Part of Hip osteoarthritis
Stages of hip arthritis, and how fast it progresses
Warning signs, and when to get help
What are the stages of hip arthritis?
They are grades from an X-ray scoring system, and the one most often behind the numbers is Kellgren and Lawrence, published in 1957 under the title Radiological assessment of osteo-arthrosis. The clue is in the title: it is a method for scoring films, developed so that researchers comparing populations could agree on what a radiograph showed. It runs from grade 0, a normal film, up to grade 4, so there are 5 steps and not 4. The features it scores are the ones visible on an X-ray:
- How much space is left between the ball and the socket, which stands in for the thickness of the cartilage, since cartilage itself does not show on a plain film.
- Bone spurs around the edge of the joint, which radiologists call osteophytes.
- Hardening of the bone just under the joint surface, which looks whiter and denser on the film.
- Change in the shape of the bone ends in the more advanced grades.
Notice what is missing from that list. Pain is not on it, and neither is stiffness. Nor is how far you can walk, whether you sleep, or whether you can get your shoe on. A grade is a description of a picture, scored by the person reading it, and two readers do not always score it the same way. In the OARSI and OMERACT comparison of three ways of grading hip X-rays, agreement between different readers on the Kellgren and Lawrence grade was only moderate, and lower than their agreement on a straight measurement of the joint space, in the 50 subjects whose films were read by more than one reader (Gossec and colleagues, 2009).
Take that as a point about the scale rather than about your hip. Two readers landing a grade apart does not mean either of them has misread the joint, and it is not a reason to dismiss a report or to go hunting for a better number.
Hips are not always graded that way either. Radiologists and researchers also measure the narrowest gap in the joint in millimeters, and the Icelandic cohort described further down used both the measurement and the Kellgren and Lawrence grade (Franklin and colleagues, 2011). So the phrase "stage 2" does not even mean one fixed thing until you know which system produced it.
There is a reason for the mismatch between what you were searching for and what you have found. People look up stages because they want a map of what happens next. The grading systems were never built to provide one.
Does the stage match how much it hurts?
Kim and colleagues took 946 participants from the Framingham study and 4,366 from the Osteoarthritis Initiative and compared where people said their hips hurt with what their X-rays showed. Among hips that were frequently painful, only 15.6 percent in Framingham and 9.1 percent in the Osteoarthritis Initiative had arthritis on the film. Looked at the other way round, among hips that did show arthritis on the film, only 20.7 percent and 23.8 percent were frequently painful (Kim and colleagues, 2015).
So about three quarters of hips with changes on an X-ray are not frequently painful, and most painful hips show nothing on the X-ray. That is not a flaw in the imaging so much as a flaw in the assumption behind the question. The film shows structure. Pain comes from a longer list that includes how irritable the joint is at the moment, how strong the muscles around it are, how well you are sleeping and how much you have been doing.
This is why NICE advises that in people aged 45 and over, osteoarthritis can usually be diagnosed without an X-ray at all when the joint aches with activity and there is either no morning stiffness at all or morning stiffness lasting no longer than 30 minutes. A film is more useful for ruling other things in or out than for grading how bad your day is.
How fast does hip arthritis progress?
It varies, and nobody can read your speed off a grade. Anyone giving you an average is giving you a number that does not apply to an individual.
The most informative study is a long retrospective cohort in Iceland. Franklin and colleagues looked at 2,953 hips in people who had undergone colon radiography between 1980 and 1997. They graded those hip X-rays, then followed the group through national registers until 2008, which gave 11 to 28 years of follow-up.
Hips with radiographic osteoarthritis were much more likely to be replaced: using the Kellgren and Lawrence grade, a hazard ratio of 12.9, with a 95 percent confidence interval of 7.9 to 21, compared with hips without it. The cumulative incidence of hip replacement was 16.9 percent in the hips the authors counted as arthritic by the other measure, a narrowest joint gap of 2.5 mm or less. And the finding the authors drew attention to is the one that matters here: more than 4 in 5 of the hips showing radiographic signs of osteoarthritis had not had a replacement for osteoarthritis by the end of follow-up (Franklin and colleagues, 2011).
The same paper points the other way as well. Its authors concluded that the risk of replacement is substantially raised in hips with radiographic osteoarthritis whether or not they were painful, and that the risk rose as the joint space got narrower. So the changes on a film are not meaningless. They are just a long way from a timetable.
