplement can say.
And there is one more element: the good news from the Cochrane review is that the reduction in pain was maintained for at least three to six months after the end of the monitored programme. The benefit does not evaporate on the day you finish the physiotherapy cycle.
Causes and risk factors
Age. It is the strongest risk factor. After 60 years, radiographic signs of hip osteoarthritis are frequent, which, as we will see, is by no means equivalent to having symptoms.
Family history. Having parents or siblings with hip osteoarthritis increases the risk, and nothing can be done about this.
Body weight. Excess weight increases the load the hip bears with every step and also contributes through metabolic pathways, not only mechanical ones.
Morphological anomalies. Hip dysplasia and femoroacetabular impingement change the way the surfaces distribute the load and can bring forward the onset of secondary hip osteoarthritis.
Major trauma. Fractures and dislocations of the hip leave an increased risk in the years that follow.
Avascular necrosis. The death of a portion of bone of the femoral head compromises its sphericity and leads to secondary osteoarthritis.
Heavy and prolonged work loads. Years of heavy lifting and long periods standing are among the factors most often cited.
Note well: being exposed to one of these factors does not mean developing the disease, and many people with radiographic hip osteoarthritis have none of these elements in their history.
The symptoms
Groin pain. It is the cardinal symptom. The pain is typically felt in the groin, not on the bony prominence of the side of the hip, and it can radiate to the front of the thigh as far as the knee, to the point that some people reach the physiotherapist convinced they have a knee problem.
Stiffness. The stiffness of hip osteoarthritis appears in the morning or after being still for a long time, and typically loosens in less than half an hour. Much longer morning stiffness points rather to an inflammatory arthritis and should be reported to the doctor.
Load-related pain. It gets worse when walking, standing for a long time, climbing stairs; it improves with rest.
Loss of movement, in a precise order. In hip osteoarthritis internal rotation is usually the first to go, followed by flexion and abduction. In practice this translates into movements that become difficult: tying your shoes, putting on socks, getting in and out of the car, crossing your legs.
Limping. It appears in the more advanced stages, because of the pain and the limitation of movement.
Creaks and crepitus. Frequent and often noisy, but on their own they do not indicate severity.
Night pain. In advanced forms the pain can also occur at rest and disturb sleep. If this is your main symptom, the article on hip pain at night may also be useful to you.
Diagnosis: why the X-ray alone does not decide
This is perhaps the most useful thing you can take away from this guide.
A study published in the BMJ compared hip pain and X-rays in two large populations. In the first, of 946 participants, among hips of people reporting frequent pain only 15.6% showed radiographic signs of hip osteoarthritis; and conversely, among hips with radiographic osteoarthritis only 20.7% hurt frequently. In the second population, of 4,366 participants, the figures were 9.1% and 23.8%. The authors conclude that relying on the X-ray alone would lead to failing to recognise many cases of clinical hip osteoarthritis.
Two practical consequences follow, in opposite directions. If you have a report that speaks of hip osteoarthritis but your symptoms are modest, you are not condemned to get worse by radiographic decree: the image is not your prognosis. If instead you have typical groin pain and limited internal rotation but the film is clean, the problem is nonetheless real and deserves to be assessed.
In practice, therefore, the clinical examination comes first: where it hurts, which movements are lost, how you walk, what happens with internal rotation. The X-ray serves to document narrowing of the joint space, osteophytes, sclerosis and cysts, and to frame the cases to be assessed for surgery. MRI is not routine: it is used to rule out other things, for example when avascular necrosis is suspected. Blood tests are normal in hip osteoarthritis and serve to exclude inflammatory arthritis.
The exercises: twelve movements to start from
An important point: before trying these exercises, make sure you have received a correct diagnosis. People often think they have one problem, but the real cause of the pain is something else. Doing the wrong exercises can make things worse instead of better.
In hip osteoarthritis the programme is built on three pillars: mobility, strength and stretching. First, though, the rules of use, which matter more than the list. Moderate discomfort during the work is acceptable; acute pain that makes you stop is not. Pain that remains worse the next day is the signal that you have asked too much. You proceed little by little, and consistency is worth more than intensity. One honest clarification: the studies cited above measured therapeutic exercise programmes, that is pathways set up and carried on continuously, not a handful of improvised sessions. The list below is a starting point to adapt to your case, not the protocol of those studies.
Mobility (4 exercises)
- Hip flexion. Lying on your back, bring the knee towards your chest, guiding it with your hands, and stop where the movement blocks without forcing. About 10 repetitions.
- Rotations. Lying on your back with the knee bent and the foot resting, rotate the leg inwards and outwards. About 10 repetitions per side. Take particular care with internal rotation, usually the most limited.
