Do I need a hip replacement?

In my experience, clients of different ages have fears and concerns about different things, but many times I find that once people reach a certain age, I hear “as long as I don’t need a hip replacement then I’m ok”.

Possibly they had a relative who needed a hip replacement, or perhaps they know friends roughly their age who have needed a hip replacement. Perhaps it’s one of those universal signs of “getting old” that we therefore naturally fear?

However, most of the time when I hear “I don’t need a hip replacement do I?” their hip actually isn’t the problem at all (so therefore no hip replacement needed).

One of the issues it that it seems that we refer to anywhere from our belly button to our mid thigh as our “hips” any pain in this region (roughly 1/3 of your body) could be construed as hip pain and possible hip replacement territory!

So I wanted to discuss:

  1. What pains could indicate hip joint arthritis, and which pains don’t.
  2. If you do have hip joint arthritis, is a hip replacement the only answer?

Is my pain hip joint pain???

Like I said, anywhere from back to pelvis to hip/groin to thigh seems to get referred to as your “hip” so pain in many different regions could be misinterpreted as hip joint pain. A hip replacement is a last resort treatment for arthritis of the ball-and-socket hip joint) is often unlikely to be hip joint pain. As is lateral hip pain, which is most often associated with bursitis/tendinopathy and NOT arthritis.

So that pain that’s kind of around your back or the bones of your pelvis – that’s unlikely to be hip joint pain, and probably doesn’t need a hip replacement. Just as that pain on the side of your hip (that hurts when you lie on your side). That’s not going to be hip arthritis either.

If you’ve got a groin pain (usually a deep ache) and maybe buttock pain, with perhaps some pain going down the front of your thigh towards your knee – THAT could be hip joint pain. On top of that if you have a lot of stiffness compared to the other side or compared to normal, then that’s also a sign that you could have hip arthritis. Finally, arthritis is usually a low grade inflammatory condition, meaning it’s usually worst first thing in the morning or after staying still for a while (like having to get up out of the car after a long drive, or standing up after watching a movie).

To summarise, hip joint pain is:

  • More a groin and/or buttock pain, with perhaps referred front of thigh pain. The most common sign is groin pain.
  • Usually worst first thing in the morning, or after being still.
  • Usually associated with loss of movement around the hip as well.
  • NOT usually in your back, or on the side of your hip.

I often say, “Diagnosis determines prognosis”. This means that it’s very important to determine what the cause of the problem/pain is first, as that will guide everything else, we do after that. If you don’t identify the correct problem, then anything you do to try and help it may not be helpful at all. If you’re having a pain and you don’t know what’s causing it or where it’s coming from – seek expert help! We can help you work out what the cause of the problem is, and therefore what you need to do about it.

IF it is hip arthritis – do I need a hip replacement??

Now while most people have heard that if you have bad arthritis you need a joint replacement… In the real world a joint replacement should absolutely be a last resort. The most important thing to know about arthritis is:

“how it looks (on a scan, etc) and how it feels can be completely different.”

We know that someone can have pretty bad arthritis on a scan but feel ok. We also know that someone can have fairly mild arthritis on a scan and be in a lot of pain. If you look at the research, you find that the extent of the arthritis and the pain aren’t very strongly correlated. (Obviously at the extreme ends of the scale that may not be the case, but most people don’t have that kind of issue).

The other thing to remember is that osteoarthritis (what would be ‘wear and tear’ arthritis) to a certain point is normal time/age related changes. Just like wrinkles and grey hairs, we know that our body changes over time. Just because it “looks worse” (like the development of wrinkles on your face) doesn’t mean it hurts. And we certainly don’t say you have ‘degenerative face disease’ and need a skin replacement!

Current best evidence management for osteoarthritis (which we are particularly focusing on hip arthritis, but most large joint arthritis should be treated the same way) is to avoid surgery unless all other management has failed. The best evidence for management of osteoarthritis is for targeted, specific exercise to build strength around the joint and promote desensitisation and adaptation within the joint to reduce pain.

Now this does go against conventional wisdom which has said “if you have arthritis you should stop doing things that hurt”.

Unfortunately, this is still very common advice, but all the data and research we have now shows without a doubt that reducing activity and exercise is detrimental in the long term. Stopping activity just makes you stiffer and weaker, and your joint more sensitive to load. So then when you do something it will hurt more, and the downward spiral continues.

The studies show that exercise to increase your strength definitely helps to reduce pain over time (even though it can be uncomfortable for the first few weeks). Better strength also means your muscles support the joint and absorb the forces around the joint better, so it actually better stabilises and reduces the loads on the joint. And finally, just like your muscles get stronger with exercise, your other tissues (ligaments and even cartilage can become more resilient and less sensitive).
Now you probably can’t regrow your cartilage (not till stem cell research gets much better in the future) but as we know, how it looks doesn’t mean it has to feel bad.

The one other thing that has been found to highly benefit joint arthritis pain is losing weight (if you are overweight). Studies have found that losing 10% of your body weight (in overweight people with arthritis) can reduce their arthritis pain by 30-50%!! If you are overweight and struggling with knee or hip arthritis, would you love to reduce your pain 50%?

So with many cases of hip arthritis (particularly mild to moderate arthritis) we find that once people commit to building strength (and also do the right exercises at the right time, so they don’t do anything that will make it feel worse) and spend enough time improving their strength – they actually start to feel much better. Yes, they may be a bit stiff, and there may be some discomfort, but the most important thing is if they are coping and under control and they can do whatever they want to do. If that’s the case, then why on earth would you have surgery? (particularly a massive surgery like a joint replacement?)

Hip replacement should be saved as a last resort (and to be honest, you should be feeling pretty bad before you have one, so then you will definitely be much better afterwards). First line treatment should include the right amount and type of strength training, done frequently enough and for long enough to make good long-term changes. Most people need some direction with what to do, and also some help keeping on track, which is where we can help.

Julian Bowen

Julian is a Director at Como Physiotherapy.  He has spent  over a decade working exclusively in private physiotherapy practice, and estimates he has performed close to 40,000 individual treatments in that time. He has worked with everyone from Paralympians,  elite athletes, WAFL Footballers, the Defence Forces and weekend warriors, to thousands of everyday people with all manner of issues.  He is passionate about injury prevention and has a special interest in the treatment of headaches, shoulder issues, hypermobility management and exercise rehabilitation for the prevention and treatment of injuries. 

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