Why conservative care is always the starting point

Inside a healthy hip, a layer of smooth articular cartilage allows the ball and socket to glide almost frictionlessly. In osteoarthritis, that cartilage gradually thins and breaks down — a process accompanied by the formation of bony spurs (osteophytes), microfractures in the underlying bone, and progressive weakening of the surrounding musculature. These are structural changes, and no tablet or injection reverses them.

That does not make conservative management ineffective. Physiotherapy, anti-inflammatory medication, and weight management all work on the parts of hip OA that can respond: they reduce inflammation, offload the joint, and strengthen the muscles that share the burden of movement. When the joint still has enough integrity to benefit, these measures can restore meaningful function and quality of life — sometimes for years. NICE NG226 (2022) reflects this consensus, positioning non-surgical management as the correct and clinically appropriate starting point before any surgical referral is considered.

Understanding what conservative care actually does — relieve symptoms, slow functional decline, compensate for structural loss — also sets realistic expectations. It is not a detour on the way to surgery; it is the right first response. Its limits only become relevant if symptoms persist despite a genuine trial of it.

What physiotherapy can — and cannot — do

Muscle strength is one of the joint's natural shock absorbers. When the muscles around the hip — particularly the glutes and deep hip rotators — are well-conditioned, they absorb a significant portion of the compressive force that would otherwise press directly through the joint during walking, stair-climbing, or standing from a chair. This is why a structured physiotherapy programme can meaningfully reduce pain and slow functional decline in earlier-stage hip osteoarthritis: it is redirecting load away from the joint surface.

The ceiling arrives when cartilage loss becomes severe. No degree of muscle conditioning can substitute for cartilage that is largely absent. Under load, the femoral head and acetabulum still make contact, and stronger surrounding muscles cannot prevent that. When hip range of motion has narrowed significantly, a secondary problem also emerges: the prescribed exercises themselves become difficult or impossible to perform correctly, reducing their therapeutic value still further.

A physiotherapist is often well-placed to identify this turning point before the patient does. If a programme that previously helped has stopped producing improvement — or if exercises are now causing more discomfort rather than less — that stalled progress is clinically meaningful information. Rather than simply switching to a different exercise set, it is worth raising the change with a GP or requesting a specialist review to assess whether the joint has moved beyond the stage where physiotherapy alone can deliver adequate benefit.

The real limits of painkillers and injections

Reaching for a painkiller is an entirely understandable response to hip pain — but the evidence behind the most commonly used options is more limited than many patients realise. Landmark analyses published in The Lancet found that paracetamol delivered minimal-to-no meaningful improvement in osteoarthritis pain or function compared with placebo. For a drug most people assume is doing something useful, that is a significant finding, and it means paracetamol alone is not a reliable long-term strategy for hip OA.

NSAIDs (such as ibuprofen or naproxen) are the most guideline-supported pharmacological option and do offer more meaningful pain and function benefits than paracetamol. The trade-off is that prolonged use carries recognised risks: gastrointestinal bleeding, cardiovascular events, and renal impairment. These are not reasons to avoid NSAIDs entirely, but they are reasons not to treat them as an indefinite holding measure.

Corticosteroid injections can provide short-term relief for some patients, but their benefit tends to shorten with repeated use. Multiple major guideline bodies — including OARSI, ACR, and EULAR — recommend against viscosupplementation (hyaluronic acid injections) and glucosamine for hip OA, so patients who have tried these and found little benefit are in line with what the evidence would predict. Opioids are similarly not recommended by leading guidelines for hip osteoarthritis, making stronger medication an unlikely answer.

When injections that once provided several months of relief are now lasting weeks — or nothing at all — that pattern is clinically informative. It is not a dead end, but it is a signal that the pharmacological toolkit may be approaching its ceiling, and that the question of whether a surgical assessment is now appropriate deserves a considered answer.