- Lying abduction. Lying on your back, straight leg, slide it sideways on the bed and back. About 10 repetitions.
- Pendulum. Standing with a safe support, let the leg swing forwards and backwards and then sideways, without effort. It is an excellent way to start the day when the hip is stiff.
Strengthening (5 exercises)
- Bridge. Lying on your back, feet on the floor, lift the pelvis by contracting the glutes. About 15 repetitions.
- Clamshell. On your side, knees bent, open the upper knee keeping the pelvis still. About 15 repetitions. It works the gluteus medius, the great stabiliser of the stride.
- Side-lying abduction. Lying on your side, lift the straight leg without rotating it. About 15 repetitions.
- Mini squat. Standing, go down only as far as where no pain appears, even just a few centimetres at the beginning. About 15 repetitions.
- Step-up. On a low step, go up and down controlling the pelvis. About 15 repetitions.
Stretching (3 exercises)
- Hip flexors. In a lunge position, move the pelvis forward keeping the trunk upright. About 30 seconds.
- Piriformis and glutes. Lying on your back, ankle resting on the opposite thigh, pull the knee towards you. About 30 seconds.
- Adductors. Seated, soles of the feet together, let the knees drop. About 30 seconds.
In hip osteoarthritis a low-impact aerobic activity should be added to these, such as walking, cycling, swimming or water exercise, because the cardiovascular part is part of the recommended package and also helps with weight. If the pain appears mainly in squatting or in sporting movements, the article on hip pain in the squat may also interest you.
The stages: what they mean, and what they do not
In clinical practice hip osteoarthritis is often described in stages, based on how much the pain limits everyday life:
- First stage. The pain is not continuous: it appears after effort or prolonged walking and goes away with rest. The limitation of movement is minimal and often goes unnoticed.
- Second stage. The pain begins to occur even at rest and extends to the groin and the front of the thigh. Rotation of the hip is reduced and certain gestures, such as tying your shoes or getting into a car, become uncomfortable.
- Third stage. The pain is constant and considerably limits walking, up to stable limping.
Be careful how this scale is used. It describes the symptoms, not the radiological image, and the two agree less than one might think: a very altered film can go with little pain, and vice versa. This is why a diagnosis of hip osteoarthritis is not enough on its own to decide the pathway: what matters is how much it limits you, not how bad the X-ray looks.
The bilateral form
When osteoarthritis affects both hips one speaks of bilateral hip osteoarthritis. It is not a different disease: it is the same condition in two joints, and it mainly changes two things in practical terms.
The first is that there is no healthy side to refer to: when only one hip is involved, the other serves as a comparison and a support in the worst moments; with both affected the load has nowhere to shift, and walking changes sooner.
The second concerns the order of things, if surgery is reached: the two hips are not operated on together, and the choice of which to treat first is made with the surgeon on the basis of which limits you more.
On the conservative side the approach does not change, namely strength, control of load and regular movement, but the dosage does: with two symptomatic hips more gradualness is needed, and more care in spreading the effort across the week.
"Is hip osteoarthritis disabling?"
This is a question we are often asked, and it has two different answers depending on what is meant.
Functionally, hip osteoarthritis can become disabling in the everyday sense of the word: in advanced forms it limits walking, sleep and independence. But it is not an automatic fate, and that is exactly why work on strength and load makes sense early, not only when the situation is already compromised.
As regards recognition of civil disability, the assessment is not made by the physiotherapist or by the treating orthopaedist: it is made by an INPS medical commission (the Italian social security institute), on the basis of clinical documentation and above all of the documented functional limitation: how far you can walk, how independent you are in daily activities, how much the condition affects work. There is no percentage that follows automatically from the diagnosis or the X-ray: two people with the same film can receive different assessments, because what is assessed is function.
What to do in practice: if you are considering this route, the useful thing is to arrive with documentation that describes the limitation concretely, what you can no longer do and since when, and not only with the imaging report. For the procedure itself, the reference is your GP and the patronato (the Italian assistance offices), not us.
Other treatment options
Exercise and education. The guidelines of the American College of Rheumatology, developed together with the Arthritis Foundation, strongly recommend exercise, self-management programmes and, a detail often overlooked, the use of a walking stick, also strongly recommended. Carrying it on the side opposite the painful hip is not a surrender: it reduces load and allows you to walk more, which is exactly what is needed.
Body weight. The same guidelines strongly recommend weight loss in people who are overweight or obese with knee and/or hip osteoarthritis. It is one of the few levers with both a mechanical and a general effect on health.
Medicines. Painkillers and anti-inflammatories have a role in hip osteoarthritis, especially during flare-ups, but they should be agreed with the doctor: oral anti-inflammatories are not harmless, particularly in older age or in the presence of other therapies.
