Hip osteoarthritis: what physiotherapy achieves – and how large the effect really is – Knowledge

1. Why this article?

People who see a doctor about hip pain usually hear two sentences. The first is: «That is osteoarthritis.» The second is: «Movement is good, go and have physiotherapy.» Both sentences are correct. And both are so short that they raise more questions than they answer.

This article answers the questions that come next:

• What actually happens inside a hip with osteoarthritis – and why does it hurt in the groin of all places?
• Why does the X-ray say so little about how badly off you are?
• What does exercise achieve, in numbers – and what does it not achieve?
• Which kind of training, how much of it, how often, and what should you do on a bad day?
• When is surgery due – and what happens before and after it?

This site already has a general guide to osteoarthritis. That one explains what osteoarthritis is, how a joint is lubricated and why images can mislead. This article is the hip version: it deals only with the hip joint, and it goes considerably deeper into the evidence. If you are looking for a knee replacement, see the guide to knee replacement; the fundamentals of strength training have their own article.

A note on honesty before we begin. In July 2026 a new Cochrane review of exercise therapy for hip osteoarthritis was published [2]. It reaches an uncomfortable conclusion: the average effect on pain is small – so small that the authors themselves write it is probably not noticeable. At the same time, the American clinical practice guideline published in November 2025 recommends exercise at the highest grade [1]. This article does not resolve the contradiction by picking a side. It explains it.

The article is written for people affected and their relatives, not for professionals. Technical terms do appear, because you will meet them in your medical reports anyway – but each one is explained the first time it turns up. The numbers in square brackets refer to the list of references at the very bottom.

And the usual, important note: this article does not replace an examination. What your doctor decides for your situation takes precedence.

2. What hip osteoarthritis is

2.1 A ball-and-socket joint, deep inside the body

The hip is a ball-and-socket joint. The head of the thigh bone – an almost perfect sphere – sits in a socket belonging to the pelvis. Both surfaces are covered with cartilage, a smooth, whitish layer that reduces friction almost to zero. A ring of tough fibrous tissue runs around the rim of the socket, the labrum; it deepens the socket and seals the joint. On the outside a strong joint capsule encloses the whole thing, lined on the inside by a membrane that produces the joint fluid.

Three things set the hip apart from the knee, and all three matter for understanding it:

• It lies deep. You cannot touch it the way you can touch a knee. What you feel at the side of your pelvis – the hard edge you lie on when you lie on your side – is not the joint but a bony prominence of the thigh bone, the greater trochanter. The joint itself sits a hand's breadth further in and forward.
• It carries a lot. With every step, forces amounting to several times body weight act on the hip joint. The reason is not the weight itself but the leverage: with every single-leg stance the muscles on the outside have to stop the pelvis tipping to the opposite side, and in doing so they press the head into the socket.
• It is surrounded by a great deal of muscle. That is where physiotherapy actually goes to work – more on this in a moment.

2.2 More than worn-down cartilage

The common picture of osteoarthritis is that of a worn brake pad: the cartilage wears away, and once it is gone, that is that. This picture is too simple and wrong in several respects.

What actually happens involves the joint as a whole [1]:

• The cartilage loses thickness and elasticity. That is the part you see on an X-ray as a narrower «joint space» – although you cannot see the cartilage itself at all, only the distance between the bones.
• The bone underneath changes: it becomes denser, forms outgrowths at the edges (osteophytes, colloquially «bone spurs») and sometimes develops small cavities.
• The capsule becomes thicker and less stretchable. This is why the hip loses range of movement, and it does so in a typical order: first internal rotation (turning the leg inwards) and bending, later everything else [1].
• The muscles around it become weaker, particularly the ones on the outside that stabilise the pelvis [1]. That is partly a consequence of the osteoarthritis – you load the painful side less – and partly its cause, because weaker muscles guide the head less well within the socket.

The last point is the most important one in this section. Physiotherapy cannot bring the cartilage back. Nor can it remove the bony outgrowths or make the capsule young again. What it can reach is what lies around the joint: the muscles, the range of movement, the walking pattern, the way load is distributed in everyday life, the handling of pain. That sounds more modest than it is – but it is also exactly what the studies measure.

2.3 How common – and the Swiss figures

Hip osteoarthritis is the most common cause of hip pain in people over fifty [1]. An American long-term study calculated the risk of developing symptomatic hip osteoarthritis during one's lifetime – that is, one that also causes complaints: around 25 per cent, so roughly one person in four [6]. In people who have already had a hip injury, the figure is higher.

There is no equivalent figure for Switzerland, but there is another, very solid one: the national implant registry records practically every artificial joint. According to it, a good 27 000 artificial hip joints are fitted in this country every year [26]. Over a four-year window, around 82 per cent of them were needed because of «primary osteoarthritis» – osteoarthritis without an identifiable underlying condition. Women account for a good half of the operations (53 per cent); their mean age is 70.8 years, that of men 67.3 years. Notably, around one operation in nine involves someone under 55 [26]. Hip osteoarthritis is not purely a disease of old age.

3. How it is recognised

3.1 The pain sits in the groin

This is the single most important sentence about recognising it, and it contradicts what most people call «hip pain». Pain coming from the hip joint typically sits at the front, in the groin, sometimes additionally at the side or at the back over the buttock [1]. And it has a peculiarity that repeatedly causes confusion:

It runs into the knee. Not infrequently the knee pain is even the loudest symptom, while the groin only pulls uncomfortably. The reason lies in the nerve supply: the hip capsule and the skin and joint areas at the front of the thigh and knee are supplied from the same levels of the spinal cord, and the brain cannot assign the message cleanly. There are people who come in because of knee pain and go home with a diagnosis of hip osteoarthritis.

