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Hip Osteoarthritis

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About Hip Osteoarthritis (OA)

Osteoarthritis (OA) is the most common cause of hip pain in older adults (> 50 years of age), with a degenerative process. Symptomatic hip OA responds well to conservative care; however, underlying pathologies requiring medical attention should be ruled out such as cauda equina syndrome, fracture, infection, or tumour.

About CCG Care Pathways

Purpose

CCG care pathways provide structured, evidence-based guidance for clinicians delivering conservative, non-operative care for common musculoskeletal conditions. They outline key steps of the clinical encounter, support safe and appropriate decision-making, and assist with referral or co-management when indicated. Pathways are designed as practical, user-friendly tools that complement, not replace, clinical judgment.

Development

Pathways are developed using the best available evidence from high-quality clinical practice guidelines when they exist, and from systematic reviews and expert consensus when guideline evidence is limited or evolving. Content is reviewed periodically to reflect emerging research and current best practices. Input from clinicians, educators, and researchers helps ensure pathways remain relevant, aligned with real-world practice, and responsive to user needs.

Principles of Conservative Care

Musculoskeletal conditions are multifactorial and often influenced by physical, psychological, social, and environmental factors. As such, there is no one-size-fits-all approach to care. Effective management should be ethical, evidence-informed, transparent, flexible, and tailored to individual needs. Shared decision-making ensures care aligns with patient goals and values. Ongoing monitoring and outcome assessment support a person-centred approach and enable timely adjustments to care plans. Care may be delivered in-person, virtually, or through hybrid models, guided by patient preference, access, and clinical judgment.

Disclaimer

CCG care pathways are intended to support, not substitute for, professional clinical decision-making or the advice of a qualified healthcare provider. Recommendations are evidence-informed and presented in simplified, accessible language to support clinical understanding and application. Terms used throughout are not intended as formal diagnostic or billing terminology, nor are pathways prescriptive, authoritative, or regulatory.

Providers are expected to apply their clinical expertise and consult authoritative sources such as regulatory standards and policies, diagnostic classification systems (e.g., ICD-10-CA), scope-of-practice documents, continuing professional education resources, and peer-reviewed literature. Pathways may not apply to every clinical scenario and should always be interpreted in the context of individual patient needs.

Hip Osteoarthritis Care Pathway

1. Record Keeping

Accurate, timely, and comprehensive documentation is an essential component of high-quality, evidence-based care. Clinical records must clearly reflect patient interactions, clinical reasoning, and progress over time, and should meet all jurisdictional regulatory standards.

Providers are encouraged to use a structured note format, such as the SOAP framework, to support consistency, clarity, and continuity of care.

Subjective: Document the patient’s reported symptoms, concerns, functional changes, contextual factors (e.g., psychosocial or environmental influences), and responses to prior care.

Objective: Record measurable or observable findings, including physical examination results, relevant diagnostic tests, functional assessments, and any clinically significant changes.

Assessment: Provide the clinical interpretation of findings, including diagnostic impressions or updates, identification of key risk factors or modifiers, and evaluation of the patient’s status or progression.

Plan: Outline the management strategy, including treatments delivered, modifications made, patient education and self-management recommendations, referrals, co-management decisions, and planned follow-up.

Documentation should be completed contemporaneously and maintained in accordance with regulatory requirements for privacy, security, and record retention. High-quality records support patient safety, facilitate interprofessional communication, enable shared decision-making, and promote continuity and accountability in care.

