Psoriatic Arthritis and Hip Pain: What You Need to Know

Technically, psoriatic arthritis, an inflammatory autoimmune disease, can attack any joint in your body. But, typically, it’s the small joints in your hands and feet that get affected — and that’s true for about half of all PsA patients, says Delamo I. Bekele, MBBS, a rheumatologist at the Mayo Clinic in Rochester, MN. “A smaller subset will tend to have the bigger joints being involved,” he explains. More often, that means the knees, but for between 7 percent and 15 percent of PsA patients, that also means the hip joints. 

While hip pain may not be that common, it can provide signs of how your condition is progressing — and what else might be going on. If your hips are achy, or feel stiff when you get up in the morning, read on to learn more about hip pain in PsA. 

Understanding Hip Pain and Psoriatic Arthritis

There are two important points about hip pain and PsA:  

Hip pain by itself is rarely the first sign of psoriatic arthritis

Instead, the hip joint gets affected after you’ve had the disease awhile, “especially in those patients with a very aggressive type of joint inflammation, usually involving several joints — hands, feet, hips, knees, ankles,” says Dr. Bekele. Usually, those are the PsA patients that have what Dr. Bekele calls a “more aggressive subtype of psoriatic arthritis” for reasons experts really don’t understand. 

There’s a difference between how you and your rheumatologist define the hip joint

“When patients talk about the sides of their hips and that kind of stuff, we don’t actually consider that the hip joint,” says Steven C. Vlad, MD, a rheumatologist at Tufts University Medical Center in Boston. It helps to think of a ball and socket: Your hip joint is where the thigh bone (the femur) fits into the pelvic cavity (or socket) known as the acetabulum.  

The Signs of Inflamed Hips in PsA

Here are some of the symptoms you’ll feel if your hip joint has been damaged: 

• Stiffness or soreness after you’ve woken up or after you’ve been sitting for a while, says Dr. Vlad, who’s also an assistant professor at the Tufts University Medical School.   
• The pain usually goes away after you start moving around, which is a typical hallmark of inflammatory arthritis conditions, says Dr. Vlad. One caveat: “Things get better, but sometimes there’s only so far [the soreness] is going to improve. It may be better than it was two hours ago, but it might still bother them,” he explains.  
• Discomfort or pain in the front of the groin or thigh. Sometimes in the buttocks (but that could be a sign of psoriatic spondylitis), says Dr. Bekele.
• Difficulty going up the stair or walking, or walking with a limp.  

If you have any of these symptoms, make an appointment with your rheumatologist or primary doctor. They’ll be able to take a history, maybe run some imaging tests, and see if it’s the hip joint that’s really involved, or if something else is going on like an infection or bursitis.  

Diagnosing Hip Pain in PsA

To check if it’s actually the hip joint being affected, a rheumatologist will do the following: 

Take a history of the pain. You’ll be asked when the pain started, where it hurts (the outer thigh, say), and when (in the morning, all day).  

Do a physical exam. Your provider will move your leg around to see what happens to the hip joint. “If there’s a problem, we expect people to feel pain as we move the joint or we might see limitations in range of motions. Those are major things,” says Dr. Vlad. 

Do some imaging tests (maybe). If you already have PsA, you’ve already had an MRI or CT-scan and there might not be any need to do more, especially if it’s clear from the history and physical exam that, yes, it’s your hip joint that’s causing the problem, says Dr. Vlad.  

In the rare instance where hip pain may be the first sign of PsA, a rheumatologist will definitely order imaging. Doctors are looking for abnormalities in the synovium, the lining of the joint. “When somebody has psoriatic arthritis and it’s affecting their hip, we can see fluid in the joint. We can see swelling of the synovium, and both of those are a hint that there’s abnormal inflammation,” he explains.

In PsA, your immune system is targeting your joints and damaging them with the resulting inflammation versus the wear and tear of osteoarthritis.  

Other Conditions That Can Cause Hip Pain

Doctors may also order imaging if there’s no inflammation in the hip joint and suspect something else might be going on, including one of the following:  

Osteoarthritis (OA) 

When the cartilage protecting the bones wears down, you develop osteoarthritis in the joints, including the ones in your hips. “OA of the hip happens in something like 2.5 percent to 5 percent of the population over life.  

That means that people who have PsA can still get OA of the hip,” notes Dr. Vlad. And while age is a risk factor for OA (the longer you live, the more wear and tear on your joints), so is having an inflammatory arthritis like PsA.