Other typical features:

• Load-dependent. The pain comes with walking, with stairs, when getting up from a chair – and eases again at rest. Only late in the course does it also hurt at night.
• Start-up pain. The first steps after sitting for a while are the worst; after a few minutes it gets better. Many people describe exactly this as the first thing they noticed.
• Morning stiffness of under an hour. This is an important distinguishing feature: stiffness that lasts considerably longer than an hour in the morning points more towards an inflammatory joint disease (rheumatoid arthritis, for example) and needs medical assessment [1].
• Everyday movements become awkward. Putting on socks, tying shoes, getting into a low car, cutting your toenails. That is the internal rotation and the bending being lost – and it is often noticed earlier than the pain.

3.2 What the examination shows

The diagnosis of hip osteoarthritis is primarily a clinical one – it is made on the person, not on the image. For people over fifty, the American guideline lists the following features [1]:

• moderate pain at the front or side of the hip during weight-bearing activities;
• morning stiffness lasting less than an hour;
• internal rotation of less than 24 degrees – or internal rotation and flexion 15 degrees below the pain-free other side;
• and/or more hip pain when the examiner passively rotates the leg inwards.

Added to this are measurements that show the course over time: range of movement in all directions, strength of the hip muscles in all directions, a walking test (six minutes of walking, say, or 40 metres at your own pace), a sit-to-stand test (how many times can you get up from a chair in 30 seconds?) and a stair test [1]. These values are not an end in themselves. They are the only thing that will tell you in six months whether anything has really changed.

3.3 What else it could be

Not every pain in the hip region comes from the hip joint. Four confusions are common enough to belong here:

• Pain at the side, over the greater trochanter. If it hurts exactly where you rest when lying on your side, and if lying on that side ruins the night, it is almost never osteoarthritis. It is usually an irritation of the gluteal tendons (gluteal tendinopathy). That is no trifle, but it responds well to treatment – and the treatment is a different one. In a well-conducted trial with 204 people, an eight-week programme of education and exercise was more effective than a corticosteroid injection after eight weeks, and considerably more effective than waiting [25].
• Pain from the back. An irritation in the lower back can affect exactly the same area. Pointers: the pain changes with the position of the back, runs down over the buttock into the leg, or there is tingling.
• Pain in young adults. Hip osteoarthritis before the age of 45 is rare and needs an explanation – a previous injury, a particular joint shape, more rarely a disturbance of the blood supply to the head of the femur. Medical assessment always belongs here.
• Warning signs that do not fit osteoarthritis: fever, night sweats, unintended weight loss, pain at rest that builds up over days and cannot be influenced by anything, or a hip that suddenly will not bear weight after a fall. These need prompt medical assessment, not physiotherapy.

4. Why the X-ray says so little

There is one study you should know about before an X-ray report frightens you. An American research group used two large population studies to test how well hip pain and signs of osteoarthritis on X-ray actually match [5]. Both were recorded independently: the complaints in an interview, the image in the radiology department.

The result is sobering and liberating at the same time:

• Of the hips in people with frequent hip pain, only about 16 in 100 showed matching signs of osteoarthritis on the image.
• Conversely, of the hips with clear signs of osteoarthritis, only about 21 in 100 hurt at all.

Put differently: the X-ray tells you something about the state of the bone. It tells you surprisingly little about how much pain you are in and how limited you are. That holds in both directions. A bad image is not a verdict – there are people with «bone on bone» who walk well. And an unremarkable image is not an all-clear – there are people with severe pain and a normal image.

Why is that? Because cartilage has no pain fibres. What hurts is the bone beneath the cartilage, the capsule, the labrum, the muscles and tendons around it and – with persistent pain – a nervous system that reports more sensitively over time. None of that appears on the X-ray.

In practice this means three things. First: an X-ray makes sense when it answers a question – before a decision about surgery, for instance, or when something does not fit the picture. As a routine check «to see how things stand» it achieves little [1]. Second: the grade on the image – you may read terms such as «Kellgren-Lawrence 3» – predicts neither how severe your pain is nor whether exercise will work for you. Third: if someone glances at your image and tells you that you must not load the joint any more, that statement has no basis.

5. What influences the risk

Some of the things that contribute to hip osteoarthritis cannot be changed. Others can. It is worth knowing both – not least in order to avoid the wrong kind of guilt.

Not modifiable are: age, heredity (osteoarthritis in the family counts), sex (in the hip, men more often show osteoarthritis on X-ray, while women slightly dominate the operation figures) and above all the shape of the joint [1].

That shape deserves a paragraph of its own. Two variations are well studied:

• Cam morphology. The transition from the head of the femur to its neck is not slender but thickened – the head is not round at this point but has a small shoulder. When bending and rotating inwards, this shoulder butts against the rim of the socket. In a Dutch study of 1002 people examined because of first hip complaints, those with a pronounced cam shape had a many times higher risk of developing end-stage osteoarthritis within five years [7]. This was particularly marked when internal rotation was restricted as well.
• A socket that is too shallow (hip dysplasia). Here the socket covers the head too little, and the load is spread over a smaller area. It is one of the most common reasons why hip osteoarthritis appears before the age of fifty.

A qualification that belongs with this: these shapes are risk factors, not diagnoses. A great many people have a cam shape and never any complaints. And examination on the couch cannot reliably detect these shapes: in a study from Bern of 2081 young men without complaints, measured internal rotation was too imprecise to infer a cam or pincer shape from it [8]. Disclosure: Roger Hilfiker is a co-author of that work. What this means in practice: a stiff hip is a reason to look more closely – but it proves nothing about the shape of the bone, and the shape of the bone alone proves nothing about your future.

Modifiable, by contrast, are: previous joint injuries (which cannot be undone, but whose consequences can be trained), marked overweight, heavy physical work over decades – farming and construction trades regularly come top in the surveys – and the training state of the muscles. The last of these is the only one you can change tomorrow.

