Why physical therapy and exercise may not help your hip pain

Ross A. Hauser, MD., Danielle R. Steilen-Matias, MMS, PA-C.

Patients are often very confused as to why a physical therapy program or exercise/activity program did not help their hip pain as much as they thought it would. Clinicians, doctors, and therapists are equally confused.

This is very typical of the patients we see. They have been to physical therapy for months and nothing seems to have improved. How can this be? Many of these patients have been listening and reading about “5 great exercises” to strengthen their hip or about “stretching and strengthening techniques” to greater hip support. These people have been told that exercise will lead to greater pain relief and an increase in mobility. So why is it not working for them, when physical therapy and exercise are so beneficial to so many others?

The discussion points of this article:

Physical therapy, initially beneficial and helpful, is no longer helping

For some people, they have reached a point where physical therapy, initially beneficial and helpful, is no longer helping. They have been dealing with hip pain and degenerative arthritis for years. They have also been trying to avoid a hip replacement surgery that they were told they should have years ago. Initially, chiropractic helped them, physical therapy helped them, and exercise and yoga helped them. But now these once effective means of alleviating their hip pain are no longer helping and in some people are now making their situation worse. Their pain is also spreading. As their hips become more unstable pain begins to pull at the groin, their thighs become tight, their knees hurt and some mornings they wake up and their whole leg has shut down and they feel like they are dragging a weight around their ankle.

When physical therapy fails – that is the signal that you must have a surgery

People like those we described above, perhaps like yourself, have spent years trying not to get a hip replacement. They may have physically demanding lines of work, want to maintain an active lifestyle, play sports, or in many cases are the primary caregivers for an ailing family member or spouse. For some when the prescribed physical therapy sessions have ended with little improvement, there is a frank discussion with their doctor about the need for hip arthroscopic surgery, a discussion about acetabular or hip labral tear repair, hip resurfacing surgery, or hip replacement surgery.

In this article, we will discuss why exercise and physical therapy failed to restore muscle strength in hip osteoarthritis patients and athletes and how regenerative injection treatments to the tendons and ligaments of the hip may add needed strength resistance to make exercise and therapy more effective for you.

Surgery recommendation over physical therapy for femoroacetabular impingement

An April 2022 paper in the journal Orthopedic research and reviews (11) gave this summary of treatment involving problems of femoroacetabular impingement. “While the exact cause of femoroacetabular impingement is unknown, it is thought to result from repetitive microtrauma to the proximal femoral epiphysis (This is the point where the femur or thigh bone meets with the ball of the hip joint. In this situation the ball of the hip and the thigh bone and not aligned)  leading to abnormal biomechanics.

Patients typically present with groin pain that is exacerbated by hip flexion and internal rotation (knee pointing inwards movement).  . . Both non-operative and surgical options have their role in the treatment of femoroacetabular impingement and its associated labral tears; however, hip arthroscopy has had successful outcomes when compared with physical therapy alone. Unfortunately, chondral lesions associated with femoroacetabular impingement have had poorer outcomes with a higher conversion rate to arthroplasty.” The researchers write in summary: “A number of operative and non-operative treatment modalities are available for femoroacetabular impingement and associated labral tears. Operative treatment encompasses a variety of open and arthroscopic procedures including osteotomy, osteoplasty, cartilage restoration, and labral debridement, repair and/or reconstruction. Non-operative treatment is generally limited to physical therapy, activity modification, and anti-inflammatory medications (injections or oral). Recent comparative meta-analyses have tended to favor arthroscopic intervention over physical therapy.”

What are we seeing in this image? Sometimes a hip is too far gone for physical therapy to help

Physical therapy may no longer be helpful for you because your hip has accelerated to a point of severe degeneration. If you have recognized that you have lost a great deal of range of motion and your hip feels like it is locked in place, hip replacement may be the only option. However, if you have maintained a good range of motion, even if that range of motion is painful, a hip replacement can be avoided in many cases. Here we have an x-ray of a severely degenerated hip. This patient has no cartilage and the bone is pressed against bone in the hip socket.