2. Informed Consent
  • Definition: A process where the patient voluntarily agrees to proposed healthcare interventions after receiving adequate information on the nature, benefits, risks, and alternatives.
  • Key Aspects:
    • Prior to interaction: Obtain consent before any diagnostic testing or treatment. Ensure the patient understands the planned examinations, treatments, expected outcomes, and is given the opportunity to ask questions.
    • Voluntarily and specific: Consent must be given willingly, without coercion, and pertain to the specific condition and proposed treatment. The patient should also understand that they can withdraw consent at any time. 
    • Transparent process: Consent must be obtained honestly, with a clear explanation of the condition and proposed interventions. Consent is not a one-time event, and involves ongoing discussions with the patient.
    • Patient understanding and agreement:
      • Diagnosis/prognosis: Explain findings clearly, using understandable language and visuals if needed.
      • Treatment plan: Outline recommended treatments and how they align with patient goals. Discuss benefits, risks, and alternatives.
      • Questions: Encourage questions and confirm understanding (e.g., “teach-back”).
    • Documentation: Record the consent process, including information provided, patient questions, and explicit consent given.
3. Health History
  • Apply cultural awareness and trauma-informed care principles.
  • Sociodemographic information: Age, gender, sex, race/ethnicity.
  • Main complaint: Location, onset, duration, radiation, frequency, intensity, character, aggravating/relieving factors, associated symptoms.
  • Body systems review: Neurologic, cardiovascular, genitourinary, gastrointestinal, muscles and joints, eyes/ears/nose/throat, respiratory, skin, mental health, reproductive.
  • Health, lifestyle, and history: Past medical conditions, medications (including opioids), supplements, injuries, hospitalizations, surgeries, diet, exercise, sleep habits, smoking, alcohol/substance use, family support, caregiver responsibilities, work/school environment.
  • Social determinants of health: Employment, childcare, education, nutrition, housing, domestic violence, child maltreatment, discrimination, social isolation.
  • Previous treatments and responses: Document prior treatments, effectiveness and any adverse effects.
  • Beliefs and expectations: Assess patient understanding of their condition, treatment goals, and outcome expectations.
  • Flag considerations: Identify red, orange, and yellow flags for potential referrals.

​​Outcomes Assessments: Prioritize approaches that align with the patient’s specific goals and clinical presentation.

  • Pain: Use pain scales (e.g., NRS), pain diagram.
  • Function and Participation: Evaluate impact of hip pain on daily activities (HOOS, WOMAC, AIMS2, PSFS, WHODAS,  LEFS).
  • Recovery: Use Self-rated recovery scales.
  • Quality of life: Assess using tools such as SF-12.
  • Work/school status: Monitor return to activities.
  • Sleep quality: Assess using tool such as PSQI.
  • Individual goals: Set SMART goal setting (Specific, Measurable, Achievable, Relevant, Timely).
  • Patient feedback: Gather and integrate patient experience and satisfaction.
4. Red Flags : Differential Diagnosis Requiring Medical Referral

ACTION: Refer immediately to emergency care:

  • Cauda Equina Syndrome: Severe back pain, saddle anesthesia, bladder/bowel dysfunction, bilateral radicular signs, progressive lower limb weakness, decreased perineal sensation, reduced anal sphincter tone.
  • Hip Infection: Rapid worsening of symptoms, red, hot, swollen joint, history of immunosuppression or TB (tuberculosis), recent infection or surgery, unexplained systemic symptoms (e.g., fever, chills), IV drug use, poor living conditions.
  • Traumatic Hip Fracture: Severe trauma, sudden onset of severe, localized pain and tenderness following trauma, redness, bruising, swelling, inability to weight bear.

ACTION: Refer to appropriate medical provider:

  • Non-traumatic Hip Fracture: Sudden, localized pain/tenderness following minor trauma or spontaneous in individuals with osteoporosis, corticosteroid use, female sex, older age (>60), history of spinal fracture/cancer. 
  • Malignancy (e.g., chondrosarcoma, multiple myeloma): Severe, progressive pain, not relieved by rest, history of cancer, constitutional symptoms (e.g., fatigue, weight loss, night pain).
  • Inflammatory Arthritides (e.g., spondyloarthropathies, polymyalgia rheumatica): Morning stiffness >1 hour, constitutional symptoms (e.g., fatigue, weight loss, fever), symmetrical joint pain, joint swelling and deformity. 
  • Referred Pain from abdominal/pelvic visceral conditions: (e.g., aortic aneurysm, endometriosis, kidney stones, pancreatitis): Abdominal pain, GI or urinary symptoms, systemic signs (e.g., fever, weight loss), abdominal/pelvic tenderness, palpable mass, specific findings (e.g., Murphy’s sign for kidney stones, Cullen’s sign for pancreatitis).
  • Avascular Necrosis (e.g., Chandler’s disease): Antalgic gait; worsening of hip pain or range of motion; history of corticosteroid use, alcoholism, trauma, hemoglobinopathies, etc.
  • Hernia (e.g., femoral or inguinal hernia): Groin pain, swelling or bulge that appears with coughing/straining and reduces with lying down. Immediate medical referral is necessary if hernia is firm, tender, or is accompanied by sudden, severe pain.
5. Orange Flags: Symptoms of Psychiatric Disorders Requiring Referral

Clinicians should promptly address symptoms of potential mental health disorders to prevent harm through appropriate and timely referrals.