6. What exercise achieves – and how large the effect really is

6.1 The number nobody likes to hear

Cochrane is an international network that evaluates medical studies under particularly strict rules; its reviews are regarded as the most careful there are. In July 2026 a group from Australia, Ireland, Mexico and Switzerland brought the Cochrane review of exercise therapy for hip osteoarthritis up to date – the previous version dated from 2014 [3].

Eighteen trials with 1368 participants were included, in all of which a draw decided who trained. All results were converted to a common 0-to-100 scale so that they could be compared. The result [2]:

• Compared with «no treatment, usual care or limited education», exercise reduced pain by 7.2 points (confidence interval 3.7 to 10.7) and improved physical function by 8.8 points (5.4 to 12.0). The certainty of the evidence was moderate.
• On quality of life exercise had virtually no effect (2.3 points, confidence interval −1.2 to 5.9 – so including «no difference»).
• Compared with a sham treatment – a treatment involving the same amount of attention but no training stimulus – the difference in pain was not statistically secure (6.3 points, confidence interval −0.4 to 13.0); for function it just was.
• As an addition to another treatment, exercise brought no extra gain in pain, function or quality of life.

And now the sentence that matters. The threshold at which a person notices a change at all on these questionnaires is around 12 points. Seven and nine are below that. This is why the authors write themselves that the improvements are «unlikely to be clinically meaningful» [2].

That stands in striking contrast to the American guideline published in November 2025, which recommends an individually tailored exercise programme at the highest grade [1]. The contrast is explicable: the guideline counts how many studies point in the right direction, and additionally draws on meta-analyses that include comparisons with «usual care» and other outcomes. Cochrane asks more strictly how large the effect is and how sure one can be of it. Both answers are correct. They answer different questions.

Nor does the Cochrane finding stand alone. A large analysis that pooled not just study results but the individual data of 4241 participants from knee and hip trials likewise arrived at a small overall effect and described it as «of questionable clinical importance, particularly in the medium and long term» [4]. That work also searched for characteristics that might identify who benefits most – age, sex, severity, baseline pain. It found none. That is an important result: to this day there is no reliable way of saying in advance for whom exercise will work well.

6.2 Why «small» does not mean «useless»

You can read these numbers in two ways. The first: «Then I might as well not bother.» The second is the right one, and it needs five considerations.

First: an average is not a person. When a trial finds seven points on average, it does not mean everyone gained seven points. It usually means that some people benefited markedly, some not at all, and everything in between. Because nobody can yet predict which group you belong to [4], all that remains is the attempt – with a deadline and an honest interim assessment. That is exactly what the measurements from section 3.2 are for.

Second: pain is not the only outcome. The Cochrane review evaluated pain, function and quality of life – the things measured with questionnaires. It did not evaluate whether someone becomes stronger, stands more securely on their feet, stays longer in their own household, or whether surgery becomes necessary. For muscle strength and muscle mass there are separate studies, and those do show changes [1]. And the question of surgery has a section of its own further down (section 17).

Third: in the trials, people often train too little. That is not an excuse but a measurement. A meta-analysis of twelve trials with 1202 participants separated the trials according to whether attendance was demonstrably high. Where it was, the effect on pain was almost twice as large as the overall average [9]. More on this in the next section.

Fourth: the comparison is a strict one. «No treatment» in these trials rarely means the comparison group does nothing. It receives education, often painkillers, sometimes a sheet of exercises. A difference of seven points on top of that is something different from seven points against doing nothing.

Fifth – and this is the real argument: the balance of benefit and harm. Exercise for hip osteoarthritis is cheap, available everywhere, has proven benefits for heart, circulation, bones, mood and the risk of falling – and practically never does harm. In the Cochrane review the number of study withdrawals was not increased in the exercise groups; added to another treatment, the rate of adverse events was even slightly lower than without exercise [2]. A review of 14 studies with more than a thousand participants likewise concluded that adverse events are rare and the risk of harm minimal [1].

The authors of the Cochrane review summed up their own conclusion publicly like this: be honest with patients that the average benefit may be modest – while knowing that people are generally worse off when they stop moving altogether. There is little to add to that sentence.

6.3 What exercise cannot do

So that expectations are right, three clear sentences.

Exercise does not build cartilage. No study shows that a narrowed joint space opens up again through exercises. Anyone who promises this – with exercises, machines or supplements – is going beyond the evidence.

Exercise does not make the hip fully mobile again. Part of the lost movement comes back as muscles and capsule become more supple. The part that is blocked by bony outgrowths does not come back.

Exercise does not replace surgery when its time has come. It can postpone it (section 17), and it improves the starting position. But there is a point at which an artificial joint is the better answer, and recognising that point is part of honest advice.

7. The dose: how much, how often, how long

If the average effect is small, it is worth asking whether part of that is down to the dose. There is a study that examined exactly this.

A Norwegian research group evaluated twelve trials with 1202 participants (mean age 66 years, just under two thirds women) and divided them into two groups: trials in which attendance was demonstrably high, and trials in which it remained unclear [9]. Across all trials the effect on pain was small. In the trials with high attendance it was moderate – almost double. The same pattern appeared for physical function.

That is an association, not a proof: people who attend regularly may simply be the ones who are doing better anyway. But the direction is unambiguous, and it matches everything known from strength training.

The dose named by the guideline [1]: an individually assembled programme, one to five times a week, 30 to 120 minutes each time, over 5 to 16 weeks. That is a very wide span, and it simply reflects the range of the studies – the data do not support a finer dose recommendation.

Translated into practice this means:

• Twice a week doing something that is an effort is the usable lower limit. Working through a sheet of exercises once a fortnight is not a treatment.
• Expect nothing before six weeks. Most trials measure after eight to twelve weeks. Anyone who gives up after two weeks has not «noticed that it does not work» – they have not done the treatment.
• It does not stop after the 5 to 16 weeks. The effect does not maintain itself. What comes afterwards – a group, a club, a gym, a fixed home programme – decides whether the gain stays.
• Supervised beats alone. A Danish study compared three groups over twelve months: supervised strength training, supervised Nordic walking and an unsupervised home programme. The unsupervised home programme came off worst in both comparisons [10].