Read the population before you read the numbers, and do not read any of these figures as your own odds. More than 4 in 5 is what happened to a group of Icelandic hips found on a scan done for something else. It is not your chance of avoiding an operation. These hip changes were found on X-rays taken for a bowel investigation, not on films ordered because someone had a painful hip. That makes it a reasonable picture of what happens to hips that show arthritis on a film, and a poor guide to what happens to someone sitting in a clinic because their hip hurts, who by definition is further along.
It is Icelandic, it is retrospective, and whether a hip gets replaced depends on surgical thresholds and health services as much as on the joint. A hip that was never replaced is also not the same as a hip that never got worse, because a register counts operations and nothing else: a hip that deteriorated but was managed without surgery, and a hip belonging to someone who died, turned an operation down or was never well enough for one, all count here as not replaced. Even with all of that, a figure of more than 4 in 5 not reaching a replacement over up to 28 years is a long way from the picture most people arrive with.
Alongside it, the NHS says osteoarthritis does not necessarily get any worse over time and can sometimes gradually improve, and that how severe the symptoms get varies greatly from person to person and between joints. Be aware that the sources do not all say the same thing here: AAOS, writing for patients in the United States, describes osteoarthritis as gradually worsening over time. Both are reputable, neither is predicting your hip, and taken together they say the course is genuinely unpredictable.
What is end stage hip arthritis, and does it mean surgery?
End stage is a phrase clinicians use among themselves, not a stage you are formally assigned. It describes a hip where the X-ray changes are at the top of the scale and, usually, where the symptoms are limiting enough that replacement is on the table. Those two conditions do not always arrive together, which is exactly the problem with reading a grade as a verdict. A grade 4 hip in someone who walks their dog twice a day and sleeps through the night is not an operation waiting to happen.
It runs the other way too, and this is the half patients are rarely told. A hip that has not reached the top of the scale is not disqualified from a replacement. If yours is dominating your life after months of proper treatment, being told the X-ray does not look bad enough is the start of a conversation rather than the end of one. The film still matters to a surgeon, for confirming that the hip joint itself is the source of the pain, for ruling other causes in or out, and for planning an operation if one is agreed. What it does not do is trigger the operation by reaching a number.
The bar for that conversation is set by symptoms and by what has already been tried. NICE advises that joint replacement is worth discussing when your hip symptoms have a big effect on your quality of life and treatment without surgery, such as exercise, weight loss and pain relief, has not worked or is not suitable. NICE also advises deciding on referral from a clinical assessment rather than from systems that score how severe the disease is, which is the formal version of the point this whole page makes.
If that description fits you, the next step is an assessment and not a wait. Take it back to your doctor and ask about referral, and treat nothing on this page as a reason to put that off. Whoever examines you decides this with you, from your symptoms, the examination, the film and what you want to be able to do again, and their assessment of your own hip comes before anything written here.
This page deliberately stops there. It does not describe the operation, the implants or the recovery. Hip replacement rehab covers what happens afterward if that is where you are heading, and treating hip arthritis without surgery covers everything that comes before it.
What makes a difference to how it goes?
The latest Cochrane review of land-based exercise for hip osteoarthritis pooled the trials. Against no exercise or usual care, exercise probably reduces pain and improves physical function slightly. The authors judged those average changes unlikely to be large enough to be clearly noticeable, and found probably little difference to quality of life (Hall and colleagues, 2026).
That is quoted in full on purpose. Trimming it would make it sound stronger than it is. What those trials measured was symptoms and function. None of them measured whether exercise changes the joint, so nothing here claims it does.
What else sits within reach is mostly mundane: keeping the leg strong, keeping the hip moving, managing weight where that applies, treating a flare as a flare and not as a collapse, and sleeping. Treating hip arthritis without surgery is where that menu is set out with what the guidelines say about each part. If you cannot start with standing exercise, seated and standing exercises for older adults is the gentler entry point, and the full staged hip osteoarthritis program is where you go once you are moving.
What a grade on a report does and does not tell you
It tells you that someone looked at a film and described what they saw, using a scale designed for exactly that. It tells a surgeon or a radiologist something useful when read next to an examination.
It does not tell you how much your hip will hurt next year, whether you will need an operation, how far you will be able to walk, or how quickly anything will change. It is not a score you need to lower, and no treatment on this site is offered on the basis that it will.
If your joint pain affects several joints, comes with swelling, and brings morning stiffness that runs on well past 30 minutes, that pattern is not the osteoarthritis one, and rheumatoid arthritis describes a condition that is diagnosed and treated differently. That is a question to raise with your doctor, not something to read off a hip X-ray. Where hip arthritis pain is felt covers the location pattern that fits the hip joint itself.
