Pictures:- All black conditioning coach Nic Gill demonstrates daily hip exercises for kids and adults
(Ref. 28)

Video solutions (about 5 minutes

Hips stretches workout (59 minutes)

Contents, this page:-

1. Introduction
2. Four movement and exercise rules for avoiding hip arthritis
3. Five posture or movement patterns that suggest that hip arthritis is on the way
4. Summary of movement-related anatomy
5. Functional hip anatomy in pictures
6. Risk factors for hip arthritis
7. How likely are you to get hip arthritis?
8. References

Introduction

We can reduce our chances of hip surgery with some daily and weekly stretches and exercises, and some daily movement pattern and lifestyle changes.  How much could we reduce hip arthritis in the general population?  - I believe that if we started early with our kids before and during their school years, the risk of hip surgery could be reduced by 50 to 75%.  We just have to ask the right questions and make the important daily changes.  The following picture collages say more than a thousand of my words.  Put five of the following into your daily movement routine and keep going for 6 weeks.  Take a before and after photo.  You’ll feel better for it, guaranteed!

Picture: hip labral tear exercises both treat and prevent hip arthritis. How many of these could you sample on a daily or weekly basis? (ref. 24)

We can reduce our chances of hip surgery with some daily and weekly stretches and exercises, and some daily movement pattern and lifestyle changes.  How much could we reduce hip arthritis in the general population?  - I believe that if we started early with our kids before and during their school years, the risk of hip surgery could be reduced by 50 to 75%.  We just have to ask the right questions and make the important daily changes.

Four movement and exercise rules for avoiding hip arthritis

(1) All the muscles around the hip joint must be strong, flexible and well maintained

(2) It becomes especially important to do the above during growth spurts (young teenage hips are especially vulnerable to knocks and sprains) if the sporting demands require rapid twists cuts and turns, and if the person or athlete must sit at desk, wheel or television for long periods daily. 

(3) A full range of movement must be practised regularly, at slow speeds to calibrate the neural guidance systems to automatically balance.

(4) The three most important daily hip joint exercises are (a) deep squat (“ass to grass”),  (b) sitting cross legged, (c) slow stepping in all directions that mimics weight shifts and stepping over, round, and up and down, as though travelling in wilderness territory that contains streams, forest trails and mountain slopes and rocks and tree trunks.  The emphasis is upon slow (for example Tai Chi), so that the brain can recalibrate and re-program the movement on a day by day basis.  Any exercise that helps the above movements to feel easy and effort free, will also help the hips last a life time.

Five posture or movement patterns that suggest that hip arthritis is on the way

(1) Knock-kneed single leg squat with hip drop on the lifted leg side
There’s a need to strengthen the back, the buttocks, the abs and the adductors – welcome to the gym, and the yoga and pilates studios!

(2) You do lots of Ice skater toe offs and golf player’s swings
There’s a special need for you to be strong and co-ordinated from the toe of your foot to the girdle of your shoulder.  If you don’t you will put jarring movement into your hip joint labrum and ligaments and you will suffer in later life!

(3) Inability to deep squat, sit nicely cross-legged, hug a knee to the opposite chest and do a nice quad stretch or sports man’s quad stretch.
There’s a need to flexibilise the muscles around the hips!

(4) Movement associated with a bad knee. 
There’s a need to take the pain out of the knee, and to use the other body parts in a smooth and coordinated way (no lurching).

(5) Can’t look smooth and coordinated doing Tai Chi
You need to practice the sort of smooth slow weight shift that would have you able to silently stalk wild game in the forest!

Summary of movement-related anatomy

This anatomy lesson uses pictures to show how - assuming that all muscles are strong and restraining structures are intact - the ball of the femur remains firmly centred in the hip socket with minimal slop and slide, such that the boney rim and cartilage are not bruised, torn or otherwise damaged by an out-of-control head and neck of femur.

Functional hip anatomy in pictures

These pictures and explanations will help you understand the reasons behind the four movement rules for avoiding hip arthritis

Picture set 1: 
The labrum, or cartilage lip, of the hip joint, holds the joint fluid in close to the hip joint surfaces so that the fluid acts as a fluid shock-absorber.  The labrum also pushes the ball back to its central location.  When intact, the labrum halves the contact stresses of the ball in the socket.

Picture set 2:
The “rotator cuff” ligaments of the hip joint spiral around the hip joint such that when the joint extends (thigh bone behind the body), the ligaments wind tight and “screw” the ball deep into the socket.  Hip joint damage can still however happen in the extended joint position if (1) the Gluteus maximus is inactive and not pulling the ball back and deep in the socket – this will lead to a labral tear in the front of the hip joint; and (2) if the adductor muscles are not controlling any excess abduction and external rotation – this will lead to impingement of the neck against the acetabular rim at the top.

If ice hockey players or  soccer players are to enjoy damage-free hip extension, they must strengthen and maintain their Gluteus maximises and hip adductors.