And on pain during training: an increase that occurs during the exercise, subsides quickly afterwards and is no worse the next morning is harmless – and the rule, not the exception. An increase that persists for hours, clearly worsens your walking the next day or wakes you at night is a signal to lower the dose, not to stop.

8. Which kind of training – and why that matters less than you think

This is the section in which most people expect the one right exercise. There is no such thing. What there is are several routes, each with its own evidence – and several head-to-head comparisons showing that the difference between them is smaller than the difference between doing it and not doing it.

8.1 Strength

Strength training is the best-founded building block, though less because of pain than because of what hangs on it. The muscles around an osteoarthritic hip become measurably weaker, especially the abductors on the outside [1] – and it is precisely these that keep the pelvis level during walking. If they weaken, the pelvis drops to the opposite side with every step, the upper body compensates sideways, and the gait becomes what specialists call a waddling gait.

What strength training demonstrably changes:

• Strength and muscle mass. In one study, progressive strength training increased the cross-sectional area of thigh muscle compared with Nordic walking and with an unsupervised home programme [1]. In another, small study, a targeted gluteal programme over twelve weeks produced a measurable increase in one of the deep hip muscles – compared with a sham programme [1].
• Everyday function. Getting up, stairs, longer walking distances.

What it looks like: two to three times a week, few exercises but genuinely loaded – so that the last two repetitions are really hard. The core exercises are leg press or squat within a range that is low in pain for you, abduction against resistance, hip extension, and – often forgotten – the calf muscles. Whether the movement is slow or fast makes no difference to walking, strength, function and pain according to a comparison over eight weeks [1]. So take the version that feels better.

The fundamentals of sets, repetitions and progression are in the guide to strength training – they apply to the hip in just the same way.

8.2 Endurance – and a revealing head-to-head comparison

Endurance training is good for heart, circulation, weight and mood. The more interesting question, though, is whether it adds anything on top of strength training. That question has been tested directly.

The Australian PHOENIX trial allocated 196 people with hip osteoarthritis by draw to two groups. Both received a home programme and nine appointments with a physiotherapist over three months. One group did strength training only, the other added moderate aerobic activity [11].

The result: no difference. Neither in pain (a difference of 0.3 points on a scale of 10) nor in function. Both groups improved – in pain by a good two points out of ten on average, which is by no means nothing – but the addition brought nothing extra. Adverse events occurred in both groups, none of them serious [11].

What to take from this: do endurance training because it is good for you and because your cardiovascular system benefits. But do not expect it to calm the hip on top of that. And if your time is limited and you have to choose: the strength part is the one with the clearer connection to the hip.

8.3 Water

In water, buoyancy carries a large part of your body weight. In chest-deep water only about a quarter to a third of the load that acts on land remains on the legs. That makes movements possible that hurt on land – and it takes away many people's fear of loading the joint.

The evidence is decent: a summary of nine studies with 303 participants (mean age 68 years, complaints for more than ten years on average) found improvements after 3 to 12 weeks in range of movement, strength, balance, walking, function and pain – with small to moderate effect sizes. Self-rated quality of life did not change [1]. The guideline therefore names aquatic therapy explicitly as a possible form of the recommended training [1].

When water is particularly useful: in a very painful phase, with marked overweight, with fear of loading, after a long break – and as a way in, to get moving again at all. What water does not replace: strength training on land. The buoyancy that makes the load comfortable also removes the training stimulus for bones and muscles. Water is a good start and a good addition, but rarely the whole plan.

8.4 Cycling – and a study worth noticing

Cycling is almost ideal for osteoarthritic hips: the range of movement is big enough to keep the hip supple, but small enough to avoid the painful end range. Your body weight rests on the saddle, not on the joint. And the load can be dosed in fine steps.

How well this works was shown by a British trial in 2025. 221 people referred from hospital to physiotherapy were allocated by draw to two groups: one received the usual one-to-one physiotherapy, the other an eight-week group programme of education and static cycling at a local leisure centre [12].

After ten weeks, the cycling group had improved more clearly on the everyday-function questionnaire: from 60.8 to 73.5 points, compared with 59.3 to 65.4 points in the physiotherapy group. The difference was 6.9 points in favour of the cycling group [12]. Here too the honest qualification the authors make themselves: the threshold for a noticeable difference in this trial was 7.4 points – the difference narrowly missed it. On the other hand the group programme was decidedly cheap, and there were no serious adverse events.

Two things about this are remarkable. First: a group programme in a leisure centre beat usual one-to-one physiotherapy – not the other way round. Second: the place where people train is evidently not incidental. Someone who can keep going to the leisure centre after eight weeks stops less often.

8.5 Walking and Nordic walking

A correction is needed here, one that shows how carefully guidelines have to be read. The Danish study that compared three forms of training over twelve months concludes in its own title: Nordic walking was superior to strength training and to the unsupervised home programme for improving function [10]. The American guideline reports the same study with the ranking reversed [1]. We follow the original paper here.

For practice, the ranking matters less anyway than what both versions have in common: supervised training – of whatever kind – was superior to the unsupervised home programme. That is the robust message of this study.

On walking itself: a stroll is healthy, but as the sole treatment for hip osteoarthritis it is too little – it does not load the muscles enough to make them stronger. Nordic walking is something else: the poles bring in the upper body, lengthen the stride and increase the load without increasing the impact. For a painful hip that is a good combination. And the poles have the same effect as a walking stick, only on both sides – more on that in a moment.

9. Everyday life: spreading the load

Between two physiotherapy appointments lie 167 hours of everyday life. What happens in those hours weighs more than what happens in the one hour. The guideline covers this part under «education on activity modification and methods of unloading the arthritic joint» and recommends it explicitly [1].

