Clinical Guidelines
MICHAEL T. CIBULKA, DPTš:EK=B7IC$M>?J;"DPTš@K:?J>ME;>HB;"PT, PhDšC7H9?;>7HH?I#>7O;I"DPT
A;;B7D;DI;A?"PT, MSšJ?CEJ>OB$<7=;HIED"DPTš@7C;IIBEL;H"MD, MSš@EI;F>@$=E:=;I"DPT
Hip Pain and Mobility
Deficits – Hip Osteoarthritis:
Clinical Practice Guidelines Linked to
the International Classification of
Functioning, Disability, and Health from
the Orthopaedic Section of the American
Physical Therapy Association
J Orthop Sports Phys Ther 2009;39(4):A1-A25. doi:10.2519/jospt.2009.0301
RECOMMENDATIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A2
INTRODUCTION. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A3
METHODS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A3
CLINICAL GUIDELINES:
Impairment/Function-Based Diagnosis . . . . . . . . . . . . . . . . . . A6
CLINICAL GUIDELINES:
Examinations. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A10
CLINICAL GUIDELINES:
Interventions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A15
SUMMARY OF RECOMMENDATIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A18
AUTHOR/REVIEWER AFFILIATIONS AND CONTACTS . . . . . . A19
REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A20
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Hip Pain and Mobility Deficits – Hip Osteoarthritis: Clinical Practice Guidelines
Recommendations*
F7J>E7D7JEC?97B<;7JKH;I0 Clinicians should assess for
impairments in mobility of the hip joint and the strength of the
surrounding muscles, especially the hip abductor muscles, when
a patient presents with hip pain. (Recommendation based on
weak evidence.)
H?IA<79JEHI0 Clinicians should consider age, hip developmental disorders, and previous hip joint injury as risk factors for hip
osteoarthritis. (Recommendation based on strong evidence.)
:?7=DEI?I%9B7II?<?97J?ED0 Moderate lateral or anterior hip
pain during weight bearing, in adults over the age of 50 years,
with morning stiffness less than 1 hour, with limited hip internal rotation and hip flexion by more than 15° when comparing
the painful to the nonpainful side are useful clinical findings to
classify a patient with hip pain into the International Statistical
Classification of Diseases and Related Health Problems (ICD)
category of unilateral coxarthrosis and the associated International Classification of Functioning, Disability, and Health (ICF)
impairment-based category of hip pain (b2816 Pain in joints)
and mobility deficits (b7100 Mobility of a single joint). (Recommendation based on strong evidence.)
:?<<;H;DJ?7B:?7=DEI?I0 Clinicians should consider diagnostic
classifications other than osteoarthritis of the hip when the
patient’s history, reported activity limitations, or impairments
of body function and structure are not consistent with those
presented in the diagnosis/classification section of this guideline, or, when the patient’s symptoms are not diminishing with
interventions aimed at normalization of the patient’s impairments of body function. (Recommendation based on expert
opinion.)
;N7C?D7J?EDÅEKJ9EC;C;7IKH;I0 Clinicians should use
validated functional outcome measures, such as the Western
Ontario and McMaster Universities Osteoarthritis Index, the
Lower Extremity Functional Scale, and the Harris Hip Score
before and after interventions intended to alleviate the impairments of body function and structure, activity limitations, and
participation restrictions associated with hip osteoarthritis.
(Recommendation based on strong evidence.)
;N7C?D7J?EDÅ79J?L?JOB?C?J7J?ED7D:F7HJ?9?F7J?EDH;IJH?9#
J?EDC;7IKH;I0 Clinicians should utilize easily reproducible
physical performance measures, such as the 6-minute walk,
self-paced walk, stair measure, and timed up-and-go tests to assess activity limitation and participation restrictions associated
with their patient’s hip pain and to assess the changes in the
patient’s level of function over the episode of care. (Recommendation based on strong evidence.)
?DJ;HL;DJ?EDI#F7J?;DJ;:K97J?ED0 Clinicians should consider
the use of patient education to teach activity modification,
exercise, weight reduction when overweight, and methods of
unloading the arthritic joints. (Recommendation based on
moderate evidence.)
?DJ;HL;DJ?EDIÅ<KD9J?ED7B"=7?J"7D:87B7D9;JH7?D?D=0
Functional, gait, and balance training, including the use of assistive devices such as canes, crutches, and walkers, can be used
in patients with hip osteoarthritis to improve function associated with weight-bearing activities. (Recommendation based on
weak evidence.)
?DJ;HL;DJ?EDIÅC7DK7BJ>;H7FO0 Clinicians should consider
the use of manual therapy procedures to provide short-term
pain relief and improve hip mobility and function in patients
with mild hip osteoarthritis. (Recommendation based on moderate evidence.)
?DJ;HL;DJ?EDIÅ<B;N?8?B?JO"IJH;D=J>;D?D="7D:;D:KH7D9;
;N;H9?I;I0 Clinicians should consider the use of flexibility,
strengthening, and endurance exercises in patients with hip
osteoarthritis. (Recommendation based on moderate evidence.)
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Introduction
7?CE<J>;=K?:;B?D;
The Orthopaedic Section of the American Physical Therapy Association (APTA) has an ongoing effort to create evidence-based
practice guidelines for orthopaedic physical therapy management of patients with musculoskeletal impairments described
in the World Health Organization’s International Classification
of Functioning, Disability, and Health (ICF).210
The purposes of these clinical guidelines are to:
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 =^l\kb[^^ob]^g\^&[Zl^]iarlb\Zema^kZirikZ\mb\^bg\en]ing diagnosis, prognosis, intervention, and assessment of
outcome for musculoskeletal disorders commonly managed
by orthopaedic physical therapists
 <eZllb_rZg]]^Ög^\hffhgfnl\nehld^e^mZe\hg]bmbhgl
using the World Health Organization’s terminology related
to impairments of body function and body structure, activity
limitations, and participation restrictions
april 2009 | number 4 | volume 39 | journal of orthopaedic & sports physical therapy
Hip Pain and Mobility Deficits – Hip Osteoarthritis: Clinical Practice Guidelines
Introduction (continued)
 B]^gmb_rbgm^ko^gmbhgllniihkm^][r\nkk^gm[^lm^ob]^g\^mh
address impairments of body function and structure, activity limitations, and participation restrictions associated with
common musculoskeletal conditions
 B]^gmb_rZiikhikbZm^hnm\hf^f^Zlnk^lmhZll^ll\aZg`^l
resulting from physical therapy interventions in body function and structure as well as in activity and participation of
the individual
 Ikhob]^Z]^l\kbimbhgmhiheb\rfZd^kl%nlbg`bgm^kgZmbhgZeer
accepted terminology, of the practice of orthopaedic physical therapists
 Ikhob]^bg_hkfZmbhg_hkiZrhklZg]\eZbflk^ob^p^klk^`Zk]ing the practice of orthopaedic physical therapy for common
musculoskeletal conditions
 <k^Zm^Zk^_^k^g\^in[eb\Zmbhg_hkhkmahiZ^]b\iarlb\Ze
therapy clinicians, academic instructors, clinical instructors,
students, interns, residents, and fellows regarding the best
current practice of orthopaedic physical therapy
IJ7J;C;DJE<?DJ;DJ
This guideline is not intended to be construed or to serve as a
standard of medical care. Standards of care are determined on
the basis of all clinical data available for an individual patient
and are subject to change as scientific knowledge and technology advance and patterns of care evolve. These parameters of
practice should be considered guidelines only. Adherence to
them will not ensure a successful outcome in every patient, nor
should they be construed as including all proper methods of
care or excluding other acceptable methods of care aimed at
the same results. The ultimate judgment regarding a particular
clinical procedure or treatment plan must be made in light of
the clinical data presented by the patient, the diagnostic and
treatment options available, and the patient’s values, expectations, and preferences. However, we suggest the rationale for
significant departures from accepted guidelines be documented
in the patient’s medical records at the time the relevant clinical
decision is made.
Methods
The Orthopaedic Section, APTA appointed content experts
as developers and authors of clinical practice guidelines for
musculoskeletal conditions of the hip which are commonly
treated by physical therapists. These content experts were
given the task to identify impairments of body function and
structure, activity limitations, and participation restrictions,
described using ICF terminology, which could (1) categorize
patients into mutually exclusive impairment patterns upon
which to base intervention strategies, and (2) serve as measures of changes in function over the course of an episode of
care. The second task given to the content experts was to describe the supporting evidence for the identified impairment
pattern classification as well as interventions for patients
with activity limitations and impairments of body function
and structure consistent with the identified impairment
pattern classification. It was also acknowledged by the Orthopaedic Section, APTA content experts that a systematic
search and review of the evidence solely related to diagnostic
categories based on International Statistical Classification of
Diseases and Related Health Problems (ICD)209 terminology would not be useful for these ICF-based clinical practice
guidelines as most of the evidence associated with changes
in levels of impairment or function in homogeneous populations is not readily searchable using the ICD terminology.
The authors of this guideline (M.T.C., D.M.W., J.W.) independently performed a systematic search of the MEDLINE,
CINAHL, and the Cochrane Database of Systematic Reviews
(1967 through August 2008) for any relevant articles related
to classification, examination, and intervention for musculoskeletal conditions of the hip region commonly treated by
physical therapists. As relevant articles were identified, their
reference lists were hand-searched in an attempt to identify
additional articles that might contribute to the outcome of
this guideline. Articles from the searches were compiled by
3 of the authors (M.T.C., D.M.W., J.W.) and this compilation was reviewed for accuracy and completeness by 3 other
authors (M.H.H., K.E., T.L.F.). Articles with the highest
levels of evidence that were most relevant to classification,
examination, and intervention for patients with hip pain,
mobility deficits, and osteoarthritis (OA) were included in
this guideline.