Here we have an x-ray of a severely degenerated hip. This patient has no cartilage and the bone is pressed against bone in the hip socket.

Four months of physiotherapist-supervised, progressive, moderate, and strength training was less effective than thought for improving muscle strength and power in patients with hip osteoarthritis

In this next section, we will explore research that examines why physical therapy may have failed you.

Doctors at the University of Copenhagen published a study in the October 2017 edition of Physiotherapy Research International (1) in which they examined patients with hip osteoarthritis. Among the symptoms that these patients exhibited were noted impairments in muscle function (muscle strength and power) and hip range of motion.

So they set about to compare the short- and long-term effects of 4 months of three different types of therapy/exercise:

They also explored the impact of each on muscle function and hip range of motion in patients diagnosed with hip osteoarthritis BUT NOT waiting for hip replacement. So this is a group of patients whose degenerative hip disease did not advance far enough yet for a hip replacement or people declining the suggestion to get a hip replacement.

The results were somewhat surprising, the treatments did not show any significant between-group differences for improvements in muscle strength and power or hip range of motion at any time points.

The results were somewhat surprising, the treatments did not show any significant between-group differences for improvements in muscle strength and power or hip range of motion at any time points.

The researchers had to conclude:

So what the researchers were suggesting was the supervised physical therapy for strength training was not helpful. But the walking, and whatever exercise the patient themselves came up with was.

What does all this mean? Muscle strength and power are problems that clearly need to be addressed to reduce pain and disability in hip osteoarthritis.

Loss of strength, muscle power, and range of motion are clear indicators of an impending hip replacement. In patients with degenerative hip disease, where connective tissue such as the tendons that attach hip muscles to the bones are damaged. It is very difficult to derive benefit from strength training where resistance is needed because the tendons that help provide that resistance are weak.

Research updated November 2021

The above study was referenced in a November 2021 paper from La Trobe University and the University of Auckland in New Zealand. It was published in the journal Review Biology (2). The goal of the paper was to determine the effect of exercise-based rehabilitation programs on hip and knee muscle function and size in people with hip osteoarthritis. This paper also found little benefit in some patients. The researchers wrote: “High-intensity resistance programs may increase hip abduction strength slightly when compared with a control group. No differences were identified in muscle function or size when comparing a high versus a low-intensity group.”

People were giving up on the exercise because it was not helping and they did not have the strength to do it.

Here is another clue that your damaged tendons and ligaments are the problem. A team of researchers from Oslo University in Norway evaluated the long-term effect of exercise therapy and patient education on a range of motion, muscle strength, physical fitness, walking capacity, and pain during walking in people with hip osteoarthritis. In the above study from the University of Copenhagen, we found that walking was beneficial and the patient’s own home exercise derive program was beneficial. Strength training was not. It should also be pointed out that in the above study, people were not waiting for hip replacement.

Published in the journal Physical Therapy, (3) the key to this Oslo University study was focus on walking as the exercise. Six minutes of walking every day. What the researchers found was no improved range of motion, muscle strength, or how much distance during the 6-minute walk the patient could cover. Another factor the researchers noted was a 53% rate of adherence to the exercise therapy program. People were giving up. Why were they giving up? Because many participants had already planned to get the total hip replacement. 

14% of hip osteoarthritis patients responded to exercise programs

First, we are going to stop at an October 2020 study (4) in the International Journal of Environmental Research and Public Health that provides realistic if surprising outcomes as to have many people benefit from exercise for their hip osteoarthritis. In this study, a research team in the Netherlands was asked to examine patients’ medical records to assess the effectiveness of exercise for hip pain. Here is what they recorded. “Exercise therapy is an important part of the conservative treatment of patients with hip osteoarthritis. Multiple trials have been conducted to study the effect of exercise therapy in hip osteoarthritis and most of them have shown a positive effect of exercise therapy compared to a non-exercise treatment or no intervention.” In this paper, the researchers looked at patients receiving exercises for hip osteoarthritis and those who did not do exercise. By their calculations, one in 7 of the people who were not exercising would benefit from exercise, about 14%.

