Hip Osteoarthritis: Why Exercise and Education Come Before Surgery

Hip osteoarthritis is a slow change in the hip joint. It causes pain in the groin or thigh, stiffness in the morning, and trouble with stairs, socks and shoes. When an X-ray report uses the word "osteoarthritis", many people ask about surgery first. This guide covers what to try first, what to expect from it, and when a joint replacement becomes a reasonable question.

Hip osteoarthritis is diagnosed from your symptoms

Osteoarthritis is a gradual change in a joint: the cartilage that covers the bone ends thins, and the bone and nearby tissues change too. In the hip, people report pain in the groin, the front of the thigh or the buttock, usually with walking, stairs or putting on a sock.

The 2022 guideline from the National Institute for Health and Care Excellence in England (NICE) says a clinician can diagnose osteoarthritis without imaging in a person who is 45 or older, has joint pain that comes with activity, and has either no morning stiffness or morning stiffness that lasts no longer than 30 minutes. A recent injury, long morning stiffness, fast worsening or a hot swollen joint call for a check for another cause.

Other hip problems can look similar. Pain on the outer side of the hip often comes from the tendons of the buttock muscles, explained in our article on gluteal tendinopathy and hip bursitis. Deep groin pain with squatting can come from the shape of the joint, covered in our guide to hip impingement.

The X-ray and your pain often disagree

An X-ray shows the bone and the space between the bones. A 2015 study in the BMJ by Kim and colleagues compared hip pain with X-ray findings in two large groups of adults in the United States. In the first group of 946 people, 15.6% of hips with frequent pain showed osteoarthritis on X-ray, and 20.7% of hips with osteoarthritis on X-ray hurt on most days. In the second group of 4,366 people, the figures were 9.1% and 23.8%.

Most painful hips did not meet the study's X-ray definition of osteoarthritis, and fewer than one in four hips with X-ray changes hurt on most days. The authors wrote that hip osteoarthritis may be missed when a clinician relies on the X-ray alone. NICE advises that management follow symptoms and physical function, and that imaging not be used routinely to guide non-surgical care.

Education and exercise are the first treatments

The Osteoarthritis Research Society International (OARSI) published guidelines in 2019 after reviewing 60 treatments. For hip osteoarthritis, the core treatments are arthritis education and structured land-based exercise. NICE gives similar advice: offer therapeutic exercise to everyone with osteoarthritis, consider supervised sessions, and combine exercise with an education programme. The 2019 American College of Rheumatology and Arthritis Foundation guideline strongly recommends exercise and notes that supervised programs tend to work better than exercise done alone at home.

Education covers how osteoarthritis develops, including flares (a short period of worse symptoms) and changes over time, and corrects common misconceptions about it. GLA:D Canada is a structured program for hip and knee osteoarthritis. Our article on knee osteoarthritis covers the knee version.

The Ottawa Panel reviewed exercise trials in hip osteoarthritis in 2016. Strength training gave the greatest improvements in pain, function and stiffness within 8 to 24 weeks, and stretching and flexibility exercises also helped.

A plan often combines strengthening of the hip and thigh muscles (standing up from a chair, bridges, step-ups, elastic bands), steady walking or cycling, and movement work for joint range. The American College of Rheumatology found insufficient evidence to recommend one form of exercise over another, so preference, access and cost decide. HealthLinkBC also lists tai chi and swimming. The OARSI panel did not recommend water exercise for hip osteoarthritis, so the pool can add to your plan while land-based work stays the core.

Trials show a small gain in hip pain

The Cochrane review of exercise for hip osteoarthritis, which combines the results of many trials, was updated in July 2026. It included 18 trials with 1,368 people. Compared with no treatment, usual care or limited education, exercise lowered pain by 7.19 points on a 0 to 100 scale and improved function by 8.79 points. The review judged these changes unlikely to be clinically meaningful, which means too small to matter in daily life. When exercise was added to another treatment, it probably made little to no extra difference to pain or function.

A 2014 JAMA trial by Bennell and colleagues compared ten physiotherapy sessions over 12 weeks with a fake treatment (an ultrasound device that was not active, with plain gel). The physiotherapy included education, manual therapy, home exercise and a walking aid when needed. Among 102 people, both groups improved. At week 13 the pain score was 40.1 out of 100 in the physiotherapy group and 35.2 in the fake-treatment group. The 6.9-point gap favoured the fake treatment and was too small to tell apart from chance.

Svege and colleagues followed 109 people for six years. One group had exercise therapy plus education and the other had education only. A hip replacement was done in 22 people in the exercise group and 31 in the education-only group. At six years, 41% of the exercise group and 25% of the education-only group still had their own hip. Function was better in the exercise group before surgery, and pain and stiffness did not differ. It is one trial.

Together, these results support an expectation of a small average change in pain, a possible gain in function, and a possible delay of surgery. NICE adds that a steroid injection gives relief for 2 to 10 weeks.

Pain during exercise needs a plan

NICE tells clinicians to explain that joint pain may increase when a person starts therapeutic exercise, that regular exercise is expected to benefit the joints, and that sticking with the plan over the long term increases the benefit. The American College of Rheumatology adds that no level of pain is agreed for when to exercise or stop, so you and your clinician set the limit.

Pain after movement is common. Skou and colleagues asked 3,889 people with hip osteoarthritis to do a 30-second chair-stand test. One in 5 reported a pain rise of 2 points or more on a 0 to 10 scale. The rise was linked to low confidence in the hip, three or more painful body sites, and fewer than 12 chair stands in 30 seconds.