This guideline was issued in 2009 based upon publications in
the scientific literature prior to September 2008. This guideline will be considered for review in 2013, or sooner if new
evidence becomes available. Any updates to the guideline in
the interim period will be noted on the Orthopaedic Section
of the APTA website: www.orthopt.org
journal of orthopaedic & sports physical therapy | volume 39 | number 4 | april 2009 | a3
Hip Pain and Mobility Deficits – Hip Osteoarthritis: Clinical Practice Guidelines
Methods (continued)
B;L;BIE<;L?:;D9;
Individual clinical research articles were graded according to
criteria described by the Center for Evidence-Based Medicine,
Oxford, United Kingdom (Table 1, below).
I
;l_Z[dY[eXjW_d[Z\hec^_]^#gkWb_johWdZec_p[ZYedjhebb[Z
jh_Wbi"fheif[Yj_l[ijkZ_[i"ehZ_W]deij_YijkZ_[i
II
;l_Z[dY[eXjW_d[Z\hecb[ii[h#gkWb_johWdZec_p[ZYedjhebb[Z
jh_Wbi"fheif[Yj_l[ijkZ_[i"ehZ_W]deij_YijkZ_[i[]"_cfhef[h
hWdZec_pWj_ed"deXb_dZ_d]"2.&\ebbem#kf
III
9Wi[#Yedjhebb[ZijkZ_[iehh[jheif[Yj_l[ijkZ_[i
IV
9Wi[i[h_[i
V
;nf[hjef_d_ed
=H7:;IE<;L?:;D9;
The overall strength of the evidence supporting recommendations made in this guideline were graded according to guidelines described by Guyatt et al,75 as modified by MacDermid
and adopted by the coordinator and reviewers of this project.
In this modified system, the typical A, B, C, and D grades of
evidence have been modified to include the role of consensus
expert opinion and basic science research to demonstrate
biological or biomechanical plausibility (Table 2, below).
GRADES OF RECOMMENDATION
BASED ON
A
B
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WdY[e\b[l[b???WdZ?LijkZ_[i"_dYbkZ_d]
ijWj[c[djie\Yedi[dikiXoYedj[dj
[nf[hjiikffehjj^[h[Yecc[dZWj_ed
9edÔ_Yj_d][l_Z[dY[
>_]^[h#gkWb_joijkZ_[iYedZkYj[Zed
j^_ijef_YZ_iW]h[[m_j^h[if[Yjjej^[_h
YedYbki_edi$J^[h[Yecc[dZWj_ed_i
XWi[Zedj^[i[YedÔ_Yj_d]ijkZ_[i
C
D
E
F
STRENGTH OF EVIDENCE
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7fh[fedZ[hWdY[e\[l_Z[dY[\hecWd_cWb
\ekdZWj_edWb[l_Z[dY[ ehYWZWl[hijkZ_[i"\hecYedY[fjkWbceZ#
[bi%fh_dY_fb[i"eh\hecXWi_YiY_[dY[i%
X[dY^h[i[WhY^ikffehjj^_iYedYbki_ed
;nf[hjef_d_ed
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[dY[e\j^[]k_Z[b_d[iZ[l[befc[djj[Wc
H;L?;MFHE9;II
The Orthopaedic Section, APTA also selected consultants from
the following areas to serve as reviewers of the early drafts of
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this clinical practice guideline:
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 <eZbflk^ob^p
 <h]bg`
 >ib]^fbheh`r
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 L^\mbhghg@^kbZmkb\lh_ma^:IM:
 F^]b\ZeikZ\mb\^`nb]^ebg^l
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 Iarlb\Zema^kZirZ\Z]^fb\^]n\Zmbhg
 Lihkmliarlb\Zema^kZirk^lb]^g\r^]n\Zmbhg
Comments from these reviewers were utilized by the authors to
edit this clinical practice guideline prior to submitting it for publication to the Journal of Orthopaedic & Sports Physical Therapy.
In addition, several physical therapists practicing in orthopaedic and sports physical therapy settings were sent initial drafts
of this clinical practice guideline along with feedback forms
to determine its usefulness, validity, and impact. All returned
feedback forms from these practicing clinicians described this
clinical practice guideline as:
 ÊFh]^kZm^ernl^_neËhkÊ^qmk^f^ernl^_neË
 :gÊZ\\nkZm^k^ik^l^gmZmbhgh_ma^i^^k&k^ob^p^]ebm^kZmnk^Ë
 :`nb]^ebg^maZmpbeeaZo^ZÊln[lmZgmbZeihlbmbo^bfiZ\mhg
hkmahiZ^]b\iarlb\Zema^kZiriZmb^gm\Zk^Ë
9B7II?<?97J?ED
The primary ICD-10 code and condition associated with hip pain
and mobility deficits is M16.1 Primary coxarthrosis, unilateral.
In the ICD, the term osteoarthritis (OA) is used as a synonym for
arthrosis or osteoarthrosis. Other, secondary codes associated
with hip OA are M16.0 Primary coxarthrosis, bilateral; M16.2
Coxarthrosis resulting from dysplasia, bilateral; M16.3 Dysplastic coxarthrosis, unilateral; M16.4 Posttraumatic coxarthrosis,
bilateral; M16.5 Posttraumatic coxarthrosis, unilateral; M16.7
Secondary coxarthrosis, not otherwise specified. The corresponding ICD-9 CM codes and conditions, which are used in the USA,
are 715.15 Osteoarthrosis of the pelvic region and thigh, localized,
primary; 715.25 Osteoarthrosis of the pelvic region and thigh, localized, secondary; 715.85 Osteoarthrosis of the pelvic region and
thigh involving more than 1 site but not specified as generalized.
The primary ICF body function codes associated with the above
noted primary ICD-10 condition are the sensory functions
related to pain and the movement-related functions related to
joint mobility. These body function codes are X(.',FW_d_d`e_dji
andX-'&&CeX_b_joe\Wi_d]b[`e_dj$
The primary ICF body structure codes associated with hip pain
and mobility deficits are i-+&&'>_f`e_dj"i-*&(CkiYb[ie\f[bl_Y
h[]_ed"andi-*&)B_]Wc[djiWdZ\WiY_We\f[bl_Yh[]_ed$
The primary ICF activities and participation codes associated with
hip pain and mobility deficits are Z*'+*CW_djW_d_d]WijWdZ_d]fei_#
j_ed"Z*+&&MWba_d]i^ehjZ_ijWdY[i"andZ*+&'MWba_d]bed]Z_ijWdY[i$
The ICD-10 and primary and secondary ICF codes associated
with hip pain and mobility deficits are provided in Table 3 on the
facing page.
april 2009 | number 4 | volume 39 | journal of orthopaedic & sports physical therapy
Hip Pain and Mobility Deficits – Hip Osteoarthritis: Clinical Practice Guidelines
ICD-10 and ICF Codes Associated With Hip Pain and Mobility Deficits
INTERNATIONAL STATISTICAL CLASSIFICATION OF DISEASES AND RELATED HEALTH PROBLEMS
Primary ICD-10
C',$'
Fh_cWhoYenWhj^hei_i"kd_bWj[hWb
Secondary ICD-10
C',$&
C',$(
C',$)
C',$*
C',$+
C',$-
Fh_cWhoYenWhj^hei_i"X_bWj[hWb
9enWhj^hei_ih[ikbj_d]\hecZoifbWi_W"X_bWj[hWb
:oifbWij_YYenWhj^hei_i"kd_bWj[hWb
FeijjhWkcWj_YYenWhj^hei_i"X_bWj[hWb
FeijjhWkcWj_YYenWhj^hei_i"kd_bWj[hWb
I[YedZWhoYenWhj^hei_i"dejej^[hm_i[if[Y_Ó[Z
INTERNATIONAL CLASSIFICATION OF FUNCTIONING, DISABILITY, AND HEALTH
PRIMARY ICF CODES
Body functions
X(.&',
X-'&&
FW_d_d`e_dji
CeX_b_joe\Wi_d]b[`e_dj
Body structure
i-+&&'
i-*&(
i-*&)
>_f`e_dj
CkiYb[ie\f[bl_Yh[]_ed
B_]Wc[djiWdZ\WiY_We\f[bl_Yh[]_ed
Activities and participation
Z*'+*
Z*+&&
Z*+&'
CW_djW_d_d]WijWdZ_d]fei_j_ed
MWba_d]i^ehjZ_ijWdY[i
MWba_d]bed]Z_ijWdY[i
SECONDARY ICF CODES
Body functions
X-(&'
CeX_b_joe\j^[f[bl_i
X-)&&
Fem[he\_iebWj[ZckiYb[iWdZckiYb[]hekfi
X-*&'
;dZkhWdY[e\ckiYb[]hekfi
X--&
=W_jfWjj[hd\kdYj_edi
X-.&&
I[diWj_ede\ckiYb[ij_÷d[ii
Body structure
i-*&'
@e_djie\f[bl_Yh[]_ed
Activities and participation
Z*'&'
IgkWjj_d]
Z*'&)
I_jj_d]
Z*'&,
I^_\j_d]j^[XeZoÊiY[dj[he\]hWl_jo
Z*)+&
Fki^_d]m_j^bem[h[njh[c_j_[i
Z*)+'
A_Ya_d]
Z*+&(
MWba_d]edZ_÷[h[djikh\WY[i
Z*+&)
MWba_d]WhekdZeXijWYb[i
Z*++'
9b_cX_d]
Z*++(
Hkdd_d]
Z*++)
@kcf_d]
Z*,&&
Cel_d]WhekdZm_j^_dj^[^ec[
Z*,&'
Cel_d]WhekdZm_j^_dXk_bZ_d]iej^[hj^Wd^ec[
Z*,&(
Cel_d]WhekdZekji_Z[j^[^ec[ehej^[hXk_bZ_d]i
journal of orthopaedic & sports physical therapy | volume 39 | number 4 | april 2009 | a5
Hip Pain and Mobility Deficits – Hip Osteoarthritis: Clinical Practice Guidelines
CLINICAL GUIDELINES
Impairment/Function-based
Diagnosis
FH;L7B;D9;
Hip pain associated with OA is the most common
cause of hip pain in older adults.7,40 Prevalence studies
have shown the rates for adult hip OA range from 0.4% to
27%.8,40,74,89,126,211
Clinicians should assess for impairments in the
mobility of the hip joint and the strength of the
surrounding muscles, especially the hip abductor
muscles, when a patient presents with hip pain.