The more hip osteoarthritis – the weaker the muscles – the more inability to do exercise – Are you too far gone?

We are going to listen now to doctors at Griffith University in Australia who will tell us about hip osteoarthritis patients with weakened muscles. This research appears in the medical journal BioMed Central Musculoskeletal Disorders (5). Basically, they looked at people, probably just like you, people with advanced hip osteoarthritis who have generalized muscle weakness of the affected side from leg to toe.

Learning points

What they found:

People with hip osteoarthritis demonstrated significantly lower:

Lack of exercise leads to weight gain, reluctance to exercise. Yet, no structural changes to the hip. Maybe you are not too far gone.

A video of an examination to realistically assess non-surgical hip treatment options

In the video below Ross Hauser, MD demonstrates a screening process to help patients determine if our treatments may be helpful.

The first patient’s examination begins at 3:35

The second patient’s examination at 5:15

The third patient’s examination at 8:10 

If avoiding hip replacement is something you want to pursue, then what we see here is that even with the loss of muscle, even with weight gain, the hip was degenerating slowly, and can be managed.

Now let’s look at another paper published in June 2019 in the BMC Musculoskeletal Disorders (6).

Here is what the researchers said:

“Reductions in lower extremity muscle strength, size and quality, and increased fat content have been reported in advanced hip osteoarthritis. Whether these differences are also evident at earlier stages of the disease and the extent to which they might develop over time is unclear. The main purpose of this 12-month exploratory prospective study was to compare changes in muscle and fat characteristics in individuals with mild-to-moderate hip osteoarthritis and healthy controls.”

In other words, your muscles are getting weaker and smaller. You are also accumulating fat. How far gone will you be in 12 months? Let’s find out what happened to the 14 people in this study.

Conclusions: “Pre-existing deficits in hip muscle strength in individuals with mild-to-moderate hip osteoarthritis were accentuated over 12-months, though no changes in symptoms or joint structure were observed. . . Interventions to prevent or slow declines in strength may be relevant in the management of mild-to-moderate hip osteoarthritis.”

If avoiding hip replacement is something you want to pursue, then what we see here is that even with the loss of muscle, even with weight gain, the hip was slowly, and able to be managed, degenerating. There is something you can do about it before you are too far gone. But you have to make exercise and physical therapy work for you.

Research: We know the hip ligaments are important, they may be more important than we think in helping restore muscle strength.

Throughout this article, we discuss the loss of muscle strength and the inability of people to benefit from physical therapy for their hip pain. We also suggest that physical therapy results can be improved if you strengthen and repair weakened and damaged tendon attachments. The tendon’s anthesis is that piece of tissue that attaches your muscle to the bone.  The term enthesopathy typically refers to a degenerated enthesis and this may have been discussed with you at one of your many doctor or PT visits.

We are going to discuss the tendons and muscles below. But let’s stop here for a moment to discuss the hip ligaments. The hip ligaments are the strong connective tissue that holds your pelvis, hip, thigh bones, sacrum, lumbar vertebrae all in place. The bones do not go wandering off on their own because the ligaments keep them in line.

When these ligaments are damaged because of degenerative wear and tear, the bones do wander off and start floating around. They start to bang against each other in unnatural damaging contact.

When you first go to a doctor with hip pain, it is rare for the doctor to acknowledge that your problem may be from the ligaments. The reason? Ligaments are not cartilage and they are not bone. It is easier to describe to someone that they have a “bone on bone” than try to describe a ligament problem.

Your physical therapy is not working because your muscles are not getting sufficient resistance because of weakened and damaged tendon attachments.

Doctors not knowing or understanding the hip ligaments and their role in hip stability are slowly recognizing ligaments as a major problem in the treatment of hip pain. Listen to what a team of German surgeons at the Department of Orthopedics at the University of Leipzig has recently published in the health journal PLusOne.(7)

Here is the concluding statement of the paper abstract:

Your physical therapy is not working because your muscles are not getting sufficient resistance because of weakened and damaged tendon attachments. The tendon attachments are weakened because the bone they are attached to may be floating around overstretching that attachment. The bone is floating around because of weakened and damaged ligaments.

