Tanya went from constant, awful pain to nearly pain-free without surgery. She’s still deciding what to do next, and her situation shows exactly why that decision is more complicated than “wait until it’s bad enough.”
Rick Olderman, MSPT is an orthopedic physical therapist with 30 years of clinical experience, former owner of an orthopedic PT clinic, and author of the Fixing You book series, including Fixing You: Hip & Knee Pain and the award-winning Pain Patterns (2025 NIEA Award winner). He created an APTA-approved continuing education course teaching other clinicians his systems-thinking approach to chronic pain.
The advice almost everyone gets, and why it’s incomplete
If you have hip osteoarthritis, you’ve probably heard some version of this from your surgeon: keep going until the pain is bad enough to justify replacing the joint. It’s reasonable advice from where they sit. A hip replacement has a lifespan, and nobody wants to use it up too early.
But for a lot of people that advice translates to: how long can I hold out? And once that’s the goal, something else starts happening that most surgeons aren’t trained to watch for.
Important: Always follow your medical team’s guidance for your specific case. This article isn’t a reason to delay a surgery your doctor has recommended, and it isn’t a diagnosis. It’s a systems-level view of what else may be happening in your body while you decide.
Hip Arthritis Pain: Should I Get Hip Replacement or Keep Exercising? — watch on YouTube
Tanya’s story: constant pain to nearly pain-free, still deciding
Tanya has bilateral hip arthritis, worse on the left. Her X-ray showed a flattened femoral head and subchondral cysts. Before finding my program, she was in constant, awful pain day and night, walking with a limp, and had consulted a surgeon who felt her hip was likely too damaged for a simpler resurfacing procedure and would need a full replacement.
She worked through my home program. The result: she’s now mostly pain-free except with some weight-bearing activities like stairs, sleeps comfortably on either side for the first time in years, and still has a slight limp. She hasn’t fully resolved everything — she still can’t fully abduct either leg — and she’s still deciding whether to move forward with surgery.
I’m not writing this to talk Tanya, or you, out of surgery. Her situation is a useful example precisely because it isn’t fully resolved. It shows what progress without surgery can look like, and it shows that correcting the mechanics first doesn’t always mean you’ll never need the operation. Sometimes it means you go into that decision from a much better starting point, with less pain, improved function, and a clearer picture of what’s driving what.
Should I wait, or have hip replacement surgery now?
There’s no universal answer. Always defer to your medical team on your specific case. But before deciding, it helps to know two things most people aren’t told.
First: structural findings — worn cartilage, a labral tear, bone-on-bone contact — don’t automatically explain your pain. Imaging studies show labral tears and cartilage defects at similar rates in hips with and without pain.1 I’ve had patients scheduled for surgery who, after correcting an underlying movement pattern, no longer needed it. A published case series on this exact pattern found patients achieved complete symptom resolution with conservative treatment alone.2
Second: waiting isn’t free. It has a cost of its own.
The hidden cost of waiting
Once “hold out as long as possible” becomes the plan, most people start compensating: limping, favoring the leg subtly, avoiding stairs — without realizing those often subconscious decisions play out somewhere else. They land in the rest of your body, and how much damage it does depends heavily on how prepared that part of your body is to absorb it.
Here’s what I see, in rough order of how well it’s documented:
- The opposite knee. People with one-sided hip osteoarthritis are more likely to eventually need their opposite knee replaced than the knee on the same side as the bad hip, tied to measurably higher loading on that knee even before hip surgery happens.3
- The opposite hip. In my clinical experience, the same asymmetric loading that stresses the opposite knee often extends up into the opposite hip as well.
- A Sidebending Problem — and from there, the back and sciatic nerve. Limping shifts your weight unevenly through the pelvis and spine. I’ve seen this create what I call a Sidebending Problem, an uneven pelvis and rib cage, which feeds directly into back pain and sciatica. I had one patient with a hip labral tear whose new left-sided back pain traced directly back to this: he’d started weight-bearing more heavily on his healthy leg to protect the torn hip, and that left side began breaking down as a result. (Watch that case here.)