ACTION: Refer for immediate care (emergency department, medical/mental health provider):

  • Suicidal ideation: Thoughts, plans, or statements about suicide or feelings of hopelessness.   
  • Severe, acute symptoms: Acute psychological distress, such as psychosis, severe panic.
  • Ideation of harm: Intent or plans to self-harm, commit violence, or harm others.

ACTION: Refer to appropriate medical/mental health provider:

  • Persistent, non-urgent symptoms: Symptoms affecting daily functioning (e.g., low mood, anxiety, sleep disturbances, social withdrawal, substance use).

ACTION: Co-management by non-medical/mental health providers:

  • Triage: Ensure primary management by medical/psychiatric providers.
  • Musculoskeletal (MSK) treatment: Manage MSK conditions related to or comorbid with psychological disorders.
  • Screening tools: Selectively use tools to monitor symptoms and severity, guide care, and support escalation without implying a diagnosis. Tools include:
    • PHQ-9 (depressive symptoms)
    • GAD-7 (anxiety symptoms)
    • FABQ (fear related to physical activity/work) 
    • PCS (catastrophic thoughts) 
    • ORT (opioid risk)
6. Yellow Flags: Psychosocial Factors that May Delay Recovery

Non-health barriers can delay recovery; early identification and intervention can enhance outcomes.

Factors:

  • Individual: Worry, fear of movement, low recovery expectations, limited self-efficacy, reliance on passive treatments, activity avoidance.
  • Social: Lack of family/social support, limited connections.
  • Socioeconomic: Employment status, financial stress, litigation/compensation.
  • Environmental/cultural: Social inequality, unsafe/unsupportive environments.
  • Life events: Major transitions (e.g., divorce, job loss), chronic stressors (e.g., caregiving).
  • Work/school: High stress, poor work-life balance, limited accommodations for injury/illness.

ACTION: Co-management by non-medical/mental health providers: 

  • Education & self-care: Provide resources for (e.g., stress management, coping strategies, graded activity).  
  • Monitor & coordinate: Regularly assess psychosocial challenges; refer to medical/mental health provider if persistent.
  • Screening tools: Selectively use tools to monitor symptoms and severity, guide care, and support escalation (aligned with Orange Flag guidance), without implying a diagnosis. Tools include:
    • PHQ-9 (depressive symptoms)
    • GAD-7 (anxiety symptoms)
    • FABQ (fear related to physical activity/work) 
    • PCS (catastrophic thoughts) 
    • ORT (opioid risk)

7. Physical Examination
  • Observation: Evaluate for abnormalities, asymmetries, posture, balance, movements, gait, walking capacity (measured by distance or time), facial expression.
  • Range of Motion (ROM): Assess active, passive, resisted hip ROM (flexion, extension, internal and external rotation, abduction and adduction).
  • Palpation: Examine bone, joint, and muscle for tenderness, swelling, muscle tightness, or temperature changes.
  • Neurological Examination:
    • Motor strength testing: Assess for asymmetry or weakness in key muscle groups:
      • L2: Hip flexors (hip flexion)
      • L3: Quadriceps (knee extension)
      • L4: Tibialis anterior (foot dorsiflexion)
      • L5: Extensor hallucis longus (big toe extension)
      • S1: Gastrocnemius (plantar flexion)
      • S2: Hamstrings (knee flexion)
    • Sensory testing: Assess for sensory deficits in dermatomal distributions:
      • L1: Inguinal region
      • L2: Anterior mid-thigh
      • L3: Medial thigh at the knee
      • L4: Medial calf
      • L5: Top of foot and toes
      • S1: Lateral foot and little toe
    • Reflex testing: Assess for asymmetry, diminished/absent reflexes:
      • L4: Patellar reflex
      • L5: Medial hamstring reflex
      • S1: Achilles reflex
    • Upper motor neuron signs: Asses for increased muscle tone, hyperreflexia, pathological reflexes (e.g., Babinski sign, Clonus). May indicate central nervous system disorders (e.g., myelopathy, multiple sclerosis, stroke).
    • Lower motor neuron signs: Assess muscle atrophy, fasciculations, reduced muscle tone, symmetrical loss of function. May indicate systemic neurological conditions (e.g., radiculopathy, peripheral neuropathy, ALS).
  • Special/Orthopedic Tests: Perform as clinically indicated. 
  • Advanced Diagnostics: Radiography is generally not recommended without red flags or specific individual factors (e.g., contraindications to treatment).