C
H?IA<79JEHI
F7J>E7D7JEC?97B<;7JKH;I
The proximal femur articulates with the acetabulum to form the hip joint. The femoral head is two thirds of
a sphere covered with hyaline cartilage and enclosed in a fibrous capsule.50,168 The femoral head is connected to the femoral shaft via the femoral neck. In the frontal plane the femoral
g^\d eb^l Zm Zg Zg`e^ mh ma^ laZ_m h_ ma^ _^fnk' Mabl ÊZg`e^
h_bg\ebgZmbhgËblghkfZeer*+)™mh*+.™bgma^Z]nemihineZtion.50 In the transverse plane the proximal femur is oriented
anterior to the distal femoral condyles as a result of a medial
torsion of the femur with a normal range between 14° to 18° of
anteversion.28Ma^abichbgmblZÊ[ZeeZg]lh\d^mËlrghobZechbgm
with articular cartilage and a fully developed joint capsule allowing movement in all 3 body planes.168 The joint capsule
attaches around the acetabular rim proximally and distally at
the inter-trochanteric line. Three strong ligaments reinforce
the joint capsule, the iliofemoral and pubofemoral ligaments
anteriorly and ischiofemoral ligament posteriorly.50
In OA of the hip the entire joint structure and function is affected, with joint capsular changes (shortening and lengthening) creating limitation in hip
joint range of motion (ROM) along with subsequent articular
cartilage degeneration.120,148 Later in the disease process osteophytes or spurs may develop from excessive tensile force
on the hip joint capsule or from abnormal pressure on the
articular cartilage.6,120 Other changes also develop including
sclerosis of the subchondral bone from increased focal pressure, and sometimes the formation of cysts.98 Muscle weakness often develops around a joint with OA,171 specifically
the abductor muscles of the hip.156 Most significantly, the hip
abductor muscles progressively weaken in the later stages of
hip OA, which may create a Trendelenberg gait pattern over
time.11 Clinicians must not overlook the function of the hip
muscles at different hip positions, for example the gluteus
medius is an abductor when at 0° of flexion (standing) but
an external rotator at 90° of flexion (sitting).129
II
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Age The most common predisposing factor
for hip OA is age. The condition primarily affects
middle-aged and elderly people, most often those
over 60 years.2,154,177 Tepper and Hochberg177 found that age
was significantly associated with hip OA (adjusted odds ratio of 1.30 (95% CI: 0.60-2.81) for ages 60 to 64 years, 2.38
(95% CI: 0.83-3.44) for ages 65 to 69 years, and 2.38 (95%
CI: 1.15-4.92) for ages 70 to 74 years.
I
Developmental Disorders Many studies have demonstrated a link between developmental disorders,
such as Legg-Calve-Perthes disease, congenital hip
dislocation, or slipped capital femoral epiphysis, and premature OA of the hip.1,61,62,91,92,139,214 The majority of the evidence
also shows that dysplasia of the femur and the acetabulum is
associated with hip OA.49,52,92,94,162,178,185-188 Dysplasia is defined
as any change in orientation of the acetabulum or the proximal femur, which creates a change in how the femur and the
acetabulum articulate with each other.93 Types of dysplasia
include coxa vara, coxa valga, femoral anteversion, femoral
retroversion, acetabular anteversion, acetabular retroversion,
coxa plana, and coxa profundus.20,92,93 However, a few authors
show limited association between hip dysplasia and OA of
the hip.20,90,108,207
I
Race Studies of non-Caucasian populations including Asian, African, and East Indian populations
indicate a very low prevalence of primary hip OA
when compared to that of Caucasians of European ancestry.81,211 Thus, race likely plays some sort of role in the development of hip OA. This role, however, is unknown at this
time.
III
Gender Few studies have been performed that
examine the association between gender and hip
OA.41,97,145,154 Tepper and Hochberg177 found that
males have a slightly greater prevalence of hip OA compared
I
april 2009 | number 4 | volume 39 | journal of orthopaedic & sports physical therapy
Hip Pain and Mobility Deficits – Hip Osteoarthritis: Clinical Practice Guidelines
to females (3.2% compared to 3.0%). Although little if any
difference in incidence exists between genders, men and
women appear to have different patterns of hip OA. Women
have a more superiomedial femoral migration while men have
a more superiolateral migration.44,111 There is strong evidence
that superiolateral migration is an important prognostic factor in the progression of hip OA.15
Genetics Siblings show a high association of hip OA,
suggesting a possible genetic role.109 While the nature of the genetic influence is still speculative, it
has been postulated that hip OA involves either a structural
defect (ie, collagen) or alterations in cartilage or bone metabolism.106,121,122 Genetics is often linked to hip OA because of the
low prevalence of hip OA in Asian and African populations in
their native countries and the familial association of hip OA
in Caucasians.81 Some studies have shown that genetic factors
may play a role in the development of hip OA,100,106,124 or in
reducing the risk of hip OA in women.113 Although there has
been much interest and speculation in looking for a genetic
link to hip OA, currently there is insufficient evidence to explain how genetics is related to the development of hip OA.
II
Occupation Numerous researchers in Europe and
the United States have found a higher prevalence of
hip OA in male workers whose occupation involved
lifting very heavy loads over a prolonged period.125,201,203,204
Farming, in particular, has been identified as a high-risk occupation for the development of hip OA. However, a specific aspect of farming which leads to the development of hip OA has
not been identified. Suspected risk factors have been suggested, including regular heavy lifting, tractor driving (vibration),
and walking on uneven ground.36,84,125,179-182,208 Vibration was
specifically studied and reported to not be associated with the
development of hip OA.96 In summary, there is weak evidence
linking the development of hip OA to some occupations.114
III
Sports Exposure Epidemiological studies have
demonstrated participation in certain competitive
sports to increase the risk for OA.25,115 Running has
low risk for OA,107 but high-intensity, direct-impact activities,
such as American football and hockey, appear to increase the
risk of hip OA.24,25
II
Previous Injury Proximal hip fracture results in
changes to the articular surfaces of the hip joint
that creates abnormal joint load bearing and has
been shown to be related to the development of hip OA. 60
A history of a previous hip injury is also associated with hip
OA.35,177 Cooper et al35 reported an odds ratio for hip OA when
having a previous hip injury of 4.3 (95% CI: 2.2-8.4). In addition, patients with OA of 1 hip are at increased risk of developing OA in the opposite hip.206
I
Body Mass Index A few studies have shown body
mass index (BMI) to be related to hip OA.35,116,200
Other studies, however, have shown little to no association between hip OA and BMI.59,73,92,95,117 The most current evidence shows BMI is not related to hip OA.161 What
seems apparent is that obesity is probably associated with the
progression of hip OA rather than onset,127 and the therapeutic value of weight loss is important.52,202
III
Leg Length Disparity Several studies have suggested that a difference in leg lengths may be an
important etiological factor in hip OA.63-65,68,140 A
few studies have demonstrated the biomechanical and clinical problem of leg length disparity and its relationship to hip
OA.63-65 Nahoda141 reported on the importance of correcting
leg length disparity in the prevention of hip OA. Golightly68
noted an association between radiographic hip OA and leg
length disparity. A few papers on leg length disparity suggest
a relationship with hip OA; however, more research is needed
before leg length disparity can be considered an important
risk factor. It should be pointed out that leg length disparity could also occur as a result of OA of the hip, particularly
when there is superior migration of the femoral head in the
acetabulum.
II
A
Clinicians should consider age, hip developmental
disorders, and previous hip joint injury as risk factors for hip osteoarthritis.
D7JKH7B>?IJEHO
The natural history of individual hip OA is imperfectly understood. Many different factors contribute to this. The
clinical manifestations that develop in patients with hip
OA include changes in the shape, density, length, and function of the bones, cartilage, and fibrous tissue surrounding
the hip joint itself as well as the surrounding muscles. The
changes that occur around the arthritic hip include a decrease in the joint space between the femur and acetabulum
(more common superior and lateral than medial), shortening
of the fibrous joint capsule, flattening of the femoral head,
the appearance of osteophytic growth around the margins
of the femoral head and acetabulum (in some individuals
boney overgrowth does not occur), a superior-lateral or medial migration of the femoral head, and the development of
subchondral sclerosis or cysts in the femoral head and acetabulum.4,6,42,72,98,167 Changes that occur outside of the hip
joint include a decreased amount of hip joint ROM (usually mostly affecting internal rotation and then flexion) and
muscle weakness (particularly the abductor muscles), which
eventually may result in difficulty with ambulation.7,116,118,148
The progression of these changes are usually slow but may
be quite rapid in some cases.21 Currently, there is no reliable,
journal of orthopaedic & sports physical therapy | volume 39 | number 4 | april 2009 | a7
Hip Pain and Mobility Deficits – Hip Osteoarthritis: Clinical Practice Guidelines
generally accepted classification of the stages or severity of hip
OA and the rate of progression varies from patient to patient,
even when the demographics of the patients are similar.7
:?7=DEI?I%9B7II?<?97J?ED
The diagnosis of hip OA can be made with a
reasonable level of certainty on the basis of the
history and physical examination.2,16 Joint space
narrowing along with other radiographic features including
osteophytes and subchondral sclerosis on plain film radiographs is considered the definitive diagnosis.6,19,37,42,45 The
following clinical criteria are typically present in individuals
who have radiographic findings consistent with hip OA.2,16,18
Reports of moderate pain in the lateral or anterior hip with
weight bearing. This pain may progress to the anterior
thigh or knee region
Adults, greater than 50 years of age
Limited passive hip joint ROM in at least 2 of its 6 directions (flexion, extension, abduction, adduction, internal
rotation, and external rotation)
Morning stiffness, which improves in less than 1 hour
I
Clinical criteria for the classification of patients
with hip pain associated with OA were developed
through a multicenter study by the American College of Rheumatology.2 One hundred fourteen patients, with
a mean age of 64 years and 87 controls with a mean age of
57 years, were included in the study. Patients were classified
as having hip OA if they (1) reported experiencing hip pain,
and (2) presented with either one of the following clusters of
clinical findings:
Hip internal rotation less than 15°, along with
Hip flexion less than or equal to 115°
Age greater than 50 years
Or,
Hip internal rotation greater than or equal to 15°, along
with
Pain with hip internal rotation
Duration of morning stiffness of the hip less than or equal
to 60 minutes
Age greater than 50 years
I
When patients were classified using these clinical criteria
compared to a radiographic reference standard of joint space
narrowing and osteophytes, the following diagnostic accuracy
statistics were reported: sensitivity, 86%; specificity, 75%;
positive likelihood ratio (LR+), 3.44; negative likelihood ratio (LR–), 0.19.2
Hip OA is classified as primary in the absence of any obvious underlying joint abnormality, or secondary if degeneration occurs as a result of a pre-existing abnormal joint
a8
|
problem.81 Some suggest that all hip OA is secondary to
some pre-existing problem (eg, dysplasia). 119 The clinical
and/or radiological criteria presented above are usually sufficient to diagnose a patient with OA of the hip and the associated ICF impairment-based category of hip pain (b2816
Pain in joints) and mobility deficits (b7100 Mobility of a
single joint).