Picture set 3:
The muscles that surround the hip joint:  all these muscles are more or less parallel with the neck of the femur and work to pull (or is that push?) the head of the femur deep into the socket of the hip. If they are all strong and flexible, and all co-ordinating well with each other, the result is superb centring of the ball in the hip sockets with minimal strain damage or pressure upon the non-muscular labrum and ligaments

Picture 3a: the muscles behind the hip joint help to pull the ball deep into the socket

Picture 3b:
the muscles of the inner thigh help to pull the ball deep into the socket

 

Picture 3c: the hip flexor muscles help to pull the ball deep into the socket

Risk factors for hip arthritis

How likely are you to get hip arthritis?  What makes hip arthritis more likely?  What can you do to prevent hip arthritis?  Due to commercial risk, medical and surgical companies won’t ask these questions because if they did, they’d perform fewer hip surgeries and could no longer look forward to exponential growth in what is already a $15 billion per annum industry in the USA(1).

How likely are you to get hip arthritis?

I internet searched to find the original papers  and meta studies to find the following risk factors for hip arthritis:

Age
7.4% of Europeans in a study from Spain developed hip arthritis during their 60s and 70s

Sex
6.7% of men and 8% of women may go on to develop hip arthritis.

Race and ethnicity
African Americans are likely to suffer hip arthritis twice as often as Europeans, who are twice as likely to suffer hip arthritis as Chinese and other eastern Asians(26).  Saudi Arabians also have very low rates of hip arthritis, but are not of the same racial type as Asians. They do however share the daily lifestyle habits of toilet squatting and sitting crosslegged(35) - see next paragraph.

Daily deep squatting and cross legged habits
Chinese and other east Asians still use squat toilets and sit cross legged, and so do Saudi Arabians.  Genetic differences between races are generally smaller than genetic differences within races(26). Check out the pictures of All Blacks coach teaching flexible hips to kids at the top of the page

Vitamin D in women (probably men as well)
Vitamin D blood tests below 55 nanomoles per litre (deficient range) were associated with a 3 times increased risk of cartilage narrowing in retirement aged women(11).  Over a period of 8 years, the hips of this deficient group developed more x-ray signs of hip arthritis. So it seems likely that vitamin D supplements over a whole lifetime could halve the risk of hip arthritis.  And the same may apply to the prevention of osteoporotic hip fracture (12)

Obesity
In women, obesity at age 18 is strongly associated with total hip replacement in later life(12).  It’s five times more likely in very obese women of age 18.  If you are very obese and over the age of 18, don’t worry there’s still a lot you can do.  If obese adult women in general lost weight, they might halve their hip arthritis risk.

Sports
Sports that put a lot of twists and sideways movements into hip joints massively increase the risk of hip arthritis in later life.  These sports include soccer(7,8), basketball and hockey.  This hip arthritis is strongly associated with injuries causing labral tear and impingement (22).  The higher the level of sport the more the damage.  Damage may be particularly high if children and teenagers perform at a high level in their sport through their growth years (9).

Surgery for labral tears (which was perfected and made common between the years 2002 and 2013) (9) seems to have massively reduced the prevalence of hip arthritis in retired professional soccer players - from about 10 times higher than matched controls in 2003, to about 2.5 times higher in 2018.  This provides a useful clue as to how injury from childhood through active adulthood, leads to hip arthritis in later life. 

We conclude and suggest that the reason soccer players get hip arthritis in later life is that the game puts massive destabilising forces into their hip joint such that:-

1. When the thigh is behind the body the ball of the femur slides forward over the front rim of the hip socket
2. When the thigh is adducted (across the midline of the body), the femur slides upwards over the side rim of the hip socket
3. When the thigh is flexed (knee forcefully brought up to the opposite chest in the presence of very tight deep buttock muscles), the ball stays deep in the socket such that the neck of femur and the rim of hip socket impinge.

Heredity
Hip arthritis has a hereditary factor of 50% over the entire average western population. This means that if all your parents and their generation all had bad hips, then all things being equal, you’d have a 50% chance of developing hip arthritis. But you can put the odds in your favour, if you correct the known risk factors from an early age and do things better than your elders.

Farmers
Farmers have a doubled chance of developing hip arthritis.  This is likely due to a mixture of long hours of tractor driving and occasional heavy lifting, both of which will tend to stiffen and dis-coordinate the muscles and movement patterns around the hip joints. 

Lettuce
A study also showed that lettuce eaters develop less hip arthritis, if they ate one or more portions of lettuce every day.  I suspect that the lettuce eaters were less obese and tended to avoid sugars, seed oils and processed foods, and they may have been other than your average couch potato. This was the real reason for the lettuce eater’s healthy hips!

Conclusion

Best thing you can do is daily look for hip flexibility that's as good as that of the kids in your life!
Check what you've learned - try our quiz!