8. Clinical Presentations for Hip OA
  • Estimated to impact 10% of individuals globally
  • Anterior, posterior, or lateral hip. May refer into the groin, thigh, and/or calf.
  • Pain may present as aching, sharp, or stiff, unilaterally or bilaterally, with variable intensity, worsened by activity (e.g., walking or stairs), relieved by rest, and often accompanied by morning stiffness (<1 hour) and surrounding muscle stiffness or weakness.
  • Pain reproduced by hip provocation tests; neurological deficits not present.
9. Treatment Considerations for Hip OA

Approach to Treatment (Gibbs et al., 2023)

The treatments outlined in this section reflect core domains of care consistently identified across high-quality clinical practice guidelines and established clinical practices. These include interventions shown to improve patient-important outcomes such as pain, function, and quality of life. Management plans should be tailored to the individual’s needs, goals, and preferences, taking into account clinical presentation, response to care, and contextual factors.

Not all domains need to be included in every care plan or at every stage of recovery. Clinicians are expected to apply professional judgment in selecting the most relevant components based on the clinical context.

This pathway is not prescriptive, nor does it list every possible intervention. Readers are encouraged to consult individual guidelines for specific treatment protocols, dosage, and condition-specific considerations.

While a range of other interventions may be in use, such as passive physical modalities, these have mixed or limited evidence of clinical benefit and are therefore not recommended for routine use. If applied, such therapies should be used as adjuncts to the core, evidence-based components of care, and not as standalone treatment.

