Deciding to have a total hip replacement is rarely a quick decision. Most patients reach this point after months or years of pain, limited activity, and trying one treatment after another. This guide covers what causes the hip to break down, how doctors evaluate the joint, what non-surgical options are usually tried first, and how patients and surgeons decide together when surgery is the right next step.
This is Blog 2 of 4 in our Total Hip Replacement cluster. If you are new to the topic, start with our Total Hip Replacement Overview to understand what the surgery involves.
What Causes the Hip Joint to Break Down?
The hip is built to handle decades of walking, sitting, and standing. Several conditions can wear the joint down or damage it faster than normal use would.
Osteoarthritis
Osteoarthritis is by far the most common reason people end up needing a hip replacement. The National Institute of Arthritis and Musculoskeletal and Skin Diseases describes it as a degenerative joint disease in which the tissues inside the joint gradually break down.
In a healthy hip, smooth cartilage covers the ball and socket so they glide against each other. In osteoarthritis, that cartilage wears thin, bone eventually rubs on bone, and pain and stiffness build up over time. It usually develops slowly over years.
Rheumatoid Arthritis
Rheumatoid arthritis is an autoimmune condition. The immune system, which normally fights infection, mistakenly attacks the tissue that lines the joints. Inflammation builds up, cartilage and bone are damaged, and the joint becomes painful and stiff. Unlike osteoarthritis, rheumatoid arthritis often affects multiple joints at once and can appear at a younger age.
Post-Traumatic Arthritis
Arthritis can also develop after a serious hip injury or fracture. The joint surface may not heal evenly, and the uneven wear pattern leads to arthritis years or even decades later. Old sports injuries, car accidents, and falls can all contribute.
Avascular Necrosis (Osteonecrosis)
Avascular necrosis happens when the blood supply to the femoral head (the ball of the hip) is cut off or reduced. Without blood, the bone tissue dies and eventually collapses. Causes include long-term steroid use, heavy alcohol use, certain blood disorders, and some hip injuries. Avascular necrosis can lead to severe hip damage at a younger age than typical osteoarthritis.
Hip Fractures
A hip fracture, often caused by a fall in an older adult, can damage the joint beyond simple repair. In some cases, replacing the hip is the best way to restore mobility quickly and avoid long-term complications from reduced movement.
Childhood Hip Conditions
Conditions present from birth or childhood can show up as hip problems in adulthood. Developmental dysplasia of the hip (where the socket does not form correctly) or conditions like Legg-Calvé-Perthes disease can lead to joint damage that eventually requires replacement.
Who Is at Higher Risk?
Hip damage does not happen for one reason alone. The American Academy of Orthopaedic Surgeons describes several factors that raise the risk of hip osteoarthritis:
- Age. The risk increases as cartilage naturally thins with age.
- Family history. Genetics play a role in how quickly joints break down.
- Previous hip injury. Old fractures or dislocations can lead to arthritis later.
- Obesity. Extra weight puts more stress on weight-bearing joints, including the hip.
- Abnormal hip development. If the hip joint did not form perfectly at birth, wear patterns can develop over time.
- Repetitive stress. Jobs or sports that repeatedly load the hip joint can accelerate wear.
Having one or more of these risk factors does not mean someone will definitely need a hip replacement. Many people with risk factors never require surgery. Still, these patterns help doctors and patients understand why symptoms may be appearing.
How Doctors Diagnose Hip Problems
If hip pain has been ongoing, the next step is usually an evaluation by a primary care doctor or an orthopedic specialist. Diagnosis generally involves three parts: a conversation, a physical exam, and imaging.
Medical History and Conversation
The doctor starts by asking questions like:
- When did the pain start?
- Where exactly does it hurt (hip, groin, thigh, lower back)?
- What makes it better or worse?
- Does the pain disturb sleep?
- How is it affecting daily activities, work, and exercise?
- Are there any related medical conditions or past injuries?
These questions help shape the rest of the evaluation. Hip pain can sometimes come from the spine or knee rather than the hip itself, and a careful history helps point in the right direction.
Physical Examination
During the exam, the doctor typically:
- Checks tenderness around the hip joint
- Moves the leg through its full range of motion (both with the patient relaxed and with the patient actively moving it)
- Listens or feels for a grinding sensation (called crepitus), which can signal bone-on-bone contact
- Watches how the patient walks, since hip problems often change gait
- Examines the surrounding muscles and tendons to rule out injuries that mimic hip arthritis
Imaging Tests
Imaging is how doctors confirm what is happening inside the joint.
- X-rays are the primary tool. They can show loss of joint space, bone changes, and bone spurs, all of which are signs of wear.
- MRI scans show soft tissue in more detail and can help identify avascular necrosis, ligament injuries, or labral tears when the X-ray is not conclusive.
- CT scans may be used when the surgeon wants a more detailed view of the bone, particularly if there has been a previous injury or unusual anatomy.
- Blood tests are occasionally ordered to check for rheumatoid arthritis, infection, or other systemic conditions.
Some clinics also use functional scoring tools (such as the Harris Hip Score or Oxford Hip Score) to track how much the hip affects daily life. These are simple questionnaires about pain, walking, stairs, sitting, and other activities.