Back to the muscles: There is limited evidence that physical therapy helps patients with hip osteoarthritis and we think it may be the gluteus minimus muscle

Researchers in Australia and New Zealand are embarking on a new study. They hope to be able to answer the question as to why physical therapy is not helping many patients.

Here are the learning points of what this pending research is trying to do published in the clinical journal Trials (8):

What this study is doing is focusing on the gluteus minimus muscle dysfunction. The goal of the study is to show that if you make this muscle stronger, you can eliminate a lot of pain in hip osteoarthritis patients and improve mobility and function.

We agree it is the gluteus minimus muscle when there is gluteus medius tendinopathy

The inability to benefit from strength training is a clear sign of total hip joint degeneration

It is difficult to isolate one part of the pelvic-hip-spin complex when treating a patient with problems of Gluteus Medius tendinopathy.

The constant strain on the muscles to produce strength and stability in the hip is actually causing more degenerative problems because of tendon destruction.

In our article Gluteus Medius tendinopathy, we discuss how

Prolotherapy, more effective for patients who developed osteoarthritis as a result of developmental dysplasia of the hip than surgery or exercise

In this article, we make the case that without strong ligament and tendon attachments, there is not sufficient resistance to allow the muscles to strengthen. In our clinic, we address this problem with the use of Prolotherapy.

Prolotherapy is the injection of simple dextrose, sugar, which calls native repair cells to the areas of damaged soft tissue. Specifically the tendon and ligament attachments.

A February 2020 study comes to us from orthopedic surgeons operating in Turkey, specifically the Department of Orthopedics Surgery at Tokat State Hospital and the Department of Sports Medicine, Health Sciences University Gulhane Medical Faculty, Ankara, Turkey. The study was published in the journal Medical Science Monitor. (9)

In this study, the research team looked at patients who developed osteoarthritis as a result of developmental dysplasia of the hip, (the socket of the hip joint being too shallow). This is a major cause of hip pain and disability.

According to the researchers, “the aim of the study was to compare the effectiveness of prolotherapy injections versus exercise protocol for the treatment of developmental dysplasia of the hip.”

The study concluded: “To our best knowledge, this study is the first regarding the effects of an injection method in the treatment of osteoarthritis secondary to developmental dysplasia of the hip. According to our study, Prolotherapy is superior to exercises. Prolotherapy could provide significant improvement for clinical outcomes in developmental dysplasia of the hip and might delay surgery.

In this video, Ross Hauser, MD demonstrates and describes the Prolotherapy treatment. A summary transcription is below the video.

Exercise for hip osteoarthritis

Many doctors believe that exercise will not help an osteoarthritic hip. It is better, some of these doctors think, to just get these people hip replacements and move on. While that can be our opinion this is not an option that is ours alone.

A paper published in Osteoarthritis Cartilage (10) in November 2021 describes these phenomena: “Clinicians’ attitudes and beliefs about physical activity and exercise therapy in osteoarthritis seem to reflect an outdated narrative which describes osteoarthritis as a wear-and-tear disease with inevitable disease progression to joint replacement surgery. Clinicians need to adopt a contemporary narrative, which accurately reflects current knowledge and evidence-based practice, thereby ensuring consistent utilization of exercise therapy as first-line care as recommended in osteoarthritis guidelines. ”

Much of this article surrounds the failure of physical therapy and exercise in patients with hip osteoarthritis. Many of the problems of failure, as outlined above, surround the inability to exercise because of pain and fatigue and simply that the hip itself does not have the range of motion to successfully induce enough resistance to strengthen the muscles.

In the patients that we see who are treated with Prolotherapy, it is very important that they are put on a realistic exercise program to help with their recovery and to increase strength and function.

In order to strengthen the hip joint, the hip needs motion. In our office, we guide patients on what types of exercises are best for their condition and typically allow patients to restart exercising approximately four days after treatment. There are a variety of ways to keep up your fitness level without necessarily hurting the hip further while it is being treated. Gradually increasing back up to high-impact sports is typically recommended. Some preferred exercises include swimming, aqua jogging, cycling (if realistic), balance, and core work. The general rule is to not aggravate the pain. Some dull pain is normal after exercise. But if the hip pain is lingering more than a couple of hours, it likely means you did too much.