A recent preliminary study of patients with hip
symptoms identified 5 possible clinical predictors for
diagnosis: pain aggravated with squatting, lateral or
anterior hip pain with the scour test, active hip flexion causing
lateral hip pain, pain with active hip extension, and passive
range of hip internal rotation less than 25°.175 The LR+ of having hip OA when all 5 predictors were present was 7.3, while
the LR– was .87.175 One limitation of this study was the small
sample of patients (21 of 79) who had hip OA on radiographs.
This could have resulted in spurious findings. Future studies
are needed to validate these results prior to clinical use.
II
Birrell et al18,19,20 also used a standard clinical and
radiographic examination to assess the predictability of hip OA from hip ROM. In their study,
195 patients with recent onset of hip pain with radiographic
evidence of OA had restricted movement at the hip compared with those without radiographic evidence of hip OA.
Restriction in internal rotation was the most predictive and
flexion the least predictive of radiographic OA. When comparing sides, a ROM difference of more than 15° between the
painful and nonpainful side was considered a limitation of
joint mobility. Restriction in hip ROM was predictive of the
presence of OA. The diagnostic accuracy for restriction in a
single plane of hip motion for patients with severe hip OA
was as follows: sensitivity, 100%; specificity, 54%; LR+, 2.17;
LR–, 0.01. The diagnostic accuracy for restriction in a single
plane of hip motion for patients with moderate hip OA was
the following: sensitivity, 86%; specificity, 42%; LR+, 1.48;
LR–, 0.33. The diagnostic accuracy for restriction in all 3
planes of hip motion for patients with moderate hip OA was:
sensitivity, 33%; specificity, 98%; LR+, 16.5; LR–, 0.67.2,16,18
I
Moderate lateral or anterior hip pain during weight
bearing, in adults over the age of 50 years, with
morning stiffness less than 1 hour, with limited
hip internal rotation and hip flexion by more than 15°, when
comparing the painful to the nonpainful side, are useful clinical findings to classify a patient with hip pain into the International Statistical Classification of Diseases and Related
Health Problems (ICD) category of unilateral coxarthrosis
and the associated International Classification of Functioning, Disability, and Health (ICF) impairment-based category
of hip pain (b2816 Pain in joints) and mobility deficits (b7100
Mobility of a single joint).
A
april 2009 | number 4 | volume 39 | journal of orthopaedic & sports physical therapy
Hip Pain and Mobility Deficits – Hip Osteoarthritis: Clinical Practice Guidelines
:?<<;H;DJ?7B:?7=DEI?I
patient’s impairments of body function.
The following differential diagnoses should
be considered in an individual with signs or symptoms suggestive of hip OA:
Bursitis or tendinitis
Chondral damage or loose bodies
Femoral neck or pubic ramus stress fracture
Labral tear
Muscle strain
Neoplasm
Osteonecrosis of the femoral head
Paget’s disease
Piriformis syndrome
Psoriatic arthritis
Rheumatoid arthritis
Sacroiliac joint dysfunction
Septic hip arthritis
Referred pain as a result of an L2-3 radiculopathy
V
The following physical examination measures may be helpful
in the differential diagnostic process when differentiating hip
pain from other sources of pain:
The Scour test for labral tears175
FABER (Patrick’s) test for labral tears137
Fitzgerald’s test for labral tears54
Flexion-adduction internal rotation tests for labral tears112
Sacroiliac joint provocation tests for sacroiliac joint pain110
Femoral nerve stretch test for L2-3 radiculopathy184
Clinicians should consider diagnostic classifications
other than osteoarthritis of the hip when the patient’s history, reported activity limitations, or impairments of body function and structure are not consistent
with those presented in the diagnosis/classification section
of this guideline, or, when the patient’s symptoms are not
diminishing with interventions aimed at normalization of the
F
?C7=?D=IJK:?;I
Imaging studies, specifically plain film radiographs,
are confirmatory for moderate to severe hip joint OA; however, radiographs are less useful in demonstrating early osteoarthritic joint changes.53,98 Joint space narrowing detected
on radiographs may be a relatively late stage phenomenon of
OA.23 Joint space narrowing has been advocated as the best
indicator and best predictor of arthritic change in patients
with hip OA, with joint space narrowing occurring more superiolateral than superiomedial.37,42,45 The normal hip joint
space is 3 to 5 mm. A reduction of greater than or equal to
0.5 mm represents a clinically relevant and significant reduction in joint space width.4 Hip joint OA is considered moderate when joint space is less than 2.5 mm and severe when
joint space is less than 1.5 mm.16 The development of newer
imaging techniques, such as gadolinium enhanced magnetic
resonance imaging, has been suggested as a method to detect
deficiencies in cartilage structure that may represent early
arthritic changes in young patients.103
In addition to joint space narrowing, other criteria, including
osteophytic spurs and subchondral sclerosis, also are used
to identify patients with hip OA.6,19 The Kellgren/Lawrence
scale has been used to classify degenerative findings associated with hip OA. The scale consists of 4 grades: grade 1, no
radiographic evidence of OA; grade 2, doubtful narrowing
of joint space and possible (minute) osteophytes; grade 3,
moderate definite osteophytes, definite moderate narrowing
of joint space; grade 4, large osteophytes, severe joint space
narrowing, subchondral sclerosis, and definite deformity of
bone contour.99 A potential caveat when using the Kellgren/
Lawrence scale is spurs or osteophytes are emphasized138,144
and not all patients with hip OA have osteophytes.
journal of orthopaedic & sports physical therapy | volume 39 | number 4 | april 2009 | a9
Hip Pain and Mobility Deficits – Hip Osteoarthritis: Clinical Practice Guidelines
CLINICAL GUIDELINES
Examination
EKJ9EC;C;7IKH;I
The most commonly used outcome measure for
hip OA is the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC).14 The WOMAC
has been validated and its reliability has been shown in many
different studies and in many different countries.12,169,183,198,212
The ordinal-scale version of the index consists of 24 questions
(5 about pain, 2 about stiffness, and 17 about physical function), which are assigned a score of between 0 (extreme) and 4
(none). Individual question scores are then summed to form a
raw score ranging from 0 (best) to 96 (worst). Finally, raw scores
are normalized by multiplying the raw score by 100/96, creating a score of between 0% (best) to 100% (worst). Test-retest
reliability of the WOMAC as measured by intraclass correlation
coefficients (ICCs) has been shown to be good, ranging between
0.74 and 0.89.166 The minimal clinically important difference
(MCID) for the WOMAC score, as a change from the baseline
score, has been reported in the range of 12% to 22%.9,10,46 Angst
el al9 found the MCID for improvement in a sample of 192 patients with lower extremity OA to be in the range of 17% to
22% change from the baseline score. A prospective cohort study
consisting of 122 patients diagnosed with hip or knee OA from
an inpatient rehabilitation clinic found a 12% change from the
baseline score as the MCID for the WOMAC.10
I
I
The Lower Extremity Functional Scale (LEFS) is
another reliable and valid outcome measure that
is often administered to patients with hip OA.17
Ma^E>?Lnl^lZghk]bgZel\Ze^_khf)!Ê^qmk^f^]b__b\nemr
hk ngZ[e^ mh i^k_hkf ma^ Z\mbobmrË" mh - !Êgh ]b__b\nemrË"
for the patient to rate the ability to perform 20 different
activities, such as getting into or out of the bath tub, sitting for 1 hour, squatting, and rolling over in bed. The total
score ranges from 0 to 80, with 80 representing maximum
function based on the scale. The reliability and validity of
the LEFS have been shown to be good when determined
using a sample of 107 patients with lower extremity musculoskeletal problems. In that same study, the minimum
detectable change (MDC90) and MCID90 were both 9 scale
points.17
Another often used functional outcome measure
is the Harris Hip Score.77 The Harris Hip Score is
derived from scoring 10 different variables, including pain, ROM, gait/limp, gait distance, function, activities
of daily living, and deformity. Scores range from 0 (worst) to
100 (best).77
I
Clinicians should use validated functional outcome measures, such as the Western Ontario
and McMaster Universities Osteoarthritis Index,
the Lower Extremity Functional Scale, and the Harris Hip
Score before and after interventions intended to alleviate the
impairments of body function and structure, activity limitations, and participation restrictions associated with hip
osteoarthritis.