9.1 The walking stick – the most effective immediate measure

In hip osteoarthritis a walking stick is not a sign of giving up. It is the only thing that lowers the load on the joint immediately and substantially.

The reason is leverage. When standing on one leg, the muscles on the outside of the hip have to stop the pelvis tipping to the other side. Because their lever is short and that of body weight is long, they have to pull very hard – and that pull presses the head into the socket. A stick on the opposite side acts on the longer lever. Even a fraction of body weight on the stick takes a considerable part of the work off the muscles – and thus a considerable part of the load off the joint.

So: stick in the hand of the good side. If the right hip hurts, the left hand holds the stick, and it goes forward at the same time as the right leg. Most people do it the other way round at first, because that feels more intuitive.

The height: with the arm hanging down, the handle should be roughly at wrist level. And a sentence many people need to hear: a stick on a hike or on the way to the shops is not a permanent state – it is a tool you use when the distance would otherwise be too far.

9.2 Twelve small things that add up

• Split the load. Two half-full bags are better than one full one – and a rucksack is better than both.
• Carry on the right side. If you have to carry on one side, take the load in the hand of the affected side. That sounds wrong, but it reduces the tipping moment and unloads the hip.
• Seat height. The lower the chair, the more force is needed to stand up and the more the hip has to bend. A cushion on the sofa and a higher office chair make a noticeable difference.
• Do not sit for more than an hour at a stretch. Start-up pain after long sitting is not a sign of damage, but it can be almost entirely avoided with short interruptions.
• Get into the car sitting down. Sit down on the seat backside first, then swing both legs in together – rather than stepping in one leg at a time.
• Socks and shoes. A long shoehorn and a sock aid cost little and solve a daily annoyance. Shoes with velcro or elastic laces do the same.
• Footwear. Cushioned soles and secure grip matter more than any insole. Insoles have no evidence behind them in hip osteoarthritis.
• Stairs. Up with the good leg first, down with the affected leg first.
• Break the distance up. Three short trips a day are better tolerated than one long one – for the same total distance.
• Bed and sleep. A pillow between the knees when lying on your side unloads the joint and takes the pull off the outside.
• Warmth before movement. A warm shower or a heat pack before getting up makes the first steps more bearable. That treats nothing, but it helps in the moment – and you move more.
• Do not spare the joint, dose it. The difference is decisive. Sparing means: I leave out what hurts. Dosing means: I do it, but in an amount I tolerate – and then I increase it.

10. Body weight – more honestly than it is often presented

Overweight is a recognised risk factor for developing hip osteoarthritis [1]. It does not automatically follow, however, that losing weight improves existing hip osteoarthritis – and here the evidence really is weaker than you would expect.

Two things need to be kept apart:

For the knee the benefit is well established. There are large trials in which weight loss combined with exercise clearly improved pain and function. This is why the international society OARSI counts weight management among the core treatments for the knee. For the hip it does not – there the core treatments consist of education and structured land-based exercise [20]. That is not an oversight; it reflects the thinner evidence.

The American guideline nevertheless recommends support with weight loss for people with hip osteoarthritis who are overweight – although based on a review of other guidelines rather than on treatment trials of its own, and in collaboration with a physician, a dietitian or a nutritionist. The order of magnitude named is 5 to 7.5 per cent of body weight [1].

How to reconcile this without being dishonest: losing weight has proven benefits for heart, circulation, blood sugar, back and knees. For the hip itself the evidence is weak. What follows from that is above all what does not follow: nobody should be told they must lose weight before exercise or surgery can be considered. And nobody should be given the impression that their hip pain is a weight problem – there are very slim people with severe hip osteoarthritis.

11. What knowing does – and why groups work

Education sounds like the part you can skip. In osteoarthritis it is a core treatment in every guideline [20][1] – and not out of politeness.

The reason is simple: what you believe about your hip determines what you do with it. Someone who believes the joint is used up and that any loading harms it moves less, becomes weaker, has more pain – and sees this as confirmation. Someone who knows that loading does not harm the joint, that pain does not equal damage and that a bad X-ray says little about the future makes different decisions.

The Danish GLA:D programme has taken exactly this combination to scale: standardised education plus supervised neuromuscular exercise, delivered by specially trained physiotherapists, with a national registry recording the outcomes [13]. In that registry, pain, function and activity improved at three and twelve months, and painkiller use fell. The programme has also been available in Switzerland since 2019; it comprises two education sessions and twelve group training sessions and is covered by health insurance when a doctor prescribes it.

A qualification that belongs here: registry data are not randomised trials. Without a comparison group, one cannot say how much of the improvement is due to the programme and how much to the natural course or to expectation. What registry data do show well is that such a programme is feasible in real life – and who takes part in it.

On coping with pain there is a well-conducted Australian trial: 144 people with hip osteoarthritis received either education plus an exercise programme, or the same plus an automated internet-based pain coping skills programme [1]. After eight weeks the group with the additional programme was better on pain and function. After 24 and 52 weeks the difference had gone – the coping skills remained, the advantage did not. Read honestly, that means such programmes can help at the start but do not replace the training.

12. Manual therapy: the open contradiction

Manual therapy is what many people know as «treating the hip»: guided, passive movements at the joint, traction along the axis of the leg, soft-tissue techniques, massage. In our practice it is part of the craft. That makes it all the more important to say honestly what the evidence looks like – and it contradicts itself.

One side. The American guideline gives manual therapy the highest grade of recommendation: it should be used to increase range of movement, reduce pain and improve function in mild to moderate hip osteoarthritis [1]. This rests on five newer studies, including trials of traction along the axis of the leg. An interesting detail from them: stronger traction worked better on range of movement, weaker traction better on pain [1]. The usual dosages are one to three times a week over 6 to 12 weeks.