  1. Education and Self-Management
    These interventions address modifiable prognostic factors for recovery [see Section 10].
    • Education & reassurance: Emphasize hip OA’s a chronic, progressive joint condition. Use tailored, evidence-based information in various formats (written, digital, visual) to empower individuals. Limited evidence suggests no single superior type of education for improving patient outcomes, but consistent reinforcement improves understanding and engagement.
    • Self-care: Encourage regular exercise, nutrition, sleep hygiene, stress management, weight maintenance, and avoidance of smoking/substance abuse. Employ SMART goals and Brief Action Planning for sustained engagement.
    • Daily activities: Promote continued movement and discourage prolonged bed rest to enhance recovery and prevent functional decline.
    • Social & work engagement: Encourage participation using pacing strategies and workplace accommodations to support social functioning and productivity.
    • Mobility devices: Recommend assistive devices (e.g., walkers, canes) to enhance safety and independence as needed. 
  2. Psychosocial and Psychological Support 
    • Address barriers: Screen for psychosocial barriers (e.g., fear of movement, low recovery expectations, anxiety) using tools (e.g., FABQ, PHQ-9, GAD-7, ORT, PCS). Addressing psychosocial factors improves overall treatment outcomes and engagement. Provide education and strategies within the scope of care to support recovery (e.g., stress management, self-efficacy building, social/occupational engagement) [see Sections 5 and 6].
    • Resources & instruction: Offer resources (e.g., online tools, written materials, mindfulness programs). Refer to mind-body practitioners (e.g., yoga, meditation, tai chi) for further support when conservative care is insufficient.
    • Medical/mental health referral: Refer people with severe, persistent, or impairing symptoms to qualified medical/mental health providers or community support services to address psychological and social barriers to recovery [see Sections 5 and 6].
  3. Exercise Therapy
    • Develop individualized programs focused on improving strength, mobility, and aerobic fitness, tailored to patient needs and preferences. Exercise has demonstrated benefits in reducing pain, improving functional capacity, and enhancing quality of life. No single exercise type is shown to be superior, so programs should align with patient capabilities and goals. Monitor psychological responses to exercise; refer to medical/mental health providers if signs of distress or aversion arise.
  4. Weight Loss
    • Incorporate weight management to reduce load on the joints and improve pain in the long term and overall health. Continuous motivation and support are needed. 
  5. Manual Therapy
    • Incorporate manipulation/mobilization, and soft tissue techniques to reduce pain and improve function. Manual therapy should be integrated as part of a broader care plan to maximize effectiveness.
  6. Medication
    • Short-term relief: Consult a medical provider. NSAIDS can be considered for short-term use. Long-term opioid use is discouraged due to dependency risk.
  7. Walking Aids
    • Incorporate walking aids to maintain independence and reduce fall risk. Examples include canes, walkers, orthotic devices. Prescribe based on individual needs and preferences.
10. Risk and Prognostic Factors for Hip OA
  • Common Risk Factors: (Cooper et al., 1998; Hulshof et al., 2021; Valdes & Spector, 2011)
  • Prognosis: (Holla et al., 2010; Lievense et al., 2002; Teirlinck et al., 2019) 
    • Depends on several factors (e.g., OA severity, treatment response, overall health). The majority of individuals with mild to moderate OA have a favorable prognosis, but symptomatic OA can recur or persist for many.
    • Common Negative Prognostic Factors: Age, type of bone response, obesity, comorbidity, higher Kellgren and Lawrence grade, superior or (supero) lateral femoral head migration, subchondral sclerosis, activity limitations, bilateral hip ain, morning stiffness in the knee, low active hip flexion, poor general health perception, pain coping strategy.
11. Ongoing Follow-up
  • Monitor progress: Reassess symptoms, functional status, and patient-reported outcomes at appropriate intervals. Confirm that care remains aligned with the patient’s goals, values, and expectations.
  • Adjust treatment plan: Continuously realign the management plan based on evolving goals, treatment response, clinical findings, and professional judgment. Modify interventions, dosage, frequency, or focus as needed to support meaningful improvement.
  • Support self-management: Reinforce the patient’s understanding of home strategies, activity recommendations, and behavioural approaches. Encourage adherence and address barriers that may affect progress.
  • Recognize plateaus or change in status: Identify when the patient is improving, stable, or worsening. Reassess for contributing factors such as comorbidities, psychosocial influences, or new functional limitations.
  • Referral and co-management: Consider referral or co-management with an appropriate provider when there is limited or no significant improvement within an expected timeframe (for example 6 to 8 weeks), when new or concerning findings emerge, or when additional expertise is required to support optimal care.
  • Documentation: Record follow-up assessments, changes to the plan, patient feedback, reassessment of goals, and any referral or co-management decisions.
12. Criteria for Discharge
  • Discharge criteria: Establish clear criteria for concluding active care. These may include achieving the patient’s initial goals, demonstrating meaningful improvement in symptoms or function, reaching a plateau in progress, or transitioning to self-management as the primary approach. Consider patient preferences, functional demands, and clinical judgment when determining readiness for discharge.
  • Clinical reassessment: Prior to discharge, complete a focused reassessment to confirm stability of symptoms, functional status, and the patient’s confidence in managing their condition. Address any remaining concerns and ensure no new issues require further evaluation.
  • Post-discharge planning: Discuss ongoing self-management strategies, including activity recommendations, home exercises, behavioural or lifestyle modifications, and symptom monitoring. Provide guidance on when to return for follow-up, when to seek additional care, and what indicators should prompt medical evaluation.
  • Future care needs: Clarify options for episodic care, preventive visits, or re-engagement with the provider if symptoms recur or functional demands change. Encourage ongoing communication if new concerns arise.
  • Documentation: Record the rationale for discharge, the patient’s status at the time of discharge, self-management recommendations provided, and the agreed-upon follow-up plan

References