A
79J?L?JOB?C?J7J?ED7D:F7HJ?9?F7J?EDH;IJH?9J?EDC;7IKH;I
6-Minute Walk Test
a10
ICF category
C[Wikh[c[dje\WYj_l_job_c_jWj_ed0mWba_d]bed]Z_ijWdY[i
Description
7f^oi_YWbf[h\ehcWdY[c[Wikh[m^_Y^Wii[ii[i^em\WhWf[hiedYWdmWba_d,c_dkj[i*.
Measurement method
:kh_d]j^[f[h\ehcWdY[e\j^[,#c_dkj[mWbaj[ij,CMJ"fWj_[djiWh[_dijhkYj[ZjeYel[hWickY^Z_ijWdY[Wifeii_Xb[Zkh_d]
j^[,#c_dkj[j_c[\hWc["m_j^j^[effehjkd_jojeijefWdZh[ij_\h[gk_h[Z$J^[j[ij_iYedZkYj[ZedWdkdeXijhkYj[Zb[l[bikh\WY[$
J^[Yekhi[_icWha[Ze÷_dc[j[hi"WdZj^[Z_ijWdY[jhWl[b[ZXo[WY^ikX`[Yj_ic[Wikh[Zjej^[d[Wh[ijc[j[h$IjWdZWhZ_p[Z
l[hXWb[dYekhW][c[dj"ÇOekWh[Ze_d]m[bb"a[[fkfj^[]eeZmehaÈ_ifhel_Z[ZWj,&#i[YedZ_dj[hlWbi$FWj_[djiWh[f[hc_jj[Zje
ki[j^[_hh[]kbWhmWba_d]W_Zi_\d[[Z[Z$'&(
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,CMJm_j^?99("'e\&$/*/+9?0&$..#&$/.$J^[C:9/&\ehj^[,CMJZ[j[hc_d[Z\hecWiWcfb[e\'+&ikX`[Yjim_j^^_fWdZad[[
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|
april 2009 | number 4 | volume 39 | journal of orthopaedic & sports physical therapy
Hip Pain and Mobility Deficits – Hip Osteoarthritis: Clinical Practice Guidelines
Self-Paced Walk Test
ICF category
C[Wikh[c[dje\WYj_l_job_c_jWj_ed0mWba_d]i^ehjZ_ijWdY[i
Description
7f^oi_YWbf[h\ehcWdY[c[Wikh[m^_Y^Wii[ii[i^em\WijWf[hiedYWdmWba\eh*cWdZ\eh*&c
Measurement method
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el[h[n[hj_d]oekhi[b\ÈWdZj_c[Zm_j^WijefmWjY^m^_b[j^[omWba(b[d]j^ijkhd[nYbkZ[Ze\W(&#c_dZeehYekhi['&(
Nature of variable
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J^[j[ij#h[j[ijh[b_WX_b_joe\j^[IFMJ\eh*&c^WiX[[d[nWc_d[ZXoA[dd[Zo[jWb$'&(J^[o\ekdZWd?99e\&$/'/+9?0&$.'#&$/-$A[dd[Zo
[jWb'&(Wbiei^em[Zj^[IFMJmWih[ifedi_l[_dZ[j[Yj_d]Z[j[h_ehWj_edWdZ_cfhel[c[dj_dj^[[Whbofeijef[hWj_l[f[h_eZ\ebbem_d]
Whj^hefbWijo$J^[C:9/&\ehj^[*&#cIFMJZ[j[hc_d[Z\hecWiWcfb[e\'+&ikX`[Yjim_j^^_fWdZad[[E7e\m^_Y^,/kdZ[hm[djJ>7
mWi*$&*i[YedZi$'&(?dWYe^ehje\*/(ebZ[hWZkbjij^[h[Yecc[dZ[ZYh_j[h_ed\ehikXijWdj_Wbc[Wd_d]\kbY^Wd][\eh]W_jif[[ZWj'&\j"*
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Stair Measure
ICF category
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Description
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Measurement method
:kh_d]j^[f[h\ehcWdY[e\j^[ijW_hc[Wikh[ICfWj_[djiWh[_dijhkYj[ZjeWiY[dZWdZZ[iY[dZ/ij[fiij[f^[_]^j"(&Yc_d
j^[_hkikWbcWdd[h"WdZWjWiW\[WdZYec\ehjWXb[fWY['&(
Nature of variable
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Timed Up-and -Go Test
ICF category
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Description
7f^oi_YWbf[h\ehcWdY[c[Wikh[m^_Y^Wii[ii[i^emm[bbWf[hiedYWd][jkf\hecWY^W_hm_j^Whch[iji"mWbaWi^ehjZ_ijWdY[
)c"jkhdWhekdZ"h[jkhd"WdZj^[di_jZemdW]W_d'(.
Measurement method
:kh_d]j^[f[h\ehcWdY[e\j^[j_c[Zkf#WdZ#]ej[ijJK="j^[fWj_[dji_ji_dWY^W_hm_j^Whch[ijiWdZ_iWia[ZjeijWdZkf\hec
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f[h\ehcWdY[e\j^_ij[ij_ij_c[Z$
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journal of orthopaedic & sports physical therapy | volume 39 | number 4 | april 2009 | a11
Hip Pain and Mobility Deficits – Hip Osteoarthritis: Clinical Practice Guidelines
F>OI?97B?CF7?HC;DJC;7IKH;I
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ICF category
C[Wikh[c[dje\_cfW_hc[dje\XeZo\kdYj_ed0ceX_b_joe\Wi_d]b[`e_dj
Description
J^[Wcekdje\fWii_l[^_fhejWj_edWdZfWii_l[^_fÔ[n_edc[Wikh[Zfhed[WdZikf_d["h[if[Yj_l[bo$7bj^ek]^Wii[ii_d]j^[hWd][
_dWbb,Z_h[Yj_edi)fbWd[ie\^_fcej_ed_i_cfehjWdj_dfWj_[djim_j^^_fE7"\ehXh[l_jo"m[_dYbkZ[Zj^[)ceijYeccedbob_c_j[Z
^_fcej_edi$J^[fWj_[dj_iWbieWia[ZjehWj[j^[Wcekdje\fW_d[nf[h_[dY[ZZkh_d]j^[cel[c[djedW&#je#'&dkc[h_YWbfW_d
hWj_d]iYWb[DFHI$
Measurement method
>_f?dj[hdWbWdZ;nj[hdWbHejWj_ed0J^[fWj_[dj_ifei_j_ed[Zfhed[m_j^\[[jel[hj^[[Z][e\j^[jh[Wjc[djjWXb[$J^[^_f
c[Wikh[Z_ifbWY[Z_d&–e\WXZkYj_ed"WdZj^[YedjhWbWj[hWb^_f_ifbWY[Z_dWXekj)&–e\WXZkYj_ed$J^[h[\[h[dY[ad[[_i
\b[n[Zje/&–"WdZj^[bem[h[njh[c_jo_ifWii_l[bocel[ZjefheZkY[^_fhejWj_ed$J^[cel[c[djWhce\j^[]ed_ec[j[h_i
Wb_]d[Zl[hj_YWbboWbed]j^[i^W\je\j^[j_X_Wm^_b[j^[ijWj_edWhoWhc_iWb_]d[ZWbed]Wd_cW]_dWhol[hj_YWbb_d[$CWdkWb
ijWX_b_pWj_ed_iWffb_[Zjej^[f[bl_ijefh[l[djf[bl_Ycel[c[djWdZWbieWjj^[j_X_e\[cehWb`e_djjefh[l[djcej_edhejWj_ed
ehWXZkYj_ed%WZZkYj_ed"m^_Y^YekbZX[Yedijhk[ZWi^_fhejWj_ed$-.J^[j_X_W_ij^[dcel[Z_dj^[\hedjWbfbWd[jefheZkY[
^_f_dj[hdWbWdZ[nj[hdWbhejWj_ed$J^[cej_ed_iijeff[ZWdZc[Wikh[c[djijWa[dm^[dj^[[njh[c_joWY^_[l[i_ji[dZhWd][
e\fWii_l[^_fhejWj_edehm^[df[bl_Ycel[c[dj_id[Y[iiWho\ehWZZ_j_edWbcel[c[dje\j^[bem[h[njh[c_jo$7d_dYb_dec[j[h
cWoWbieX[ki[Zjec[Wikh[^_fhejWj_ed$J^[_dYb_dec[j[h_i\_hijÇYWb_XhWj[ZÈXofbWY_d]_jWbed]j^[Z_ijWbi^W\je\j^[
l[hj_YWbboWb_]d[Zj_X_W"`kijfhen_cWbjej^[c[Z_WbcWbb[ebkiWdZj^[di[jj_d]j^[_dYb_dec[j[hZ_Wbjep[he$J^[d"j^[[njh[c_jo
_ifWii_l[bocel[ZjefheZkY[^_fhejWj_edWdZ_dYb_dec[j[hc[Wikh[_ijWa[dm^[dj^[^_fWY^_[l[i_ji[dZhWd][e\fWii_l[
_dj[hdWbWdZ[nj[hdWbhejWj_ed$*>_f<b[n_ed0M_j^j^[fWj_[dj_dj^[ikf_d[fei_j_ed"j^[^_f_ifWii_l[boÔ[n[Zm_j^j^[cel[c[djWhce\j^[]ed_ec[j[hWbed]j^[
bed]Wn_ie\j^[\[ckhWdZj^[ijWj_edWhoWhce\j^[]ed_ec[j[hWbed]j^[bed]Wn_ie\j^[jhkda"m^_b[ijWX_b_p_d]j^[bkcXWhif_d[
jeWle_ZWdofeij[h_ehf[bl_Yj_bj$.)