The other side. The largest and methodologically cleanest single trial on this subject comes from Melbourne. 102 people with hip osteoarthritis received by draw either a comprehensive physiotherapy programme – manual therapy, exercises, advice, walking aids, home programme – or a sham treatment: an inactive ultrasound application and an inert gel, applied by the same therapist, with the same time and the same attention [15].

After 13 and after 36 weeks there was no difference in pain or function. Both groups got better. And the active group reported adverse effects more often – mostly mild, temporary increases in pain [15].

And a third trial from New Zealand compared four options in 206 people with hip or knee osteoarthritis: manual therapy, exercise therapy, both together, or neither [16]. Both manual therapy and exercise therapy were individually better than usual care. But – and this is the genuinely puzzling part – the combination was no better than either one alone. Two effective treatments do not add up here.

How we handle this. Manual techniques can open a window in a painful phase in which movement becomes possible again. They are a means, not the goal. What they are not is a substitute for what you do yourself. If a course of treatment consists essentially of passive applications over months and your strength values do not change, then something is going wrong – regardless of how good the treatment feels. The guideline says this too, incidentally: as soon as movement improves, exercises belong with it in order to keep the gain [1].

13. Dry needling: when an «A» means little

In dry needling, a thin acupuncture needle without any medication is inserted into a tense point in a muscle. In 2025 the American guideline added a new recommendation at the highest grade: for hip osteoarthritis of grades II and III, applied to five particular hip muscles, for short-term improvements in extensibility, pain, range of movement, function and force production [1].

This section is here because it shows how a recommendation has to be read.

If you look up what the «A» rests on, you find four studies and one secondary analysis [1]. All come from the same Spanish research group. The group sizes lie between 15 and 19 people. Treatment lasted three weeks in each case, and nothing was measured beyond three weeks. In its own «gaps in knowledge» section the guideline writes that the long-term effect is unknown and that it remains unclear whether dry needling contributes anything at all when combined with exercise [1].

It becomes clearer still if you ask the same research group. In 2022 they themselves published a meta-analysis of dry needling in hip and knee osteoarthritis: seven studies, 291 participants. Result: short-term improvements in pain and function, no difference in the medium and long term – and because of risk of bias, inconsistency and imprecision the authors themselves rate the certainty of the evidence as «very low» [17].

The largest of these individual trials – 45 people in three groups, three treatments – shows the pattern: clear improvements in pain, strength and function compared with sham treatment and with doing nothing, with large effect sizes, but over three weeks [18].

How we handle this: if you have painful muscle tension around the hip, dry needling can release something in the short term, and in the trials it caused no adverse events. But it is a door-opener, not a treatment of the osteoarthritis, and the letter «A» in the guideline says more here about the rules of guideline-making than about the strength of the evidence. Anyone selling you a course of twelve needling sessions as «the evidence-based therapy» has not read the studies.

14. What achieves little

Completeness is part of honesty. These things are offered, and this is the evidence on them:

• Therapeutic ultrasound. The 2017 guideline still recommended it at moderate strength. A new, good trial compared four variants – continuous, pulsed, ultrasound with electrical stimulation and sham – in moderate hip osteoarthritis. After two and after fourteen weeks no difference could be found between any of the groups. In 2025 the recommendation was therefore downgraded to «conflicting evidence»: it may be used as part of a shared decision, but people must be informed about the conflicting evidence and the potential cost [1].
• Braces and supports. There has not been a single new study since 2017. The guideline sticks to its expert opinion: not as a first-line treatment; possibly when exercise and manual therapy have not helped and the issue is activities involving turning or pivoting [1].
• Supplements. For glucosamine, chondroitin, hyaluronic acid and the like there is insufficient evidence in hip osteoarthritis [1]. That does not mean they do harm – it means you can spend the money differently.
• Sulphur baths and similar spa treatments. A smaller trial found advantages after twelve weeks for sulphur baths plus exercise over exercise alone. The guideline considers this interesting but too thin to recommend [1].
• Passive long-term treatments with no active part. Massage, heat, electrotherapy, ultrasound – all of these can be pleasant during a bad phase. But if a course of treatment leaves no measurable change in strength, walking distance or sit-to-stand after twelve weeks, it was not a treatment of the osteoarthritis but a pleasant hour.

15. Medication and injections – which we do not prescribe, but can put in context

Medication is a matter for your doctor. Three points nevertheless belong here, because they affect your decisions.

Anti-inflammatory painkillers (NSAIDs – ibuprofen or diclofenac, for example) work on osteoarthritic pain. The guideline points out the known gastrointestinal side effects and notes that older suggestions of an accelerated loss of cartilage are not conclusive [1]. The useful practical question is: what am I taking it for? A painkiller that enables you to do your training and to walk is working for you. A painkiller that enables you to carry on exactly as before is working against you.

Corticosteroid injections into the hip joint deserve a closer look. They can help markedly in the short term. But a follow-up study from Boston attracted attention: among people who had received an injection into the hip or knee, rapid deterioration of the joint occurred more often than among comparison persons without an injection – in some cases up to collapse of the joint surface [19]. That study was not a randomised trial, and it is possible that the worse hips were precisely the ones that received an injection. But it has led to injections into the hip being given more cautiously today and to people being informed about it. If you are offered an injection, the question «how often, at what interval and what happens afterwards?» is a fair one.

And the most important point: neither tablets nor injections make the muscles stronger. At best they create a window of time. What you do in that window decides whether it was worth it.

16. Sport, hiking, running

The most common question after the diagnosis is: «Am I still allowed to?» In almost every case the answer is yes – with adjustments.

On running there is a summary of 25 studies covering more than 125 000 people [21]. The frequency of hip and knee osteoarthritis was 3.5 per cent among recreational runners, 10.2 per cent among people who did not run and 13.3 per cent among competitive runners at a high level. This is no proof that running protects – people in pain stop running, and that distorts such comparisons. But it refutes the widespread picture of recreational running «wearing out the joints». What the figures suggest is that both no loading at all and very heavy loading over very many years go along with more osteoarthritis.

