Hip Osteoarthritis Clinical Practice Guideline 2025: APTA Revision Updates Treatment Recommendations

Hip osteoarthritis (OA) affects millions of Australians, causing significant pain, mobility deficits, and reduced quality of life. As physiotherapists, we are often the first point of contact for patients seeking non-surgical management of this progressive condition. The American Physical Therapy Association (APTA) has now released an updated clinical practice guideline that provides contemporary, evidence-based recommendations for our management of hip OA.

The 2025 revision incorporates substantial new evidence published since the previous guideline, strengthening recommendations for exercise therapy while clarifying the role of adjunct interventions including aquatic therapy, manual therapy, and patient education.

What's New in the 2025 Revision?

The updated guideline reflects significant advances in our understanding of hip OA management. Key changes include:

Strengthened Exercise Recommendations

Exercise therapy remains the cornerstone of hip OA management, but the 2025 revision provides more specific guidance on program design:

• Individualised programming is emphasised over generic protocols
• Progressive loading principles should guide exercise prescription
• Multimodal approaches combining strengthening, flexibility, and aerobic exercise show superior outcomes
• Long-term adherence strategies are critical for sustained benefit

Updated Evidence for Aquatic Therapy

The guideline now provides stronger support for aquatic therapy as an effective treatment option:

• Aquatic exercise demonstrates equivalent benefits to land-based exercise for pain and function
• Particularly beneficial for patients with severe symptoms or obesity
• Reduced joint loading allows exercise progression in patients intolerant of land-based programs
• Can be used as a bridge to land-based exercise or as ongoing maintenance

Refined Manual Therapy Recommendations

Manual therapy remains an adjunct intervention with updated guidance:

• Joint mobilisation may provide short-term pain relief
• Soft tissue techniques can address muscle guarding and flexibility deficits
• Should complement rather than replace exercise therapy
• Combined manual therapy and exercise shows superior outcomes to either alone

Evidence-Based Recommendations Summary

The 2025 CPG uses a standardised grading system to indicate strength of recommendations. Here are the key takeaways for clinical practice:

Strong Recommendations (Grade A)

Intervention	Recommendation
Therapeutic Exercise	Individualised strengthening, flexibility, and aerobic exercise programs
Patient Education	Self-management strategies, activity modification, weight management
Supervised Exercise	Initial supervised programs with progression to independent exercise

Moderate Recommendations (Grade B)

Intervention	Recommendation
Aquatic Therapy	Alternative or complement to land-based exercise
Manual Therapy	Adjunct to exercise for short-term pain relief
Walking Aids	Appropriate assistive devices when indicated
Weight Management	Integration with exercise for overweight patients

Exercise Prescription Parameters

The guideline provides specific guidance on exercise dosage:

Strengthening Exercises:

• Target hip abductors, extensors, quadriceps, and core
• 2-3 sessions per week minimum
• Progressive resistance with 8-12 repetitions
• Include both open and closed kinetic chain exercises

Flexibility Exercises:

• Daily stretching recommended
• Target hip flexors, adductors, and external rotators
• Hold positions for 30-60 seconds
• Address muscle length deficits identified on examination

Aerobic Conditioning:

• 150 minutes per week of moderate intensity activity
• Low-impact options preferred (cycling, swimming, walking)
• Progress duration and intensity based on tolerance

Clinical Examination Recommendations

The guideline emphasises the importance of comprehensive assessment to guide individualised treatment:

Activity Limitation and Participation Measures

• Hip disability and Osteoarthritis Outcome Score (HOOS)
• Lower Extremity Functional Scale (LEFS)
• 6-Minute Walk Test
• Timed Up and Go (TUG)
• 30-Second Chair Stand Test

Physical Impairment Measures

• Hip range of motion (flexion, extension, abduction, rotation)
• Hip muscle strength testing (particularly abductors and extensors)
• Gait analysis including Trendelenburg assessment
• Leg length discrepancy measurement