Nature of variable
9edj_dkekiHECWdZehZ_dWbfW_d
Units of measurement
:[]h[[iWdZ&#je#'&DFHI
Measurement properties
B_c_j[ZHEC_iWiieY_Wj[Zm_j^^_]^b[l[bie\Z_iWX_b_jo_dfWj_[djim_j^^_fE7$'-(J^[h[b_WX_b_jo\eh^_fhejWj_edWdZ^_fÔ[n_edHEC
c[Wikh[c[dji^WiX[[di^emdjeX[[nY[bb[dj"?99e\&$/+je&$/-*-\ehhejWj_edWdZ?99e\&$/*/+9?0&$./#&$/-)&\ehÔ[n_ed$HEC
c[Wikh[c[dji_d((_dZ_l_ZkWbim_j^^_fE7Z[cedijhWj[Z[nY[bb[dj_djhWhWj[hj[ij#h[j[ijh[b_WX_b_jo?993$/-\eh^_fÔ[n_ed$'+(9he\j
[jWb).i^em[Z]eeZW]h[[c[djWced],j[ij[him^[dWii[ii_d]\eh^_fhejWj_edWdZ^_fÔ[n_ed_dfWj_[djim_j^^_fE7$Ij[kbj`[di
[jWb'-(Wbiei^em[Z]eeZh[b_WX_b_jom^[dWii[ii_d]j^[^_f`e_dj_dfWj_[djim_j^E7$J^[C:9/+\eh^_fÔ[n_ed"Z[j[hc_d[Zki_d]((
fWj_[djim_j^ad[[E7WdZ'-ikX`[Yjim_j^ekjbem[h[njh[c_joiocfjeciehademdfWj^ebe]o"_i+–"c[Wd_d]WdoY^Wd][ceh[j^Wd+–
_iYedi_Z[h[ZjeX[Y^Wd][X[oedZc[Wikh[c[dj[hheh$)&J^[C:9/+\ehfW_dm_j^^_fÔ[n_ed_i'$(edj^[&#'&DFHI$)&J^[Yb_d_YWbbo
_cfehjWdjZ_÷[h[dY[\ehj^[DFHI"Z[h_l[Z\hecfWj_[djim_j^bemXWYafW_d"^WiX[[di^emdjeX[Wh[ZkYj_ede\(fe_dji$(-"+'
Hip Abductor Muscles Strength Test
a12
ICF category
C[Wikh[c[dje\_cfW_hc[dje\XeZo\kdYj_ed0fem[he\_iebWj[ZckiYb[iWdZckiYb[]hekfi
Description
7j[ijjeZ[j[hc_d[j^[ijh[d]j^e\j^[^_fWXZkYjehckiYb[i
Measurement method
J^[^_fWXZkYjehckiYb[iijh[d]j^j[ij_if[h\ehc[Zm_j^j^[ikX`[Yj_dj^[ikf_d[fei_j_edWdZj^[^_f_dWd[kjhWbfei_j_ede\
Ô[n_ed%[nj[di_ed"WXZkYj_ed%WZZkYj_ed"WdZ[nj[hdWb%_dj[hdWbhejWj_ed$7ÇcWa[Èj[ijki_d]W^WdZ^[bZZodWcec[j[h_iki[ZXo
Wia_d]j^[ikX`[Yjjefki^j^[ceijj^[oYWdW]W_dijj^[^WdZ^[bZZodWcec[j[hWffb_[Zedj^[bWj[hWbWif[Yje\j^[Z_ijWbj^_]^"
`kijWXel[j^[ad[[$J^[^_fWXZkYjehckiYb[icWoWbieX[j[ij[Z_dj^[i_Z[bo_d]fei_j_edm_j^j^[^_f_dWXZkYj_edWdZib_]^j
[nj[di_ed$7ÇXh[WaÈj[ij_if[h\ehc[ZXoj^[j[ij[hWffbo_d]\ehY[l_Wj^[^WdZ^[bZZodWcec[j[hWffb_[Zedj^[bWj[hWbWif[Yje\
j^[Z_ijWbj^_]^`kijWXel[j^[ad[[$J^[Z_h[Yj_ede\\ehY[Wffb_YWj_ed_ijemWhZWZZkYj_edWdZib_]^jÔ[n_edm^_b[j^[f[bl_i_i
ijWX_b_p[Zm_j^j^[ej^[h^WdZ$'&'
Nature of variable
9edj_dkeki
Units of measurement
<ehY[_dD[mjedi
Measurement properties
?dj[hhWj[hWdZ_djhWhWj[hh[b_WX_b_joe\\ehY[c[Wikh[c[djieXjW_d[Z\hecYebb[][W][mec[dm[h[[nY[bb[djki_d]W^WdZ^[bZZodWcec[j[h
\ehj^[WXZkYjehckiYb[i_djhWhWj[h?99"$..#$/,1_dj[hhWj[h?99"$/&#$/+$)'<ehY[c[Wikh[c[djie\^_fWXZkYjehi_d((_dZ_l_ZkWbim_j^^_f
E7Z[cedijhWj[Z]eeZ_djhWhWj[hj[ij#h[j[ijh[b_WX_b_jo?99e\$.*$'+(J^[C:9/+"Z[j[hc_d[Z\hecWiWcfb[e\/&ikX`[YjiW][hWd]["((#
-&o[Whim_j^ekjWdofh[l_ekickiYkbeia[b[jWbfheXb[ci"mWi+$*e\XeZom[_]^j\ehcWb[iWdZ+$)e\XeZom[_]^j\eh\[cWb[i$(')
|
april 2009 | number 4 | volume 39 | journal of orthopaedic & sports physical therapy
Hip Pain and Mobility Deficits – Hip Osteoarthritis: Clinical Practice Guidelines
The FABER (Patrick’s) Test
ICF category
C[Wikh[c[dje\_cfW_hc[dje\XeZo\kdYj_ed0fW_d_d`e_dji
Description
7j[ijjeZ[j[hc_d[j^[_hh_jWX_b_joe\j^[^_f`e_dj
Measurement method
J^[<78;Hj[ij_iWZc_d_ij[h[Zm_j^j^[ikX`[Yj_dikf_d["j^[^[[be\j^[bem[h[njh[c_jojeX[j[ij[ZfbWY[Zel[hj^[effei_j[
ad[[$J^[^_f`e_dj_ifWii_l[bo[nj[hdWbbohejWj[ZWdZWXZkYj[ZXoj^[[nWc_d[hWffbo_d]cWdkWbfh[iikh[el[hj^[_fi_bWj[hWb
ad[["m^_b[ijWX_b_p_d]j^[YedjhWbWj[hWb_ddec_dWj[m_j^j^[effei_j[^WdZ$7\j[hX[_d]p[he[ZW]W_dijWmWbb"j^[_dYb_dec[j[h
_i fbWY[Z ed j^[ c[Z_Wb Wif[Yj e\ j^[ j_X_W e\ j^[ j[ij[Z bem[h [njh[c_jo" `kij Z_ijWb je j^[ c[Z_Wb j_X_Wb YedZob[$ HEC
c[Wikh[c[dj_ijWa[dWjj^[fe_dje\cWn_cWbfWii_l[h[i_ijWdY[ehWjj^[fe_djm^[h[j^[fWj_[djijefij^[j[iji[YedZWho
jefW_d$ )&J^[fWj_[dj_iWbieWia[ZjehWj[j^[beYWj_ede\j^[fW_dWim[bbWij^[Wcekdje\fW_d[nf[h_[dY[ZZkh_d]j^[
cel[c[djedW&#je#'&DFHI$
Nature of variable
9edj_dkekiHECWdZehZ_dWbfW_d
Units of measurement
&#je#'&DFHI
Measurement properties
?djhWhWj[hh[b_WX_b_joe\HEC?993&$/,1/+9?0&$/(#&$/.WdZfW_d?993&$.-1/+9?0&$-.#&$/*c[Wikh[c[djimWi[nY[bb[dj\eh
j^[<78;Hj[ij$)&9_XkbaW(.\ekdZj^[<78;Hj[ijmWih[ifedi_l[_dZ[j[Yj_d]_cfhel[c[dj_dHECWdZ_dh[fehje\fW_d_dfWj_[dji
m_j^^_ffW_d$J^[C:9/+"Z[j[hc_d[Z\hecWiWcfb[e\((fWj_[djim_j^ad[[E7WdZ'-ikX`[Yjim_j^ekjbem[h[njh[c_joiocfjeci
ehademdfWj^ebe]o"mWi.–\ehHECWdZ'$,fe_djiedj^[DFHI$)&J^[Yb_d_YWbbo_cfehjWdjZ_÷[h[dY[\ehj^[DFHI"Z[h_l[Z\hec
fWj_[djim_j^bemXWYafW_d"^WiX[[di^emdjeX[Wh[ZkYj_ede\(fe_dji$(-"+'
The Scour Test
ICF category
C[Wikh[c[dje\_cfW_hc[dje\XeZo\kdYj_ed0fW_d_d`e_dji
Description
7j[ijjeZ[j[hc_d[j^[_hh_jWX_b_joe\j^[^_f`e_dj
Measurement method
J^[^_fIYekhj[ij_if[h\ehc[Zm_j^j^[fWj_[djbo_d]_dj^[ikf_d[fei_j_edm^_b[j^[Yb_d_Y_Wd\b[n[iWdZWZZkYjij^[^_fkdj_b
h[i_ijWdY[ je cel[c[dj _i Z[j[Yj[Z$ J^[ Yb_d_Y_Wd j^[d cW_djW_di \b[n_ed _dje h[i_ijWdY[ WdZ ][djbo cel[i j^[ ^_f _dje
WXZkYj_ed"j^[dXh_d]_d]j^[^_fj^hek]^(\kbbWhYie\cej_ed$?\j^[fWj_[djh[fehjidefW_d"j^[dj^[[nWc_d[hh[f[Wjij^[
j[ijm^_b[Wffbo_d]bed]#Wn_iYecfh[ii_edj^hek]^j^[\[ckh$J^_ij[ijckijX[WZc_d_ij[h[Zm_j^iec[YWkj_edieWijedej
_hh_jWj[j^[^_f`e_dj$J^[fWj_[dj_iWia[ZjehWj[j^[fW_d[nf[h_[dY[ZZkh_d]j^[cel[c[djedW&#je#'&DFHI$)&
Nature of variable
EhZ_dWb
Units of measurement
&#je#'&DFHI
Measurement properties
J^[_djhWj[ij[hh[b_WX_b_joe\j^[IYekhj[ij_i]eeZ?993&$.-1/+9?0&$-,#&$/)\ehhWj_d]e\^_ffW_d$)&J^[C9?:\ehj^[DFHI^Wi
X[[di^emdjeX[Wh[ZkYj_ede\(fe_dji$(-"+'J^[C:9/+\ehj^[IYekhj[ijmWiZ[j[hc_d[Z\hecWiWcfb[e\((fWj_[djim_j^ad[[
E7WdZ'-ikX`[Yjim_j^ekjbem[h[njh[c_joiocfjeciehademdfWj^ebe]o$J^[C:9/+\ehfW_dmWiWY^Wd][e\ceh[j^Wd'$,fe_dji
edj^[&#je#'&DFHI$)&
FHE=DEI?I
In most cases, OA of the hip progresses
slowly197 with total hip replacement/arthroplasty
(THR/THA) being the primary clinical endpoint
for individuals with severe hip OA. 69 The prognosis of hip
OA depends primarily on the extent of radiographic evidence of hip OA.167 The severity and progression of hip OA
is commonly assessed with the Kellgren/Lawrence scale of
joint space narrowing on plain film radiographs. 99 A patient’s baseline Kellgren/Lawrence radiographic grade is
an important predictive factor for having THA.44,160,199 Reijman et al159 found that a Kellgren/Lawrence score of II or
higher is a strong predictor of progression in patients with
I
hip OA. Gossec et al70 reported that a Kellgren/Lawrence
grade of III had an odds ratio of 3.3 and a grade of IV had
an odds ratio of 5.3 that patients would have a THA. Gossec et al70 also reported that the most important predictive
factors of having a THA include Kellgren/Lawrence radiographic grades of III or higher, a high global assessment
of pain, and a previous trial of nonsteroidal anti-inflammatory drugs (NSAIDs).4,70,72 Altman et al5 have suggested
that the measurement of individual radiographic features
may be superior to the Kellgren/Lawrence global measurement in detecting arthritic progression. In OA of the hip, a
single anteroposterior radiograph assessing for joint space
narrowing and cyst formation yielded high sensitivity in
journal of orthopaedic & sports physical therapy | volume 39 | number 4 | april 2009 | a13
Hip Pain and Mobility Deficits – Hip Osteoarthritis: Clinical Practice Guidelines
detecting change. The MCID for joint space narrowing progression is greater than 0.5 mm/y.4,43 The rate of joint space
narrowing in patients with slowly developing hip OA is less
than 0.2 mm/y and in patients with rapidly developing hip
OA greater than 0.2 mm/y.66 In summary, joint space narrowing and the Kellgren/Lawrence scale are important