Symptoms that signal conservative treatment is no longer working

Pain that begins waking a patient at night marks one of the clearest turning points in hip osteoarthritis. During the day, activity can be adjusted — a shorter walk, avoiding stairs, pacing movements — but night pain allows no such workarounds. When the hip aches at rest or during sleep, disease has progressed beyond the point where activity modification and analgesia can provide adequate control. Sleep disruption caused by hip pain should not be dismissed as mild discomfort; its cumulative effect on energy, mood, and general health is considerable.

Alongside rest and night pain, several functional markers indicate that conservative care is no longer meeting the joint's demands:

• Daily tasks have become unreliable. Difficulty putting on shoes or socks, walking normal distances, or managing a flight of stairs points to a functional threshold that painkillers and physiotherapy are not reaching.
• A persistent limp has developed. Altered gait places uneven load on the lower back, the opposite knee, and the contralateral hip — producing secondary pain in those areas that can be mistakenly attributed to a separate problem rather than the original joint.
• Injections are providing diminishing returns. Relief that once lasted months and is now lasting weeks, or has stopped altogether, reflects a structural deterioration rather than the wrong injection choice.
• X-ray findings show bone-on-bone contact. When imaging reveals Stage 3–4 cartilage loss, with the femoral head and acetabulum in direct contact, the clinical conversation changes. This finding does not automatically mean surgery is inevitable, but it does mark the point at which patients are generally considered candidates for a replacement assessment rather than further non-operative management.

Not every item on this list needs to be present before arranging a specialist review. Rest pain alone, or significant sleep disruption, is frequently sufficient reason to seek one.

What clinical guidelines say about when to seek a surgical opinion

NICE NG226, published in October 2022, sets out the clearest policy anchor for this decision: orthopaedic referral should be offered when non-surgical management is unsuitable or ineffective — a threshold that NICE CKS frames as approximately three months of adequate conservative treatment. Three months is not an arbitrary waiting period; it is broadly the point at which a clinician can judge whether physiotherapy, analgesia, and lifestyle modification have been given a genuine trial and have failed to provide satisfactory relief.

One of the most practically important aspects of the NICE guidance is its explicit removal of common gatekeeping barriers. The guidelines state that patients must not be excluded from orthopaedic referral on grounds of age, sex, BMI, smoking status, or comorbidities. Patients who have been advised to lose weight before a referral will be considered, or to wait until they are older, are not receiving care that reflects current national guidance. Those conditions are matters for joint surgical planning — not reasons to withhold an assessment in the first place.

The referral decision is not tied to reaching a specific symptom score or waiting a fixed number of years. It turns on whether conservative management has been adequate in scope and whether it has demonstrably stopped delivering sufficient benefit — assessed through the symptom pattern, functional loss, and imaging findings described in the sections above.

Why the timing of surgical assessment matters

The idea of holding off — waiting a little longer before seeking a surgical opinion — can feel like the more measured path. Clinically, indefinite delay carries its own risks that are easy to underestimate.

Modern hip implants are projected to last approximately 25 years in around 58% of cases, and contemporary surgical techniques and implant design may extend that further. That single fact reframes the timing decision: postponing replacement does not generally preserve the joint or add years to an implant's eventual life. What it adds is time spent in functional decline before surgery happens.

Prolonged mechanical compensation amplifies that cost. An altered gait sustained over months or years loads the lower back and opposite knee asymmetrically, and by the time replacement takes place those secondary problems may still be present — adding complexity to an otherwise straightforward recovery.

The question, then, is not whether to consider surgery eventually, but when the clinical picture supports doing so. This is the judgement at the heart of Professor Paul Lee's assessment practice at the Royal London Hospital and 108 Harley Street: weighing symptom pattern, functional loss, and imaging to establish whether the balance has shifted, or whether conservative management still has something to offer. For patients where the picture does support surgery, his preferred approach — the SPAIRE technique, which preserves key posterior soft tissues — is designed to support early stability and confident mobilisation in selected cases.

Many patients who proceed at the right point describe reaching what is sometimes called 'forgotten joint' status: a hip that no longer shapes what they can and cannot do. A specialist assessment is the step that makes it possible to answer, with clinical precision, whether that outcome is now genuinely within reach.