In practice, with hip osteoarthritis already present:

• Usually well tolerated: cycling, swimming (a front-crawl leg kick is usually more comfortable than breaststroke), hiking with poles, Nordic walking, classic cross-country skiing, strength training, aqua fitness, dancing in moderation.
• Often tricky: sports with abrupt turning and stopping on one leg – tennis, squash, football – deep positions combined with rotation, and long descents.
• The rule for everything else: do it. Watch how the hip is the next morning. If it is the same, the dose was right. If it is clearly worse and takes more than 24 hours, the dose was too high – then shorten the duration, not the sport.

And for mountain walks in Valais: it is the descent that is the load, not the climb. Poles, shorter steps and – where possible – the cable car down are not weakness but good planning.

17. Can surgery be postponed?

For many people this is the most important question of all, and there is exactly one trial that has followed it over years.

In Norway, 109 people with hip osteoarthritis were allocated by draw to two groups: both received patient education, one group additionally exercise therapy over twelve weeks. They were then followed for six years to see who received an artificial hip joint [22].

The result:

• In the exercise group 22 of 55 were operated on, in the education group 31 of 54.
• After six years, 41 per cent of the exercise group still had their own joint, compared with 25 per cent in the comparison group.
• The median time to surgery was 5.4 versus 3.5 years – almost two years' difference.

How much weight can this bear? It should be treated with restraint. It is a single trial with a good hundred participants; the question of surgery was not the original main question but a follow-up; and when someone is operated on also depends on how much discomfort they are prepared to bear and on what the surgeon tells them. The confidence interval of the result reaches close to «no difference».

Even so, it is the best we have on this question, and it points in a clear direction. Together with the observation that the exercise group had better hip function before surgery [22], a sensible attitude emerges: train in order to gain time – and in order to go into the operation in better condition, should it come. Not: train in order to avoid the operation at any price.

18. The operation – and the time before and after

If a hip hurts so much despite everything that it takes away your sleep, your journeys and your enjoyment of life, an artificial joint is not a defeat. It is one of the most reliable operations medicine knows.

When? There is no internationally agreed moment [1]. As a rule of thumb: non-surgical treatment has been exhausted when the complaints do not improve sufficiently over months despite sensible treatment. In practice three things usually decide it – pain at rest and at night, a markedly shortened walking distance, and the loss of activities that matter to you. An X-ray alone is not a reason to operate.

How long does it last? An analysis of case series and national registries covering more than 200 000 artificial hip joints concluded: after 25 years the joint is still in place in around 58 of 100 people [23]. The Swiss registry figures fit with this: 2.5 per cent of implants need further surgery within two years, and after eleven years the figure for osteoarthritis as the reason is 5.1 per cent [26].

Does training before the operation help? Here the answer is nuanced. A summary of 22 trials with 1601 people found for the hip: small improvements in pain and function before surgery – but no measurable advantage after it [24]. In other words: you go into the operation better prepared, but six months later the difference can no longer be seen. That is still not an argument against preparation – someone who already knows how to walk on crutches, how getting up works and which exercises are coming has an easier time in the first weeks. It is only an argument against exaggerated promises.

And afterwards? As a rule the operation takes away the pain. It does not take the strength with it – that has to be fetched back. By the time of surgery the muscles around the hip have often been getting weaker for years, and a new joint does not change that in itself. That is precisely why aftercare is more than a check-up. Someone who is pain-free after six weeks and therefore stops is left with a weak hip – and an increased risk of falling.

19. Falls – the overlooked part

Falls are rarely discussed in osteoarthritis, even though the connection is obvious: a painful joint, weaker muscles, an altered gait and sometimes painkillers – that is four known fall risks at once.

How common it actually is was shown by an analysis from the Danish GLA:D registry: around one person in four starting a structured education and exercise programme for knee or hip osteoarthritis had fallen in the preceding year [14]. Disclosure: Roger Hilfiker is a co-author of that work; it is a conference contribution, not a full publication.

The American guideline draws a practical conclusion from this and recommends measuring balance and fall risk in people with hip osteoarthritis – particularly where function is reduced or something has already happened [1]. Simple tests such as timed single-leg stance or the four-square step test are named.

For you this means two things. First: if you have fallen or nearly fallen in the past year, say so – even if you are here «because of the hip». Second: balance training belongs in the programme in hip osteoarthritis, not just strength. What works there and what does not is in the guide to fall prevention.

20. What a programme looks like

20.1 It starts with taking stock

Before anything is practised, measurements are taken – and ones that can be repeated in three months [1]: range of movement of the hip in all directions, strength compared side to side, a walking test, a sit-to-stand test, a questionnaire on pain and daily life, and the question about falls. Without these baseline values it will later be impossible to distinguish between «it is working» and «I hope it is working».

20.2 The building blocks

A complete programme usually consists of five parts. Not everyone needs every one – the selection follows from taking stock:

That sounds like a lot. It can be combined: Nordic walking covers endurance, balance and part of the strength. An aqua fitness class covers range of movement, endurance and part of the strength. A group programme such as GLA:D covers education and training at the same time. And the British cycling trial [12] shows that a group offer in a leisure centre is not inferior to one-to-one therapy – probably precisely because people keep going there after the prescription runs out.

20.3 How to measure for yourself whether it is working

Take a few values you can repeat at home – today, in six weeks, in three months:

• Sit-to-stand test: how many times can you get up from an ordinary chair and sit down again in 30 seconds, without using your hands?
• Walking distance: how far do you get before the hip slows you down? Note a particular distance you know – to the letterbox, around the block, to the bus stop.
• Socks: can you put your socks on sitting down, without aids, without rounding your back? Yes, with difficulty, or no?
• Pain when walking on a scale from 0 to 10, averaged over the past week.
• Nights: on how many nights in the past week did the hip wake you?