prognostic predictors of OA while joint space narrowing
may be the best indicator of structural OA progression in
patients with hip OA.
Other indicators for performing a THA include
previous use of NSAIDs and pain of at least 47 mm
on a 100-mm pain scale for over 6 months.70 Pain
and function appear to be important criteria when considering THA.215
I
a14
|
THA is the most common surgical procedure for
end-stage hip OA. Despite the success of THA of
the hip and knee over the last 30-plus years, the
criteria for when to perform such surgery are not clear.3
There have been several attempts to develop guidelines to
determine the appropriate time to perform joint replacement
surgery, however few are supported by research. 3 Currently,
there is no consensus on the appropriate time to recommend
surgery as a clinical end point.3 However, the Group for the
Respect of Ethics and Excellence in Science (GREES) suggests that conservative intervention has failed if a patient
does not experience a reduction in symptoms, such as a 20%
to 25% improvement on the pain subscale of the WOMAC,
and has a progressive loss of joint space of between 0.3 and
0.7 mm/year.3
V
april 2009 | number 4 | volume 39 | journal of orthopaedic & sports physical therapy
Hip Pain and Mobility Deficits – Hip Osteoarthritis: Clinical Practice Guidelines
CLINICAL GUIDELINES
Interventions
A variety of interventions have been described for the treatment of hip OA and there is fair evidence from randomized
clinical trials and systematic reviews to support the benefits
of physical therapy intervention in these patients.
7DJ?#?D<B7CC7JEHO7=;DJI
Both over-the-counter and prescribed antiinflammatory agents including NSAIDs, Cox-2 inhibitors, and steroid injections are recommended as
part of a multidisciplinary treatment approach to hip OA.216
Randomized clinical trials evaluating the use of NSAIDs have
shown NSAIDs can be effective for the temporary relief of
symptoms and improvement in function in patients with hip
OA.189 However, it should be noted that this class of drugs
is not without risk for serious adverse events including increased gastrointestinal bleeding.67
I
There is evidence to support the use of corticosteroid injection in patients with hip OA to provide
short-term pain relief.155,163 A recent placebo-controlled trial confirmed corticosteroid injection can be an effective treatment of pain in hip OA, with benefits lasting up
to 3 months.105
I
Some evidence does suggest some NSAIDs may increase the progression of hip OA by decreasing glycosaminogly can synthesis22,86,147,159 however, further
studies are needed.
I
7BJ;HD7J?L;%9ECFB;C;DJ7HOC;:?97J?ED
Glucosamine and other similar supplements
are commonly suggested for individuals with
hip OA. To date, randomized controlled trials
evaluating the use of glucosamines have shown mixed results.130,131,205 Most of the positive results are for short-term
improvement in pain and in function.132 A recent metaanalysis of chondroitin (a specific glucosamine commonly
found in articular cartilage) for OA of the hip indicates the
symptomatic benefit of chondroitin is minimal or nonexistent and the use of chondroitin in clinical practice should
be discouraged.158 Glucosamines (also called glycosaminoglycans) are an important component of normal connective
tissue physiology; however, the short or long-term use of
glucosamines is not recommended at this time in patients
with hip OA.
I
There is some evidence to support the short-term
use of injectable viscosupplementation with hyaluronic acid into hip joint of patients with hip
OA.34 Despite a paucity of evidence, the use of injectable
synthetic hyaluronic acid (hyaluronan) into the hip joint has
been shown to be an effective treatment for symptomatic hip
OA.33,194,195 Evidence also shows that injectable hyaluronan
works best in mild to moderate hip OA, especially when conservative therapy has failed.39 A recent published meta-analysis suggests the benefit of hyaluronan for the treatment of hip
OA,34 but so far it is only approved by the Federal Drug Administration (FDA) for the knee. More controlled studies are
needed to show its effectiveness in patients with hip OA. 34
I
F7J?;DJ;:K97J?ED
Studies have shown the benefit of patient education in the self-management of patients with arthritis in decreasing pain, improving function, reducing
stiffness and fatigue, and reducing medical usage.26,58,87,88,216 A
meta-analysis has shown patient education can provide on average 20% more pain relief when compared to NSAIDs alone
in patients with hip OA or rheumatoid arthritis.174
I
An approach, called Hip School, that includes primarily patient education as an intervention has been
shown to be effective in a preliminary study for patients with signs and symptoms of hip OA.104 The Hip School
highlights the need for educating patients with hip OA, especially understanding the importance of preserving hip ROM
and muscle function, understanding what therapy is effective
and what is not, and when surgery is likely indicated.
II
Clinicians should consider the use of patient education to teach activity modification, exercise, weight
reduction when overweight, and methods of unloading the arthritic joints.
B
<KD9J?ED7B"=7?J"7D:87B7D9;JH7?D?D=
Patients with hip OA often have gait abnormalities such as asymmetry in weight bearing and
step length.29 Assistive device are often used in patients with hip OA to reduce the pain and activity limitations
associated with this condition.196 A cane in the contralateral
hand and choosing to carry loads in the ipsilateral hand has
been shown to be effective in reducing hip abductor muscles
II
journal of orthopaedic & sports physical therapy | volume 39 | number 4 | april 2009 | a15
Hip Pain and Mobility Deficits – Hip Osteoarthritis: Clinical Practice Guidelines
activity133,143 and acetabular contact pressures.133,143 One study
has shown a cane in the opposite hand can reduce hip load,
reduce hip pain, and improve function in patients with hip
OA.142
Functional, gait, and balance training is recommended to address impairments of proprioception, balance, and strength, which are
all commonly found in individuals with lower extremity
arthritis. These deficits can contribute to higher fall risk
scores in older individuals.173 Functional training of a small
cohort of elderly individuals with lower extremity impairment demonstrated improved functional performance.
Subjects underwent a program consisting of exercises simulating activities of daily living (such as gait, rising from a
chair, reaching, stepping, and squatting down) performed
at 3 different speeds (self selected, fast, and slow) with
progressive levels of difficulty. When subjects completed 1
task level correctly and without fatigue the next level was
introduced.134
II
Functional, gait, and balance training, including the
use of assistive devices such as canes, crutches, and
walkers, can be used in patients with hip osteoarthritis to improve function associated with weight-bearing
activities.
