Stages of Hip Osteoarthritis: What They Mean and How to Treat

Hip osteoarthritis is a degenerative disease of the hip joint that progresses in four characteristic stages. With each stage of osteoarthritis of the hip, symptoms such as pain, stiffness, and loss of joint mobility will progressively worsen.

Diagnosing the stage of hip osteoarthritis helps direct the appropriate treatment, ranging from weight loss and over-the-counter (OTC) pain relievers to hip replacement surgery.

Stages of Hip Osteoarthritis

Osteoarthritis (OA) is an aging-related, degenerative joint disease caused by the progressive breakdown of joint cartilage. Often referred to as "wear-and-tear arthritis," OA is characterized by irreversible changes to joints as the loss of cartilage eventually causes bone to rub against bone.

With this happens, a normal process called bone remodeling—in which old bone is continuously broken down and replaced with new bone minerals—is disrupted. Over time, the joint bones will become misshapen and less able to move smoothly within the joint socket.

As weight-bearing joints, the hips are vulnerable to OA along with the spine and knees. Hip OA affects roughly 20% of adults over 50 in the United States (although only around 4% experience symptomatic disease).

OA of the hip (or any other joint of the body) progresses in four stages:

Stage 1: Minor

Also known as early arthritis, this is a largely asymptomatic (symptom-free) stage in which wear and tear on the hip joint leads to the gradual erosion of joint cartilage. People with obesity are at high risk due to the increased weight-bear stress placed on the hip joints.

During stage 1, the cartilage is healthy enough to function normally. Even so, the loss of cartilage will be enough to trigger an inflammatory response as the body tries to repair the damage. Over time, the repairs will become increasingly haphazard, leading to the formation of bony overgrowths known as osteophytes (a.k.a. "bone spurs").

People with stage 1 hip OA are often unaware that they have OA and may only experience mild aches after a long day of strenuous activity.

Stage 2: Mild

Stage 2 hip OA is commonly referred to as mild hip osteoarthritis. At this stage, bone spurs may be readily seen on X-rays, but the space between the bones will still appear relatively normal.

With that said, there will be dramatic changes in the cartilage itself. Among these, the joint will experience fibrillation in which cartilage will start to split and develop areas of fraying.

This can lead to more pronounced symptoms, such as:

• Pain and discomfort in the hip joint, typically on one side only
• Aching or weakness in the joint after strenuous activity
• Joint stiffness, especially in the morning or after sitting for a long time

Stage 3: Moderate

Often referred to as moderate hip OA, stage 3 is characterized by the significant loss of joint cartilage. As the gap between the bones narrows, joint inflammation will increase along with the size of bone spurs.

At the same time, fragments of collagen (one of the main structural proteins found in cartilage) will start to break off and mix with synovial fluids lubricating the joint. This will make the fluid more sticky and viscous.

As this process continues, the body will respond with even more inflammation, causing the hip joint to swell and bone spurs to scrape against exposed bone and broken cartilage.

Symptoms of stage 3 hip OA include:

• Hip pain with normal activities like walking, running, squatting, or kneeling
• Joint swelling with prolonged activity or standing
• Joint stiffness in the morning or after sitting a long time
• Popping, grating, or snapping sounds (called crepitus) as the hip joint moves
• A "catching" sensation with joint movement
• An uneven gait or limping
• Increasing hip weakness

Stage 4: Severe

Stage 4 hip OA is also known as advanced or severe hip osteoarthritis. At this stage, the loss of cartilage is extreme. Chronic inflammation has further contributed to the formation of large bone spurs and the loss of synovial fluid.

Stage 4 hip OA suggests that bone is rubbing against bone and the function of the joint has been severely compromised. The body's attempts to repair itself have led to dramatic changes in the joint architecture, all but diminishing the normal function of the joint.