What matters is what you expect of these numbers. On the Cochrane figures [2], an improvement in pain of one to two points out of ten is a realistic result, not a disappointing one. And if the pain does not change but the number of sit-to-stand repetitions rises from eight to twelve, that is a success – you have gained reserve, even if the feeling has stayed the same.

20.4 The home programme

For a home programme to work, it needs three things:

• Short and firmly anchored. Ten minutes tied to an existing habit – after breakfast, after brushing your teeth – get done. Forty minutes «some time during the day» do not.
• Hard enough. This is the point at which home programmes fail [10]. If twenty repetitions are effortless, it was movement but not training. A resistance band, a filled water bottle or a rucksack solves that.
• Written down. A sheet with a few exercises, printed large, in a visible place – and a cross for every day done. That is not surveillance; it is what makes the difference. For the exercises themselves, this site has a home programme with videos.

21. Eight misunderstandings

1. «Osteoarthritis means the joint is worn out – movement wears it out further.» No. Cartilage lives on loading; it has no blood vessels and is supplied through the joint fluid, which is distributed by movement. Prolonged immobilisation harms the joint more than sensible loading does. And in the trials, exercise for hip osteoarthritis was practically free of side effects [2][1].

2. «My X-ray is bad, so things will get bad.» No. Image and complaints are only weakly connected [5], and the grade on the image tells you neither about your pain nor about your future course.

3. «If physiotherapy works, I should have distinctly less pain after a few sessions.» This is the expectation on which most treatments founder. The average change in pain is small [2], and it takes weeks. What comes faster is range of movement and confidence.

4. «It hurts, so I am damaging something.» In osteoarthritis, pain is a poor damage detector. Pain on loading that subsides quickly after the exercise and is no worse the next morning does no damage.

5. «I have to find the right exercise.» There is no such thing. Strength, Nordic walking, water and cycling all have evidence behind them [10][11][12][1], and a head-to-head comparison of strength training with and without endurance found no difference [11]. What matters is how often and for how long you do something [9].

6. «A stick makes you dependent.» The opposite: it substantially unloads the joint and makes journeys possible again that you would otherwise leave out – and journeys left out make you weaker.

7. «I should wait as long as I possibly can before surgery.» Not «as long as possible» but «as long as it is worth it». Someone who holds out for years with night pain and a shrinking walking distance goes into the operation with markedly weaker muscles – and needs longer afterwards.

8. «After the operation it is over.» The pain is usually gone; the strength does not come back by itself. The weeks and months after the operation decide whether a pain-free joint also becomes a leg that carries you.

22. When to get in touch

Prompt medical assessment – not physiotherapy – is needed for: fever together with hip pain; pain that builds up over days and does not ease at rest; a hip that will not bear weight after a fall; unintended weight loss; night sweats; or morning stiffness lasting considerably longer than an hour.

An appointment with us makes sense if:

• you have a diagnosis but nobody has told you what to do about it;
• you are exercising but do not know whether it is enough – or whether it is the right thing;
• your walking distance has shortened and you are leaving things out because of it;
• you have fallen in the past year or feel unsteady;
• surgery is on the horizon and you would like to go into it prepared;
• you have been operated on, are pain-free – and still notice that the leg does not carry you as it used to.

What to expect in our practice: taking stock with measurements – range of movement, strength side to side, a walking test, a sit-to-stand test, fall history – and from that a programme with clear goals and an agreed deadline, at the end of which we measure again and say honestly whether it has worked. Alongside that, the things that make more difference in everyday life than the choice of exercises: the stick, the seat height, the planning of journeys. And, because this belongs with a condition that lasts years, the question of how things go on without us – which group, which offer, which rhythm.

23. In summary

Hip osteoarthritis is a disease of the whole joint, not just of the cartilage – and the part physiotherapy works on is the muscles, the range of movement and the way you load the joint in everyday life [1].

The pain sits in the groin and runs into the knee. Pain at the side over the greater trochanter is usually something else and is treated differently [25].

The X-ray says little. Only about 16 in 100 people with frequent hip pain have a matching image, and only about 21 in 100 abnormal hips hurt [5].

The effect of exercise on pain is small – and we say so. Around 7 points out of 100 compared with no treatment, against a noticeability threshold of about 12 [2]. The analysis of more than four thousand individual data sets finds the same order of magnitude [4].

What nevertheless speaks for training: it works more strongly when you actually turn up [9]; it builds strength and muscle mass [1]; it appears to push surgery back by years [22]; it lowers the risk of falling; it costs almost nothing; and it practically never does harm [2].

Which kind is secondary. Strength, Nordic walking, water, cycling – all have evidence [10][12][1], and endurance added to strength training brought nothing extra in a head-to-head comparison [11].

What is not established, we say too: that manual therapy achieves more than an equally elaborate sham treatment [15]; that dry needling achieves anything beyond three weeks [17]; that ultrasound works [1]; that supplements help the hip joint [1]; and that losing weight improves existing hip osteoarthritis [20].

And if it does come to surgery, that is not a failure. After 25 years an artificial hip joint is still in place in around 58 of 100 people [23]; in Switzerland a good 27 000 are fitted every year [26]. Preparation makes the first weeks easier, even if it is no longer measurable after six months [24] – and fetching the strength back afterwards is not an extra but the actual work.

In the end it all comes down to a single question, and it is not which exercise is best. It is: will you still be moving in five years? A joint you need for another twenty years gains more from something you do for twenty years than from the theoretically best treatment you abandon after eight weeks.

References

All Digital Object Identifiers (DOIs) were individually verified against the Crossref register. The links in the reference list lead via the DOI service to the publishers' pages. Some of these are located outside Switzerland and the EU. When you click on them, your IP address is transmitted to the provider in question – this does not happen on our own site.

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