- The opposite ankle and foot, including plantar fasciitis. You won’t find this one in the research. Plantar fasciitis studies focus on foot mechanics, overpronation, or a tight calf — not on overload from a hip on the other side of the body. That’s simply outside what that research is designed to measure. But clinically, I’ve seen this many times: the “good” foot breaking down because it’s been doing double duty for months.
There’s also waiting itself. One study found that hip replacement patients who waited longer than six months after referral had greater disability going in, and realized smaller gains in quality of life and mobility afterward, than patients who had surgery sooner.4 This could point to the compensations compounding over time.
How much all of this matters also depends on something I haven’t covered yet in this series: the shape of your thigh bone. Femoral anteversion and retroversion describe the natural rotation of the thigh bone, inward or outward, and either can deliver significant stress to the hip and knee if your movement strategy doesn’t account for it. This isn’t because femoral version is a problem. It’s because how you use your body should differ depending on which shape you have. This is so important, I’ve devoted the last article in this series solely to understanding this principle.
Figure 2a, b. a. Femoral anteversion. b. Femoral retroversion.
Why your doctor won’t catch this
This gets into the division of jobs in healthcare. A surgeon’s job is to be excellent at replacing a hip joint — evaluating the joint, planning the surgery, executing it well. That’s a lot of responsibility and a valuable skill. Their job isn’t to track what months of weight shifting does to your opposite knee, your back, or your foot. That’s a physical therapist’s job. When conservative treatment hasn’t changed the pain, the assumption is often that everything possible has already been tried. In my Arthroscopic Surgery article, I go into why that assumption doesn’t always hold, and why conservative care often stops short of addressing the movement pattern actually driving the pain.
Surgery also doesn’t automatically undo the compensations, or the mechanics that helped create the problem in the first place. Research using EMG has found abnormal glute activation patterns persisting after hip replacement, sometimes for years,5 and a large long-term study found moderate-to-severe pain in 8.1% of patients two years after primary hip replacement, rising to 10.8% at five years.6 The joint gets replaced. The pattern that helped wear it out doesn’t automatically go with it.
A better decision framework than “wait until it’s bad enough”
Here’s what I’d suggest instead, whether or not you’re currently facing this decision:
Spend a few focused weeks correcting the underlying movement pattern. I walk through the specific pattern, self-test, and fix behind most hip pain in .
While you’re at it, check how your other leg is holding up. Are you limping? Is your “good” knee, hip, back, or foot starting to complain too? That’s information your surgeon isn’t going to ask you about, but it should inform your decision about pulling the trigger.
Reassess. If your pain and function meaningfully improve — the way they did for , and largely for Tanya — you may be able to delay surgery on your own terms rather than your pain’s terms, while protecting the rest of your body in the meantime.
If it doesn’t change much, surgery is a reasonable, informed choice. You’ll go into it having already reduced some of the mechanical stress on the joint, with less accumulated compensation elsewhere in your body.
That’s the value of a systems perspective. Sometimes it doesn’t hand you an answer you necessarily want, but it makes sure the decision accounts for your whole body, not just the one joint that hurts the most right now. Most medical training simply doesn’t include that systems perspective, which is exactly the gap I built my practice around.
As I mentioned, in my next article I’ll explain femoral anteversion and femoral retroversion — a potentially huge stressor to your hips that almost no one ever checks — and tell you how to work with it.
Are you in the middle of this decision yourself? Have you noticed compensation showing up somewhere else — the other knee, your back, your feet? I’d like to hear about it in the comments. And if this article helped you think through it differently, let me know.
See it for yourself
- Watch Tanya’s and Sharon’s Q&A on YouTube, where I answer their real questions about their hip pain.
- Watch Sylvia’s full story, referenced throughout this series.
- 7 Days to Better Hips. My home program, built on the same approach I used with Sylvia and Tanya, including the pain-reduction phase most people skip past too quickly on their way to more advanced exercises.
- Pain Patterns: Why You Are in Pain and How to Stop It. My 2025 National Indie Award winning book, which includes the free Pain Patterns assessment tool and goes further into this kind of systems-level decision-making than any single article can.
Read my book: Pain Patterns: Why You Are in Pain and How to Stop It
Try the program: 7 Days to Better Hips
Watch: my YouTube channel for guided exercises.