With stage 4 hip OA, symptoms include:

• Constant joint pain and stiffness with or without movement
  
• A significant loss in the range of motion of the hip
• Hip weakness or a sense that the hip may collapse under you
• Pain in the opposite hip as it is forced to compensate for the affected hip
• Muscle thinning in the legs due to the loss of mobility
• Disruption of sleep due to pain
  

Treatments

The stage of hip OA is based largely on imaging studies such as a hip X-ray, computed tomography (CT) scan, or magnetic resonance imaging (MRI). The diagnosis is essential to delivering the appropriate treatment to not only ease symptoms but also help slow disease progression.

Stage 1

Prevention is the main focus of treatment for stage 1 hip OA. This mainly involves avoiding activities that aggravate the hip joints, such as strenuous running or performing squats with heavy weights.

Other common treatments for stage 1 hip OA include:

• Weight loss if you are overweight or have obesity
• Incorporating low-impact exercises into your workout plan
• Discussing OTC glucosamine and chondroitin supplements with your healthcare provider (which some studies suggest are beneficial for hip OA and others don't)

Stage 2

The treatment of stage 2 hip OA is focused on symptom relief and supporting the muscles that help stabilize the hip joints.

These include options such as:

• OTC nonsteroidal anti-inflammatory drugs (NSAIDs) like Advil (ibuprofen) or Aleve (naproxen) for the relief of occasional arthritis pain
• Tylenol (acetaminophen), also available over the counter, which tends to be safer for older adults
• Hip-strengthening exercises, including hip flexion, hip extension, and hip abduction exercises
• Physical therapy, including manual and massage therapy and gait and balance training

Knee braces may be used if you also have knee osteoarthritis. If the knee is destabilized, it can affect the position of the hip and make hip OA symptoms worse.

Stage 3

People with moderate hip arthritis should continue the lifestyle strategies recommended for stages 1 and 2. Other important interventions may include:

• The combined use of Tylenol and OTC NSAIDs to treat more severe pain episodes
• Prescription NSAIDs like Celebrex (celecoxib)
• Corticosteroid (steroid) injections into the joint space for longer-term pain relief
• Hyaluronic acid injections into the joint space, also known as viscosupplementation, to increase joint lubrication

Stage 4

Nonsurgical treatments for stage 4 hip OA are mainly aimed at delaying hip replacement surgery. This is because hip prosthetics have a limited lifespan and most orthopedic surgeons prefer to implant one when it is most likely to last you the rest of your life.

In the meantime, the treatment may involve repeated steroid or hyaluronic acid injections, oral opioid pain relievers, and assistive walking devices such as a cane, crutches, or a walker.

If surgery is recommended, it may include:

• Hip realignment surgery: Also known as hip osteotomy, the surgery involves the removal of bone to align the hip into a more stable position. It is typically an option for people under 60.
• Total hip replacement: Also known as total hip arthroscopy, this is a procedure in which the damaged hip joint is removed and replaced with a prosthetic device.

Prevention

Not everyone with stage 1 or stage 2 hip OA will progress to stage 3 or stage 4. In fact, with the appropriate treatment, a person with stage 3 hip OA may live the rest of their life without further disease progression.

Even if you don't have hip OA, you may need to take preventive steps if you have risk factors for the disease. This includes having obesity, diabetes, a family history of OA, a previous hip injury, or an occupation that involves heavy lifting or the carrying of heavy loads.

Key preventive efforts include:

• Maintaining an optimal weight (ideally a body mass index between 18.5 and 24.9) with a healthy diet and appropriate exercise
• Trading high-impact activities like running with low-impact activities like swimming or cycling that reduce stress on the hip joint
• Controlling your blood sugar with diet, exercise, and medications (if needed) if you have diabetes
• Using assistive devices like dollies and hand trucks for lifting heavy objects
• Meeting your recommended daily intake of calcium (1,000 milligrams daily for males and up to 1,300 milligrams daily for females) to keep bones strong

Summary

Hip osteoarthritis (OA) progresses in four stages, starting from stage 1 which is largely asymptomatic to stage 2 in which symptoms are more pronounced. By stage 3, changes in the architecture of the hip may cause limping and chronic pain. By stage 4, surgery may be needed to overcome pain and disability, including the use of a total hip replacement.