References

1. Ninety-day postoperative cost in primary total hip arthroplasty: an economic model comparing surgical approaches
   https://www.ncbi.nlm.nih.gov/labs/pmc/articles/PMC6370072/
2. Prevalence of Knee and Hip Osteoarthritis and the Appropriateness of Joint Replacement in an Older Population
   https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/414396
3. Osteoarthritis of the Hip
   https://www.aafp.org/afp/2010/0215/p444.html
4. Racial-Ethnic Differences in Osteoarthritis Pain and Disability: A Meta-Analysis
   https://www.ncbi.nlm.nih.gov/labs/pmc/articles/PMC6557704/
5. Differences between race and sex in measures of hip morphology: a population-based comparative study
   https://www.sciencedirect.com/science/article/pii/S1063458419312737
6. Osteoarthritis of the hip and knee in former male professional soccer players
   https://academic.oup.com/bmb/article/125/1/121/4828014
7. Ex-professional association footballers have an increased prevalence of osteoarthritis of the hip compared with age matched controls despite not having sustained notable hip injuries
   https://bjsm.bmj.com/content/37/1/80
8. History of hip arthroscopy
   https://jassm.org/history-of-hip-arthroscopy/
9. A comprehensive review of hip labral tears
   https://www.ncbi.nlm.nih.gov/labs/pmc/articles/PMC2697339/
10. Epidemiology of Osteoarthritis
    https://www.ncbi.nlm.nih.gov/labs/pmc/articles/PMC2920533/
11. Serum vitamin d levels and incident changes of radiographic hip osteoarthritis
    https://fr.art1lib.org/book/232988/3fd2e7
12. Endogenous hormones and the risk of hip and vertebral fractures among older women. Study of Osteoporotic Fractures Research Group
    https://pubmed.ncbi.nlm.nih.gov/9731089/
13. Anterior Hip Joint Force Increases with Hip Extension, Decreased Gluteal Force, or Decreased Iliopsoas Force
    https://www.ncbi.nlm.nih.gov/labs/pmc/articles/PMC2580726/
14. Hip osteoarthritis: influence of work with heavy lifting, climbing stairs or ladders, or combining kneeling/squatting with heavy lifting
    https://pubmed.ncbi.nlm.nih.gov/17634246/
15. Muscle and motion: hip adduction with internal rotation
    https://youtu.be/DzXN930lttA
16. Labral tear
    https://www.thecenteroregon.com/pain-injury-services/hip-pain/labral-tear/
17. 3 things to watch for in athletes with femoroacetabular impingement
    https://www.sportsinjurybulletin.com/3-things-to-watch-for-in-athletes-with-femoroacetabular-impingement/
18. Hip and groin injuries: unravelling the mystery
    https://www.sportsinjurybulletin.com/hip-and-groin-injuries-unraveling-the-mystery/
19. Assessing and managing acetabular labral tears
    https://www.sportsinjurybulletin.com/assessing-and-managing-acetabular-labral-tears/
20. Prevalence of Morphological Variations Associated With Femoroacetabular Impingement According to Age and Sex: A Study of 1878 Asymptomatic Hips in Nonprofessional Athletes
    https://journals.sagepub.com/doi/full/10.1177/2325967120977892#:~:text=In%20a%20systematic%20review%20published,participants%20was%20reported%20as%2023.1%25.&text=Another%20systematic%20review%20evaluating%20asymptomatic,between%2027%25%20and%2029%25
21. Ethnic Differences in Bony Hip Morphology in a Cohort of 445 Professional Male Soccer Players
    https://pubmed.ncbi.nlm.nih.gov/27492971/
22. Prevalence of femoroacetabular impingement and effect of training frequency on aetiology in paediatric football players
    https://journals.sagepub.com/doi/abs/10.1177/1120700018781939
23. Primary osteoarthritis and occupations: a national cross sectional survey of 10 412 symptomatic patients
    https://www.ncbi.nlm.nih.gov/labs/pmc/articles/PMC1740411/pdf/v060p00882.pdf
24. Nonsurgical Treatment of Acetabular Labrum Tears: A Case Series
    https://www.jospt.org/doi/10.2519/jospt.2011.3225?
25. Muscle Activation and Movement Patterns During Prone Hip Extension Exercise in Women
    https://www.researchgate.net/publication/26249942_Muscle_Activation_and_Movement_Patterns_During_Prone_Hip_Extension_Exercise_in_Women
26. Re: The adult hip joint in Saudi Arabia
    https://www.ncbi.nlm.nih.gov/labs/pmc/articles/PMC6077034/
27. How Science and Genetics are Reshaping the Race Debate of the 21st Century
    https://sitn.hms.harvard.edu/flash/2017/science-genetics-reshaping-race-debate-21st-century/
28. All Blacks coach to Kiwi kids: 'don’t sit, squat'
    https://www.stuff.co.nz/national/75385939/all-blacks-coach-to-kiwi-kids-dont-sit-squat