When to see a physio or doctor
Book a routine appointment with a doctor or physio if hip pain is affecting your sleep or what you normally do, if it keeps returning, or if the hip stays stiff for more than 30 minutes after you wake. If you already have a diagnosis and 6 to 8 weeks of regular exercise has changed nothing, that is a reason for a review rather than a reason to stop.
If you have been given a grade and it has frightened you, take the report to an appointment and ask what the examination showed alongside it. That is a fair question and the answer usually helps.
If the hip is limiting your sleep, your walking or your work despite months of treatment, say that plainly at the same appointment and ask whether a referral to discuss joint replacement is reasonable now. Ask that too, and do not let anything on this page hold you back from asking it.
Some signs need help faster than a routine appointment. They are listed under the warning signs below, with how quickly to act on each.
Related exercise programs
Warning signs
Get emergency help now
- Emergency: you have had a fall or an injury and now have severe hip pain, or you cannot walk or put weight on the leg. Call emergency services or go to an emergency department. This can be a sign of a broken hip (hip fracture).
- Emergency: tingling or loss of feeling in the hip or leg after a fall or injury. Call emergency services or go to an emergency department.
- Emergency: pain, tingling, numbness or weakness in both legs, numbness or altered feeling around your genitals or bottom, or new trouble peeing or controlling your bladder or bowels. The same applies if you lose feeling in one leg. Call emergency services or go to an emergency department straight away. These can be signs of pressure on the nerves at the base of the spine (cauda equina syndrome).
Get help today
- Same day: the hip is hot and swollen, or the skin over it has changed color, or you have hip pain with a high temperature or feel hot, cold or shivery. Get medical help the same day, and go to an emergency department if you feel very unwell. A joint infection needs treatment quickly. If you have a very high or very low temperature, shivering you cannot control, you are breathing very fast or finding it hard to breathe, you are confused or your speech is slurred, your skin, lips or tongue look blue, gray, pale or blotchy (on brown or black skin this can be easier to see on the palms of the hands or soles of the feet), or you have a rash that does not fade when you press it, call emergency services, as this can be sepsis.
- Same day: severe hip pain that came on suddenly without a fall, or pain that is getting worse quickly over a few days. Get medical advice the same day.
- Same day: new hip or groin pain after a fall, even a small one, if you are older, have low bone density (osteoporosis) or have taken steroid tablets for a long time, even if you can still walk. Get medical advice the same day. A broken hip is not always obvious at first.
- Same day: a leg or foot that is getting weaker, for example your foot drags, catches on the ground or slaps down when you walk (foot drop). Get medical advice the same day. If the weakness is getting worse by the hour, go to an emergency department.
- Same day: a child or teenager has sudden pain in the hip, thigh or knee, is limping, or cannot put weight on one leg. Get an urgent appointment with a doctor the same day. If they have a high temperature or seem very unwell, go to an emergency department. This page is for adults, and hip pain in children has different causes.
- Same day: hip or groin pain that is worse at night or does not ease with rest, and keeps getting worse. If you are being treated for cancer now, contact your cancer team the same day.
Book an appointment
- Within a day or two: hip or groin pain that is worse at night or does not ease with rest, and keeps getting worse. If you have had cancer, now or in the past, or are losing weight without trying, see your doctor sooner, within a day or two, and mention it. This applies even if the pain is not getting worse.
- Within a few days: hip or groin pain that is worse at night or does not ease with rest, and keeps getting worse. See your doctor within a few days.
- Within a few days: new groin or hip pain and you take steroid tablets long term, or have in the past, or you regularly drink a lot of alcohol. This can be a sign of a problem with the blood supply to the top of the thighbone (avascular necrosis). Book an appointment with your doctor within a few days and mention the steroids or alcohol.
Common questions
What are the 4 stages of hip arthritis?
There is no official four-stage system that patients are placed into. The pages giving four stages are repackaging an X-ray grading scale, most often Kellgren and Lawrence, which actually runs 0 to 4 and so has 5 steps including a normal film (Kellgren and Lawrence, 1957). It scores the picture: joint space, bone spurs, hardened bone and changes in the shape of the bone ends. It does not score pain, stiffness or what you can do.
What does stage 3 hip arthritis mean?
On a Kellgren and Lawrence report it means the person reading the film judged the changes moderate rather than mild or severe, based on the features of the film. It does not place you on a path or set a timetable, and agreement between different readers on this grade in hip X-rays is only moderate (Gossec and colleagues, 2009), so the same film does not always get the same number. If a grade is driving a decision you are being asked to make, ask what the clinical examination showed, because NICE advises deciding on referral for joint replacement from an assessment of the person rather than from systems that score how severe the disease is.