HealthLinkBC advises starting with 10 minutes of activity once or twice a day and building up. It says sharp or unusual pain may signal an injury.

A simple tracking method uses the same 0 to 10 scale. Write down your pain before a session, right after it and the next morning. If the next-morning score matches the score before, the dose (how much you did) suited you and can go up by one step. If it is higher, repeat or reduce the dose with fewer repetitions, less weight or a shorter walk. Change one thing at a time. Sharp pain or new pain in a different place means stop and get it assessed. A physiotherapist adjusts this method, because the research gives no single limit that fits everyone.

Weight management and walking aids may help

NICE tells clinicians to advise people living with overweight or obesity that weight loss improves quality of life and physical function and reduces pain. Any amount is likely to help, and losing 10% of body weight is likely to be better than 5%. The American College of Rheumatology strongly recommends weight loss for hip or knee osteoarthritis in people who are overweight, and the benefit grows with exercise added. A 2022 review of 15 guidelines found weight loss recommended for hip osteoarthritis in 10 of the 11 guidelines that covered the hip.

NICE says to consider a walking stick or similar aid for lower limb osteoarthritis, and describes walking aids as devices that improve walking pattern and balance or reduce weight on the affected joint. The American College of Rheumatology strongly recommends a cane when osteoarthritis affects walking, stability or pain enough to justify one. A physiotherapist can set the height of a cane and check your walking with it.

When to ask about joint replacement

NICE says to consider referral for joint replacement when symptoms such as pain, stiffness, reduced function or progressive deformity have a large effect on quality of life, and when non-surgical care such as exercise, weight loss and pain relief is ineffective or unsuitable. It says to use clinical assessment instead of scoring systems. It also says age, sex, smoking, other health conditions and overweight should not exclude a person from referral, although surgical risks vary with those factors.

Two questions help you decide when to ask. Do hip symptoms limit your walking, sleep or work? Have you followed a supervised, progressed exercise plan for long enough to judge it? If you do have surgery, our guide to rehab after hip replacement shows the first six months. The 2019 OARSI guideline did not recommend corticosteroid injections for hip osteoarthritis.

Warning signs that need a doctor first

Call 911 or go to the Lions Gate Hospital emergency department for severe hip pain after a fall or injury, especially if you cannot put weight on the leg. The NHS lists a broken hip as the possible cause.

A hot, swollen hip, especially with a fever, needs urgent medical care. The same NHS page names infection in the joint as a possible cause.

Night pain that does not ease when you change position, with weight loss you cannot explain, needs a prompt medical assessment. A family medicine review from 2003 lists night pain, weight loss and fever as signs that call for a check for tumour, infection or inflammatory arthritis.

For hip pain without these signs, you do not need a referral to book physiotherapy in British Columbia. The clinic is at 1325 Marine Drive, North Vancouver, BC V7P 3E5. You can book at medstar.janeapp.com or call (604) 988-5411. You can check any BC physiotherapist in the public registry of the College of Health and Care Professionals of BC. Our page on hip pain lists other causes of hip pain.

Bring any X-ray or MRI report to the first assessment. The physiotherapist starts from your symptoms and how you move.

This article is general information, not personal medical advice, and is not a substitute for assessment by a regulated practitioner. A regulated practitioner can confirm whether the patterns described apply to you.

Sources

• NICE. Osteoarthritis in over 16s: diagnosis and management (NG226), 2022
• Bannuru RR, et al. OARSI guidelines for the non-surgical management of knee, hip, and polyarticular osteoarthritis. Osteoarthritis Cartilage, 2019
• Kolasinski SL, et al. 2019 American College of Rheumatology/Arthritis Foundation Guideline for the Management of Osteoarthritis of the Hand, Hip, and Knee. Arthritis Care Res, 2020
• Hall M, et al. Exercise for osteoarthritis of the hip. Cochrane Database Syst Rev, 2026
• Bennell KL, et al. Effect of physical therapy on pain and function in patients with hip osteoarthritis: a randomized clinical trial. JAMA, 2014
• Svege I, et al. Exercise therapy may postpone total hip replacement surgery in patients with hip osteoarthritis: a long-term follow-up of a randomised trial. Ann Rheum Dis, 2015
• Kim C, et al. Association of hip pain with radiographic evidence of hip osteoarthritis: diagnostic test study. BMJ, 2015
• Brosseau L, et al. Ottawa Panel evidence-based clinical practice guidelines for therapeutic exercise in the management of hip osteoarthritis. Clin Rehabil, 2016
• Skou ST, Gronne DT, Roos EM. Prevalence, severity, and correlates of pain flares in response to a repeated sit-to-stand activity. J Orthop Sports Phys Ther, 2020
• Lim YZ, et al. Recommendations for weight management in osteoarthritis: a systematic review of clinical practice guidelines. Osteoarthr Cartil Open, 2022
• Zywiel M, et al. Implementation of the Good Life with osteoArthritis in Denmark (GLA:D) Program across Canada. Healthc Q, 2021
• HealthLinkBC. Osteoarthritis: Exercising With Arthritis
• NHS. Hip pain
• Evaluation and management of hip pain: an algorithmic approach. J Fam Pract, 2003
• College of Health and Care Professionals of BC: public registry

This article is for general information only and does not constitute medical advice, diagnosis, or treatment. Individual presentations vary, and assessment findings and treatment plans differ from person to person. If you are experiencing severe symptoms, neurological changes (numbness, weakness, bowel or bladder changes), or a significant trauma, contact your physician or emergency services. Care at Medstar Sport Physio & Health is provided by practitioners registered with their respective British Columbia regulatory colleges.