C
C7DK7BJ>;H7FO
Some evidence exists for using manual therapy to increase hip joint ROM and reduce pain
short-term in patients with hip OA, especially in
patients who do not have signs of severe hip OA (eg, osteophytes and significant joint space narrowing).82
I
One study has recommended mobilization/manipulation as a
component of the management program for patients with hip
OA.82 This randomized controlled trial compared the use of
manual therapy and therapeutic exercises in patients with hip
OA.82 The manual therapy session consisted of (1) stretching
techniques of shortened muscles surrounding the hip joint,
(2) traction of the hip joint, (3) traction manipulation (highvelocity thrust technique) in each limited position. All manipulations were repeated during each session until the therapist
concluded optimal results of the session were achieved. The
focus of the therapeutic exercise intervention was to improve
hip ROM, muscle length, and strength along with walking endurance. The outcomes for hip function (Harris Hip Score),
ROM, and pain as measured by the visual analogue scale
were compared for specific subgroups of hip OA depending
on limited function, ROM, or level of pain.82 After 5 weeks of
intervention, the success rate (primary outcome) of manual
therapy was 81% versus 50% for exercise therapy (odds ratio,
a16
|
1.92; 95% CI: 1.30-2.60).82 Manual therapy was found to be
superior to exercise therapy in some patients with hip OA
but was not shown to be any more effective than exercise in
patients with highly limited function, ROM, or high levels
of pain.82 When intervention stopped, the improvements in
function declined after 5 weeks. However, some improvement
lasted up to 29 weeks for the patients in the manual therapy
group.82
MacDonald et al123 published a case series describing the outcomes of individual patients with hip OA
treated with manual physical therapy and exercise.
The series included 7 patients diagnosed with hip OA on the
basis of the clinical examination. All patients were treated
with manual physical therapy followed by exercises to increase hip strength and ROM. Six of 7 patients completed a
Harris Hip Score at initial examination and discharge from
physical therapy. Patients exhibited reductions in pain and
increases in passive ROM, as well as a clinically meaningful
improvement in function.123
IV
Harding et al,76 in a study using cadaveric models, showed
that a posterior-anterior (P/A) mobilization of the hip produced about 1 mm of movement in the hip joint when using a
force of 356 N. Distal distraction of the hip, however, created
motion ranging from 2 to 7 mm of displacement when using
forces between 89 to 356 N.76 This cadaveric study suggests
that when attempting to mobilize the hip joint, the amount
of movement produced at the hip most likely depends on the
direction the joint is mobilized.76
Risks of adverse events associated with manual therapy of
the hip typically include self-limiting soreness of the hip region. There are no studies documenting an increased risk for
serious adverse events associated with manual therapy of the
hip.
Clinicians should consider the use of manual therapy procedures to provide short-term pain relief and
improve hip mobility and function in patients with
mild hip osteoarthritis.
B
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There are 3 categories of exercise therapy employed
for OA: ROM/flexibility exercises, muscle-strengthening exercises, and aerobic conditioning/endurance exercises. Often
all 3 types of exercises are utilized jointly for patients with
hip OA. Adequate joint motion and elasticity of periarticular tissues are necessary for cartilage nutrition and health,
protection of joint structures from damaging impact loads,
function, and comfort in daily activities. Exercise to regain
april 2009 | number 4 | volume 39 | journal of orthopaedic & sports physical therapy
Hip Pain and Mobility Deficits – Hip Osteoarthritis: Clinical Practice Guidelines
or maintain motion and flexibility is achieved by routines
of low-intensity, controlled movements that do not cause
increased pain.52 Muscle weakness around an osteoarthritic
joint is a common finding.171 Progressive resistive/strengthening exercises load muscles in a graduated manner to allow
for strengthening while limiting tissue injury. Aerobic exercise has been shown to be helpful in patients with hip OA.216
Aerobic exercises are usually designed to provide a workload
to the cardiovascular and pulmonary system at 60% to 80%
of maximal capacity and sustained for duration of at least 20
minutes.216
ROM and strengthening exercises have been advocated by many authors as a component of the
management for patients with hip OA.32,56,80,85,123,
135,150,157,164,165,176,190,192,193,216
Van Baar et al191 showed that exercise
is effective in patients with OA of the hip using an exercise
program previously reported by Oostendorp et al146 that consisted of flexibility, hip muscle strengthening, and an aerobic
exercise program. The emphasis of the stretching was on hip
muscles, including the iliopsoas, rectus femoris, and hip adductors. Before stretching it was advised to heat the specific
muscle and then stretch gently without excessive force for
15 to 30 seconds, performed 5 to 10 times preferably daily,
but at least 3 times a week. Hip muscle strengthening was
performed with either free weights or exercise machines.146,191
Depending on the therapist’s findings on evaluation and the
patient’s needs and goals, the specific type, intensity, frequency, and duration of exercise were determined. The typical exercise prescription ranged from 1 to 3 times per week
with a duration of 30 minutes for each exercise session for 12
weeks.191 Treatment could be discontinued within the 12-week
period if, according to the therapist, the treatment goals were
achieved. When patients stopped exercising after 12 weeks,
Van Baar et al191 reported that the beneficial effects of reduced
pain, less use of medication, and improved function declined,
losing any earlier gain that were made.192 A confounding factor of the Van Baar et al192 trial was that data from patients
with hip OA were pooled with data from patients with knee
OA. Therefore, determining specific treatment effect in patients with hip OA was not possible.
II
Many of the published articles on exercise report
findings that combine subjects with either hip
or knee OA. However, in a recent meta-analysis,
Hernandez-Molina et al79 contacted authors of several studies and obtained data which only pertained to hip OA. They
found 9 articles where hip-strengthening exercises showed
a beneficial effect in reducing pain and improving function
in patients with hip OA.79 In another study, moderate evidence was found for long-term effectiveness on reduced pain,
improved self-reported physical function, and improved observed physical function with exercise for patients with hip
II
OA.150 Studies have also shown aerobic exercise may offer
additional improvement in function when combined with
stretching and strengthening.153,216
Minor et al136 studied 120 patients with well-defined
rheumatoid arthritis (n = 40) or OA (n = 80) of the
hip, knee, or ankle. Patients received 1 of 3 interventions: a stretching and strengthening exercise program
(control), or the same program combined with 1 of 2 aerobic
conditioning/endurance exercises: pool activities or walking.
All patients participated in a 12-week program, which met
3 times each week for 1 hour, and all performed supervised
ROM and isometric exercises. The 2 groups doing the aerobic
exercises also performed up to 30 minutes of walking or pool
exercises to increase their heart rates to 60% to 80% of each
person’s estimated baseline maximum. At 12 weeks, study
participants were assessed for changes in aerobic capacity,
flexibility (trunk bending, shoulder ROM, and ankle ROM),
function tests (exercise endurance on a treadmill test, time to
walk 50 feet, and reported daily activity), and self-reported
health status using the Arthritis Impact Measurement Scale,
which is an arthritis-specific functional status instrument
that reliably measures psychological health, physical health,
and pain. Patients in both of the aerobic exercise groups increased aerobic capacity and decreased times to walk 50 feet
compared to their baseline scores and compared to the patients in the control group. Following 12 weeks of supervised
exercises, all groups demonstrated improved trunk, shoulder,
and ankle joint flexibility. The gains in endurance and flexibility in all 3 groups were achieved without exacerbating the
study participant’s arthritis signs and symptoms.
II
The use of aquatic exercise (hydrotherapy) in the
treatment of patients with OA of the hip has been
assessed.13,32,55,57,71,80 Aquatic exercise appears to
have some beneficial short-term effects for patients with hip
and/or knee OA while no long-term effects have been documented.13 In a recent study Hinman et al80 used a randomized
controlled trial and compared a 6-week program of aquatic
physical therapy to no intervention. The aquatic physical
therapy group demonstrated significantly less pain and improved physical function, strength, and quality of life after the
intervention.80 However, effect size calculations revealed only
small benefits of aquatic physical therapy for pain, stiffness,
right hip abductors strength, and quality of life, and doubtful
clinical benefits for physical function and left hip abductors
strength.80 Patients who have an intolerance to land-based
exercise because of pain or obesity may better tolerate aquatic
based exercise.80
II
B
Clinicians should consider the use of flexibility,
strengthening, and endurance exercises in patients
with hip osteoarthritis.
journal of orthopaedic & sports physical therapy | volume 39 | number 4 | april 2009 | a17
Hip Pain and Mobility Deficits – Hip Osteoarthritis: Clinical Practice Guidelines
CLINICAL GUIDELINES
Summary of Recommendations
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april 2009 | number 4 | volume 39 | journal of orthopaedic & sports physical therapy
Hip Pain and Mobility Deficits – Hip Osteoarthritis: Clinical Practice Guidelines
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journal of orthopaedic & sports physical therapy | volume 39 | number 4 | april 2009 | a19
Hip Pain and Mobility Deficits – Hip Osteoarthritis: Clinical Practice Guidelines
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25.8kYamWbj[h@7"CWhj_d@7$IfehjiWdZeij[eWhj^h_j_i$Curr Opin Rheumatol. (&&*1',0,)*#,)/$
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32.9eY^hWd[J":Wl[oH9"CWjj^[i;ZmWhZiIC$HWdZec_i[ZYedjhebb[Z
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april 2009 | number 4 | volume 39 | journal of orthopaedic & sports physical therapy
Hip Pain and Mobility Deficits – Hip Osteoarthritis: Clinical Practice Guidelines
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journal of orthopaedic & sports physical therapy | volume 39 | number 4 | april 2009 | a21
Hip Pain and Mobility
N e c k P Deficits
a i n : C l–iHip
n i cOsteoarthritis:
a l P r a c t i c e Clinical
G u i d e Practice
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april 2009 | number 4 | volume 39 | journal of orthopaedic & sports physical therapy
Hip Pain and Mobility Deficits – Hip Osteoarthritis: Clinical Practice Guidelines
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journal of orthopaedic & sports physical therapy | volume 39 | number 4 | april 2009 | a23
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april 2009 | number 4 | volume 39 | journal of orthopaedic & sports physical therapy
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journal of orthopaedic & sports physical therapy | volume 39 | number 4 | april 2009 | a25