Exercise is supposed to strain muscles not joints. Joints are not supposed to be hot or swollen after exercise or activity. Exercise that causes sharp joint pain or results in joint pain lasting longer than two hours after the exercise has stopped has put too much pressure on the joint and is part of the chronic pain problem, not the solution. Sometimes improvement in exercise technique is needed to reduce joint stress. This is where a patient can benefit from working with a trainer or therapist who can re-train the body, specifically the hip and pelvic regions to include the low back to do proper form and movements that do not cause shear force on these areas.

Sheer forces put a strain on the hip ligaments and the hip labrum as well as the entire hip joint capsule. Shear forces occur when one bone is rotating while the adjacent bone is stationary. This puts strain on joint structures and increases joint instability and may cause all treatments to be less effective. Make sure exercise is done with stress on the muscles, not on the joints and no sheer or torque (twisting) forces are applied on the joint with exercise.

Exercise ability is an excellent gauge for determining the true status of the hip joint. When people cover up the pain for years with NSAIDs and cortisone shots, they do not truly know how the joint is doing because they keep exercising on an injured joint, and therefore continue the wear and tear process. With Prolotherapy, those items are taken out of the equation, and the person knows the joint is getting stronger because activities are gradually increased without the aid of pain pills. In essence, the person acts as his or her own control for the success of the treatment.

Ross Hauser, MD and Danielle Matias, PA-C discuss the types of cases we see at Caring Medical Florida with chronic tight hip flexors, snapping hip, and other instability-related conditions.

Summary and contact us. Can we help you?

A myriad of conditions lead to chronic hip pain, including trochanteric tendinitis or bursitis, pelvic floor dysfunction, ischiofemoral impingement, iliopsoas bursitis, myofascial pain syndrome of the tensor fascia lata, gluteal muscle tears and strain, as well as ligament sprains of the hip.

For the chronic hip pain patient where hip instability has been identified, the source of the pain is most commonly due to ligament laxity. Physical therapy modalities, such as TENS units, electrical stimulation units, massage, and ultrasound, will decrease muscle spasms and permanently relieve pain if muscles are the source of the problem. The chronic pain patients’ muscles are in spasm or are tense usually because the underlying joint is hypermobile, or loose, and the muscles contract in order to stabilize the joint.

The reason that these treatments will now work is that chronic muscle tension and spasm is a sign that the underlying joints have ligament injury. However, many therapies for hip osteoarthritis or chronic hip pain exist and do relieve pain, including physical therapy, chiropractic care, massage, etc. However if the therapy temporary helps relieve one of the factors in osteoarthritis, it will only help, but it will not cure. For example, if someone with hip instability from ligament laxity and resultant osteoarthritis seeks out the care of a physical therapist, they may find that exercise to strengthen their muscle helps their pain somewhat, but may not completely resolve it. (Note: If instability is present due to muscle dysfunction, including weakness or imbalances, physical therapy could cure the condition.)

Chiropractic care may help by temporarily reducing hip subluxations, but if the ligaments remain loose, these adjustments will likely not ‘hold’ and the patient may not experience long-term pain relief. (If the person does not have lax/loose ligaments, chiropractic care may be very beneficial to helping joint pain long-term).

Similarly, massage may help relieve the symptoms of muscle spasm for a short time, but the muscles may continue to spasm to compensate for the ligament laxity, preventing massage from providing any long-term benefits.

Lastly, a neoprene sleeve for the knee or compression shorts for the hip will give some stabilization to those respective joints; they help, but on their own they will not cure the underlying condition. Now, when used in tandem with Prolotherapy, these stabilization devices will help provide stability to the joint while the ligaments heal, thus working at curing the underlying condition.

We hope you found this article informative and it helped answer many of the questions you may have surrounding your hip problems and hip instability.  If you would like to get more information specific to your challenges please email us: Get help and information from our Caring Medical staff

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This article was updated January 6, 2022


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