How fast does hip arthritis progress?
There is no average anyone can apply to you. The most informative long study followed 2,953 hips in Iceland for 11 to 28 years and found that hips with arthritis on X-ray were far more likely to end up replaced, with a hazard ratio of 12.9, and yet more than 4 in 5 of those hips had still not been replaced by the end of follow-up (Franklin and colleagues, 2011). Replacement did become more likely as the joint space got narrower. Those changes were picked up on X-rays taken for an unrelated reason, so the group is not the same as people attending a clinic in pain, and neither figure is a personal risk for anyone.
Does hip arthritis always get worse?
No. The NHS says osteoarthritis does not necessarily get any worse over time and can sometimes gradually improve, and that how severe the symptoms get varies greatly from person to person and between joints. AAOS, writing for patients in the United States, does describe osteoarthritis as gradually worsening over time, so the two sources differ on exactly this question. In the clinic, plenty of hips settle into a pattern of good months and worse months, not a steady downhill line. That is also why a flare is not evidence that the joint has changed, which hip arthritis flare ups goes into.
What is end stage hip arthritis?
It is a working phrase rather than a diagnosis you are given. In practice it describes a hip whose X-ray shows the most advanced changes and whose symptoms are limiting enough that joint replacement is being discussed. Those two do not always arrive together, which is the whole problem with reading a grade as a verdict. A grade on its own neither books an operation nor rules one out. That decision is made with you by the clinician examining you, from your symptoms, the examination, the film and what you want to be able to do.
Does a worse X-ray mean more pain?
Not reliably. In the Framingham study of 946 people, 20.7 percent of hips with arthritis on X-ray were frequently painful, and in the Osteoarthritis Initiative with 4,366 people the figure was 23.8 percent (Kim and colleagues, 2015). The mismatch runs the other way too: most hips in people with frequent hip pain showed no arthritis on the film at all.
Can hip arthritis stay the same for years?
Yes, and in the Icelandic cohort most hips with radiographic arthritis went 11 to 28 years without reaching a replacement (Franklin and colleagues, 2011). Not reaching a replacement is not proof that a hip stayed the same, because that study counted operations, not symptoms. What tends to change over that time is how the hip is managed and how strong the leg is, as much as what the joint looks like. Nothing on this page claims exercise alters what shows on an X-ray, because that is not what the exercise trials measured.
References
- Kellgren JH, Lawrence JS. Radiological assessment of osteo-arthrosis. Annals of the Rheumatic Diseases. 1957;16(4):494-502. https://doi.org/10.1136/ard.16.4.494
- Gossec L, Jordan JM, Lam MA, et al. Comparative evaluation of three semi-quantitative radiographic grading techniques for hip osteoarthritis in terms of validity and reproducibility in 1404 radiographs: report of the OARSI-OMERACT Task Force. Osteoarthritis and Cartilage. 2009;17(2):182-187. https://doi.org/10.1016/j.joca.2008.06.009
- Kim C, Nevitt MC, Niu J, et al. Association of hip pain with radiographic evidence of hip osteoarthritis: diagnostic test study. BMJ. 2015;351:h5983. https://doi.org/10.1136/bmj.h5983
- Franklin J, Ingvarsson T, Englund M, Ingimarsson O, Robertsson O, Lohmander LS. Natural history of radiographic hip osteoarthritis: a retrospective cohort study with 11-28 years of followup. Arthritis Care and Research. 2011;63(5):689-695. https://doi.org/10.1002/acr.20412
- Hall M, Lawford BJ, Hinman RS, et al. Exercise for osteoarthritis of the hip. Cochrane Database of Systematic Reviews. 2026;(7):CD007912. https://doi.org/10.1002/14651858.CD007912.pub3
- National Institute for Health and Care Excellence. Osteoarthritis in over 16s: diagnosis and management (NG226). 2022. https://www.nice.org.uk/guidance/ng226
- American Academy of Orthopaedic Surgeons. Osteoarthritis of the hip. OrthoInfo. https://www.orthoinfo.org/en/diseases--conditions/osteoarthritis-of-the-hip/
- NHS. Osteoarthritis. https://www.nhs.uk/conditions/osteoarthritis/
Written and checked by the PocketPhysio editorial team. Last updated 2026-10-18.
This page is general education, not a diagnosis or a personal treatment plan. See a physiotherapist or doctor for advice about your own situation.