The Role of Aquatic Therapy

One notable update in the 2025 revision is the strengthened evidence for aquatic therapy. For many of our patients with hip OA, land-based exercise may be challenging due to:

• Severe pain with weight-bearing
• Obesity increasing joint loading
• Comorbidities limiting exercise tolerance
• Fear of movement or falling

Aquatic therapy addresses these barriers by:

1. Reducing joint loading through buoyancy (up to 90% weight reduction in chest-deep water)
2. Providing resistance for strengthening through water viscosity
3. Enabling cardiovascular training with reduced impact
4. Improving confidence in a supportive environment

The evidence shows aquatic exercise produces comparable improvements in pain and function to land-based programs, making it a valuable option for appropriate patients.

Patient Education: A Core Component

The 2025 guideline reinforces patient education as essential to successful management:

Key Education Topics

• Understanding osteoarthritis: Explaining the condition without catastrophising
• Pain neuroscience: Helping patients understand that movement is safe
• Activity modification: Adapting rather than avoiding activities
• Self-management strategies: Heat/cold, pacing, flare management
• Weight management: Impact of body weight on joint loading
• Long-term prognosis: Setting realistic expectations

Exercise Adherence

The guideline acknowledges that exercise only works if patients actually do it. Strategies to improve adherence include:

• Involving patients in program design
• Setting meaningful functional goals
• Regular follow-up and program progression
• Home exercise programs with clear instructions
• Integration with daily activities

When to Consider Surgical Referral

While the guideline focuses on conservative management, it provides guidance on appropriate surgical referral:

Consider referral when:

• Significant functional limitation persists despite 3-6 months of adequate conservative treatment
• Severe radiographic changes with persistent symptoms
• Night pain significantly affecting sleep quality
• Quality of life substantially impaired

Important considerations:

• Pre-operative physiotherapy improves post-surgical outcomes
• Patient expectations should be discussed prior to surgery
• Total hip replacement has excellent outcomes for appropriate candidates
• Conservative management may still be preferred by some patients

Applying the Guideline in Australian Practice

While this is an American guideline, the evidence-based recommendations translate well to Australian physiotherapy practice:

Medicare and Private Health Considerations

• Chronic Disease Management plans support ongoing physiotherapy
• Group exercise programs offer cost-effective options
• Aquatic therapy may be accessed through community facilities
• Telehealth can support exercise adherence between appointments

Indigenous and Rural Populations

• Consider access barriers to supervised programs
• Community-based exercise options may be valuable
• Telehealth delivery of education and exercise review
• Cultural considerations in exercise prescription

Clinical Implementation Checklist

When managing patients with hip OA, ensure you address:

✓ Comprehensive assessment using validated outcome measures

✓ Individualised exercise program addressing identified impairments

✓ Patient education on self-management and activity modification

✓ Progressive loading with regular program review

✓ Aquatic therapy consideration for appropriate patients

✓ Manual therapy as adjunct for short-term symptom relief

✓ Weight management integration for overweight patients

✓ Long-term adherence strategies and independent exercise transition

✓ Surgical referral when conservative management inadequate

Key Takeaways

✓ Exercise is the primary intervention for hip OA—this recommendation is now stronger than ever

✓ Individualisation is essential—generic programs are less effective than tailored approaches

✓ Aquatic therapy is effective and should be considered for patients intolerant of land-based exercise

✓ Manual therapy complements exercise but should not replace it

✓ Patient education drives self-management and long-term adherence

✓ Multimodal approaches combining exercise, education, and weight management show best outcomes

✓ Conservative management is first-line—surgery reserved for those who fail adequate physiotherapy

The 2025 APTA Clinical Practice Guideline provides a robust framework for evidence-based management of hip osteoarthritis. By implementing these recommendations, we can optimise outcomes for our patients while ensuring our practice aligns with contemporary evidence.

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This article is part of our Clinical Evidence Series, designed to help Australian physiotherapists stay current with high-quality research and clinical guidelines relevant to daily practice.