FAQ
Not necessarily. Check rather than assume. In my experience the compensating leg usually has capacity left. The sooner you address both the hip pattern and how the other leg has been absorbing load, the more of that capacity you protect.
There isn’t a universal number of months that’s safe for everyone. The more useful question is what happens to your pain, function, mobility, and compensatory patterns while you wait — which is exactly what this article walks through.
Sometimes. If symptoms and function improve enough, some people choose to postpone surgery, the way Tanya has. Physical therapy isn’t guaranteed to eliminate the need for replacement when the joint is severely compromised, but it can change the timeline and the starting point you go into surgery from.
Not automatically. The hip joint changes, but the movement patterns that developed while you were compensating don’t necessarily go with it, because they are subconscious. This is exactly why I recommend addressing this whether or not surgery is in your future.
No. This genuinely falls outside a surgeon’s scope of training — not because they’re not thorough, but because their expertise is the joint and the operation itself. Raise it with a clinician trained to look at the whole system, alongside your surgical care, not instead of it. Hopefully your PT will know how to look at it all.
Yes. This is exactly what I built into my home programs and Pain Patterns: a way to check how well-prepared the uninvolved side is, rather than waiting for it to start hurting on its own.
Yes, though the compensation pattern looks a little different. You may be shifting more toward the less-affected hip rather than a fully uninvolved leg. The same principle holds: check how that side is handling the extra load rather than assuming it’s fine.
No, and I wouldn’t want to promise that. Some people, like Sylvia, avoid it. Others, like Tanya, make significant progress but may still choose surgery. Either way, you’re making a more informed decision than “wait until it’s unbearable.”
Send it below. I read every question, and use the most common ones to shape future articles, videos, and my monthly email — sometimes by featuring them (never with identifying details) in a public answer. I ask for your email in case I need more detail, or want to let you know when I’ve covered it.
Footnotes
- Heerey JJ, Kemp JL, Mosler AB, et al. What Is the Prevalence of Hip Intra-Articular Pathologies and Osteoarthritis in Active Athletes with Hip and Groin Pain Compared with Those Without? A Systematic Review and Meta-Analysis. Sports Medicine. 2019. Found labral tears and cartilage defects at similar rates in people with hip/groin pain and pain-free controls, undermining the assumption that a structural finding alone explains pain.
- Grant C, Pajaczkowski J. Conservative Management of Femoral Anterior Glide Syndrome: A Case Series. Journal of the Canadian Chiropractic Association. 2018;62(3):182–192. Patients with this exact pattern achieved complete symptom resolution using conservative treatment alone.
- Shakoor N, Block JA, Shott S, Case JP. Asymmetric Knee Loading in Advanced Unilateral Hip Osteoarthritis. Arthritis & Rheumatism. 2003;48(6):1556–1561. Found that people with unilateral hip osteoarthritis are preferentially predisposed to develop progressive osteoarthritis in the contralateral (opposite) knee rather than the knee on the same side as the affected hip.
- Garbuz DS, Xu M, Duncan CP, Masri BA, Sobolev B. Delays Worsen Quality of Life Outcome of Primary Total Hip Arthroplasty. Clinical Orthopaedics and Related Research. 2006;447:79–84. Patients who underwent hip replacement more than six months after referral had greater preoperative disability and realized smaller gains in quality of life and mobility than patients treated sooner.
- May MC, Zanirato A, Puce L, Giannarelli E, Trompetto C, Marinelli L, Formica M. Electromyography After Total Hip Arthroplasty: A Systematic Review of Neuromuscular Alterations and Functional Movement Patterns. Journal of Clinical Medicine. 2026;15(1):400. Found postoperative EMG consistently reveals non-physiological activation patterns, including delayed or prolonged gluteus medius activity, persisting after hip replacement.
- Singh JA, Lewallen D. Predictors of Pain and Use of Pain Medications Following Primary Total Hip Arthroplasty (THA): 5,707 THAs at 2-Years and 3,289 THAs at 5-Years. BMC Musculoskeletal Disorders. 2010;11:90. Moderate to severe pain was reported by 8.1% of patients at two years, rising to 10.8% at five years.