Non-Surgical Treatments Tried Before Surgery
In most cases, total hip replacement is not the first treatment a doctor recommends. Orthopedic specialists typically start with less invasive options and escalate only if those are not enough.
Lifestyle Changes
- Activity changes. Reducing high-impact activities (running, long hikes, jumping) while staying active in lower-impact ways (walking, swimming, cycling).
- Weight management. Losing even a modest amount of weight can significantly reduce stress on the hip joint.
- Ergonomic adjustments. Supportive shoes, seat cushions, and changes to how someone sits, stands, or lifts can all help.
Physical Therapy
A physical therapist can design a program that:
- Strengthens the muscles around the hip (especially the glutes and core)
- Improves flexibility and range of motion
- Trains balance and walking patterns to reduce strain on the joint
Physical therapy is often the most underused treatment. When done consistently, it can meaningfully delay the need for surgery in many patients.
Medications
- Acetaminophen for mild to moderate pain
- Nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen or naproxen for pain with inflammation. Long-term NSAID use should be discussed with a doctor because of stomach, kidney, and cardiovascular considerations.
- Topical medications applied to the skin for localized relief
Injections
When oral medications and physical therapy are not enough, doctors sometimes use injections directly into the joint:
- Corticosteroid injections can reduce inflammation and provide temporary pain relief.
- Hyaluronic acid injections are used less often in the hip than in the knee. Their role in hip arthritis is still debated.
Assistive Devices
Canes, walking sticks, and walkers can reduce the load on a painful hip. A cane used on the opposite side of the bad hip is often enough to make a noticeable difference in daily comfort and walking distance.
Signs That Non-Surgical Treatment Is No Longer Enough
At some point, many patients reach a stage where conservative care is not giving them enough relief. Some common signals include:
- Pain that persists despite medication and physical therapy
- Pain at rest or at night that interferes with sleep
- Stiffness that keeps getting worse
- Difficulty with basic activities like walking short distances, standing up from a chair, putting on shoes, or getting in and out of the car
- Growing reliance on pain medication
- Reduced quality of life and unwillingness to do things that used to be enjoyable
These signs do not automatically mean surgery is necessary. They do signal that it is time for a serious conversation with an orthopedic specialist.
When Is Surgery Considered?
Total hip replacement is generally considered when:
- Imaging shows significant joint damage
- Symptoms meaningfully interfere with daily life
- Conservative treatments have been tried and are no longer providing adequate relief
- The patient’s overall health supports undergoing surgery
The decision is always individualized. Age is a factor but not the deciding one. Some people in their 80s are strong candidates, while others in their 50s may not be ready yet. What matters more is overall health, the extent of joint damage, and how much the condition is affecting life quality.
Questions to Ask Your Orthopedic Surgeon
Before committing to surgery, it helps to come prepared with questions. The American Academy of Orthopaedic Surgeons suggests patients ask about:
- Whether surgery is truly necessary and what the risks are of waiting
- The surgeon’s training, experience, and how many hip replacements they perform each year
- How many hip replacements are performed at the hospital or surgery center each year
- The surgical approach the surgeon recommends and why
- Expected outcomes and complication rates for similar patients
- What recovery will look like in the first days, weeks, and months
- What activity restrictions to expect
- How implant type and materials will be chosen
- What warning signs after surgery should trigger an immediate call to the office
Bringing a family member or friend to the appointment, and writing down the answers, makes it easier to review the conversation later.
Making the Decision
Choosing hip replacement is a shared decision. It combines the medical reality shown on imaging and exam, the orthopedic specialist’s recommendation, and the patient’s own priorities (pain tolerance, work, activity goals, family support for recovery).
Most patients find it useful to think about three things:
- How much is the hip problem affecting my daily life right now?
- Am I running out of meaningful non-surgical options?
- Is my overall health strong enough to support a good recovery?
If the answer to all three is “yes,” a total hip replacement is often the next reasonable step. Once a decision is made, our procedure and recovery guide covers what happens before, during, and after surgery. For specific questions about costs, timelines, and patient outcomes, our FAQ article gathers the most common concerns.
Frequently Asked Questions
Does everyone with hip arthritis eventually need surgery?
No. Many people manage hip arthritis for years or decades with lifestyle changes, physical therapy, and medication. Surgery is usually considered only when symptoms seriously limit daily life and conservative treatments no longer help.
What type of doctor should I see for hip pain?
A primary care doctor is a good starting point. They can order initial imaging and refer you to an orthopedic specialist if needed. For advanced hip problems, an orthopedic surgeon who focuses on joint replacement is the most relevant specialist.
How long can I safely delay hip replacement?
There is no single answer. Some patients delay surgery for years with good results. Others benefit from operating sooner because pain is limiting their mobility and health. An orthopedic specialist can help weigh the trade-offs in each case.
Disclaimer: This article is for general informational and educational purposes only. It is not intended as medical advice, diagnosis, or treatment. Always talk with a qualified healthcare professional for guidance about your individual situation. The information presented here does not replace a consultation with a licensed medical provider.