Injections: clarity is needed here. The largest network analysis of major randomised trials on intra-articular injections of the knee and hip, with 57 studies and over 22,000 participants, found that hyaluronic acid has no effect on pain compared with placebo, and that it is associated with more dropouts due to adverse effects and more serious adverse events. The product with the highest probability of exceeding the threshold of clinical relevance was the corticosteroid triamcinolone, but only in the 2-6 week window and on the basis of a single study. Overall, the authors conclude that, looking at the larger studies with less risk of systematic error, the effects of 16 of the 18 intra-articular interventions examined were below the minimal clinically important difference, and that most were compatible with a placebo effect. Keep this in mind when a course of injections is offered to you as an alternative to active work: in hip osteoarthritis, exercise remains the option with the best evidence. If you have already had the injection, the practical questions of the following days, walking, driving, ice, when to resume, are covered in after an injection: what to do.
Joint replacement surgery. When in advanced hip osteoarthritis the pain can no longer be controlled and quality of life is compromised, the hip replacement is a procedure with generally very good results. Here too, however, the real numbers help in deciding: a systematic review published in The Lancet estimates that, according to data from the national registries of Australia and Finland, about 58% of hip replacements are still in place at 25 years (in the published case series the estimate rose to 77.6%). It is information of particular relevance for those facing surgery at a young age, because it takes into account the possibility of a revision.
Living with hip osteoarthritis
Do not stop. With hip osteoarthritis the natural reflex in front of a joint that hurts is to protect it, but deconditioning worsens the functional picture. Movement remains the foundation of treatment.
Adapt instead of giving up. Changing the route, reducing the duration, splitting a walk into two stretches, using a bike instead of running: almost always there is a sustainable version of what you like to do.
Look after the home environment. Chairs with armrests and a seat not too low, a bed of adequate height, a long shoehorn: they are mundane details that give back independence in the gestures that hip osteoarthritis makes tiring.
Do not wait for the pain to become unmanageable before being assessed. A programme set up early is easier to follow than one that starts when you are already walking little.
Can it be prevented?
Honestly: there is no solid evidence that exercise or any other behaviour prevents hip osteoarthritis. The available research concerns almost entirely the treatment of those who already have symptoms, not the prevention of the disease in the healthy population. It is a distinction worth keeping in mind every time one reads that this or that gesture "protects the cartilage".
What can be said with more confidence is more modest: maintaining an adequate weight and treating promptly the predisposing conditions, such as dysplasia, femoroacetabular impingement and sequelae of trauma, is reasonable, makes biological sense and in any case does no harm. And it is quite different from promising that osteoarthritis will not come that way.
In summary
If you are considering whether to try the conservative route first, the comparison between the two routes district by district is in avoiding surgery: when you can and when you cannot.
Hip osteoarthritis is a chronic condition, and chronic means it is managed, not that it is cured on demand. In hip osteoarthritis exercises do not rebuild the cartilage, and the average benefit they produce on pain is measured and modest, but it is real, it lasts beyond the end of the programme and, according to the Norwegian study, can go with surgery arriving later. Weight loss, the walking stick when needed and low-impact activity complete the picture. Hyaluronic acid injections, tested against the large studies, have not kept what they promised. And if one day the replacement is needed, it will not have been a failure of the conservative pathway: it will simply be the next step.
If you live with hip osteoarthritis and want a programme built on your hip rather than on a generic list, the physiotherapists at Ri-Hub work in telerehabilitation: assessment, targeted exercises and progression followed over time, from your own home.
One of the recognised mechanical causes of hip osteoarthritis is dysplasia, often discovered late: Hip dysplasia in adults: symptoms and when to worry.
Sources
- Exercise for osteoarthritis of the hip (Cochrane Database of Systematic Reviews, 2014)
- Exercise therapy may postpone total hip replacement surgery in patients with hip osteoarthritis: a long-term follow-up of a randomised trial (Annals of the Rheumatic Diseases, 2015)
- 2019 American College of Rheumatology/Arthritis Foundation Guideline for the Management of Osteoarthritis of the Hand, Hip, and Knee (Arthritis Care & Research, 2020)
- Association of hip pain with radiographic evidence of hip osteoarthritis: diagnostic test study (BMJ, 2015)
- Effectiveness and safety of intra-articular interventions for knee and hip osteoarthritis based on large randomized trials: A systematic review and network meta-analysis (Osteoarthritis and Cartilage, 2025)
- How long does a hip replacement last? A systematic review and meta-analysis of case series and national registry reports (The Lancet, 2019)
Last source check: August 2026.
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