Hip osteoarthritis: what exercise can do, what it cannot, and when to consider a hip replacement

Osteoarthritis is the most common form of arthritis. About 33 million US adults have it, and although it is common after 45, it is not a normal part of aging [2]. Worldwide, 595 million people had osteoarthritis in 2020, and cases of hip osteoarthritis are projected to rise by about 79% by 2050 [1].

This article covers what the evidence says about managing hip osteoarthritis, including where exercise helps, where it falls short, and when a hip replacement makes sense.

Do you need an X-ray?

Not always. The UK’s national guideline says osteoarthritis can be diagnosed without imaging in people who are 45 or older, have joint pain related to activity, and have no morning stiffness or stiffness that lasts no longer than 30 minutes [5]. Imaging is still useful when symptoms are unusual or something else may be going on [5].

Exercise: first in every guideline, but modest

Exercise is a core treatment for hip osteoarthritis in the guidelines of the American College of Rheumatology [3], the international osteoarthritis society [4], the UK [5] and the physical therapy profession, which recommends individualized exercise 1 to 5 times a week for 5 to 16 weeks [6].

It is worth being honest about the size of the benefit. A 2026 Cochrane review of 18 studies found that, compared with no treatment or usual care, exercise probably reduces pain and improves function slightly, by about 7 to 9 points on a 0 to 100 scale, which the authors judged unlikely to be clinically meaningful [8]. Against a placebo or attention control, the effect on pain was little to none, with a slight improvement in function [8]. In a trial of 102 people, a 12-week physical therapy package did no better than a convincing sham treatment, and mild side effects were more common with the real treatment (41% vs. 14%) [9].

So why does every guideline still put exercise first? It is safe, low cost and can be kept up for life. Two practical findings help:

• The type of exercise matters less than doing it. In a trial of 160 people, heavy resistance training and neuromuscular (balance and movement control) exercise improved pain and function by the same amount [11].
• Sticking with it pays off. The UK guideline notes that pain may increase at first and that long-term adherence increases the benefit [5]. In a Danish national program of education and supervised exercise, people with hip osteoarthritis reported less pain at 3 and 12 months and fewer were taking painkillers, though that program had no comparison group [10].

Other things that help

• Weight loss, if you are overweight: strongly recommended by the American College of Rheumatology [3]. The UK guideline says any weight loss is likely to help, and losing 10% of body weight is likely better than 5% [5].
• A cane: strongly recommended when osteoarthritis affects your walking [3].
• Education and self-management programs, and tai chi: strongly recommended [3].
• Hands-on therapy: the physical therapy guideline supports manual therapy for mild to moderate hip osteoarthritis [6], while the rheumatology guideline advises against adding it to exercise [3] and the UK guideline supports it only alongside exercise [5].

Medicines and injections

Guidelines do not always agree on medicines and injections. Here is how three of them compare:

Treatment	American College of Rheumatology 2019	UK NICE 2022	Other guidance
Oral anti-inflammatories (NSAIDs)	Strongly recommended [3]	Consider, with stomach protection [5]	Orthopedic surgeons: strongly recommended when safe [7]
Acetaminophen	Conditional; ineffective for most people [3]	Do not routinely offer [5]	International society: conditionally not recommended [4]
Steroid injection into the hip	Strongly recommended, with ultrasound guidance [3]	Consider; relief lasts about 2 to 10 weeks [5]	International society: not recommended for the hip [4]
Hyaluronic acid injection	Strongly against [3]	Do not offer [5]	Orthopedic surgeons: strongly against [7]
Glucosamine or chondroitin	Strongly against [3]	Do not offer glucosamine [5]
Platelet-rich plasma or stem cell injections	Strongly against [3]

Anti-inflammatory gels are often used for knees, but the rheumatology guideline notes that the hip sits too deep under the skin for them to be likely to help [3]. Always check with your doctor before taking anti-inflammatory pills, which carry heart, kidney and stomach risks.

When to consider a hip replacement

The UK guideline suggests considering a referral for joint replacement when symptoms substantially affect your quality of life and non-surgical care has not worked or is not suitable. It also says people should not be excluded because of age, sex, smoking, other health conditions or weight [5].

For severe hip osteoarthritis, surgery clearly does more than exercise. A Danish trial compared total hip replacement with resistance training in 109 people aged 50 or older who already qualified for surgery:

• Total hip replacement+15.9 points
• Resistance training+4.5 points

Source: Frydendal et al., New England Journal of Medicine, 2024 [12]. People with severe osteoarthritis who already qualified for surgery.

Even so, 79% of the people in the exercise group had not had surgery 6 months later [12], and the trial says nothing about mild or moderate osteoarthritis, where exercise and the steps above remain the first choice. Hip replacements also last a long time: national registries suggest about 58% last 25 years [13].

What you can do now

• Stay active, but do not overdo it, and avoid heavy lifting and low chairs, which put extra pressure on the hips [14]
• Use an ice pack wrapped in a towel for up to 20 minutes every 2 to 3 hours on a painful day [14]
• Pick an exercise program you can keep doing, ideally with some supervision at the start [5] [11]
• See a clinician if pain stops your normal activities or sleep, keeps getting worse, has not improved after 2 weeks of home care, or comes with more than 30 minutes of morning stiffness [14]

Get emergency care for severe hip pain after a fall or injury, if you cannot walk or put weight on the leg, or if you have tingling or loss of feeling in the hip or leg after an injury [14]. Get urgent medical advice for sudden severe hip pain without an injury, a hot and swollen hip, or hip pain with a high temperature or feeling generally unwell [14].

The takeaway

• Hip osteoarthritis is common, and it can usually be diagnosed without an X-ray.
• Exercise is the first treatment in every guideline. Its benefit is modest, but it is safe and lasts as long as you keep it up.
• Weight loss, a cane and self-management programs also help. Hyaluronic acid, glucosamine and PRP do not.
• For severe osteoarthritis that limits your life, a hip replacement works better than exercise.
• A fall with severe pain or inability to bear weight needs emergency care.

You can start physical therapy in Utah without a referral. Whether you want to delay surgery, prepare for it or recover from it, an evaluation can build an exercise plan you can stick with.