“If you get enough inflammatory damage, you damage the joint and it starts to fail — and that’s osteoarthritis. So that can absolutely happen in psoriatic arthritis, but it also can just be chance and unrelated to the PsA,” he explains.  

One sign that you have OA instead of PsA in the hips: The area hurts the longer you’re on your feet, says Dr. Vlad.  Another clue: The meds you’re taking to control PsA aren’t easing the pain. 

Bursitis or enthesitis

You develop bursitis when the small, fluid-filled sacs known as bursa that cushion the bones and tendons near your joints get inflamed.  This can happen near the hip joint, especially where tendons attach to bone on the trochanter — the part of the femur that sticks out to the side, says Dr. Vlad.  

You can also have a condition known as enthesitis, which is common when you have joint inflammation. “It’s basically inflammation where the tendons attach onto bones,” explains Dr. Bekele, “so around the hip joint in the bursa.” When you have bursitis or enthesitis, you’ll feel the pain on the sides of your thigh, especially at night, notes Dr. Bekele. 

Infected hip joints

Taking immunosuppressant drugs like methotrexate or biologics can make you prone to infections, including in the hip joints.  How do the hips get infected? Usually from another bacterial infection, like a urinary tract infection (UTI) or pneumonia, when the bacteria get into the bloodstream and travel to the hip joint, notes Dr. Vlad. This can result in a painful hip. Doctors can diagnose an infected hip joint by taking blood and, sometimes, by doing a biopsy of the fluid in the joint and checking to see if it has bacteria. 

Osteonecrosis 

When the blood supply to parts of the bone is cut off, the bone tissue dies off. This can happen to the head of the femur. Doctors don’t know why the blood supply is disrupted, but they do know that long-term steroid use, especially at high doses, can up your risk.  “Luckily, this is not a big risk — this is something that happens rarely, but it does happen,” says Dr. Vlad. 

Psoriatic spondylitis

About five percent to six percent of PsA patients have spinal inflammation, or psoriatic spondylitis, says Dr. Bekele. “Again, uncommon, but those patients have a very high likelihood of developing hip involvement,” he adds.

When you have psoriatic spondylitis, you tend to feel the pain in your butt. “Patients often say they have hip pain, but they’re really referring to their buttocks or in the low back and buttock area,” says Dr. Bekele. 

Treating Hip Pain and PsA

There are several ways to treat hip pain that’s a result of PsA: short-term solutions, long-term treatment, and managing the pain with exercise and physical therapy. 

Short-term relief

One of the best ways to stop the pain is corticosteroid injections, either in the hip joint itself or into the hip bursa if you also have bursitis, says Dr. Bekele. You can also take non-steroidal anti-inflammatory drugs (NSAIDS), like ibuprofen, especially if you have a mild case of PsA. 

Long-term treatment

To get rid of the pain in the hip joint, you’ll want to get inflammation under control. But that could depend on different factors, including the meds you’ve already taken, whether other joints besides the hip are affected, and whether you have skin psoriasis as well, Dr. Bekele explains. 

Usually, though, doctors will try different medications — going from NSAIDs to DMARDs like methotrexate to biologics like TNF blockers. Steroids seem to be a last resort, in part because they make skin psoriasis worse. 

There are two caveats, say Dr. Bekele. If you were relatively young when you were diagnosed with PsA but and it affects your hip, you probably have an aggressive case of PsA. In that case, your doctor will probably pick a biologic right away.  

The same is true for those who have psoriatic spondylitis as well as hip pain. “Typically, things like methotrexate or leflunomide don’t work for those patients who have spinal inflammation,” says Dr. Bekele, so the idea is to get them on a biologic right away to suppress inflammation.  

Non-drug management 

To round out drug treatment, there are other ways to regain mobility and flexibility in the hips.  

Physical therapy

Working on stretching and strengthening the muscles around the hip joint will protect the hip joint, says Dr. Bekele. That’s why physical therapy is key. Work with a physical therapist to come up with the right set of exercises that will stretch and strengthen (not strain) the hip.  

Low-impact exercises

“Movement is good for inflammatory arthritis,” says Dr. Bekele. But low-impact workouts — pool aerobics, bicycling, walking, elliptical — are easier on your joints. Get more tips on exercising with psoriatic arthritis.    

Complications in Hip Pain in PsA

The biggest one: Your damaged hip joint wears out until it fails, and then you’ll need a hip replacement. Yes, this type of wear and tear can happen to anyone, but when you’re older or weigh more than is good for your health, that wear and tear happens more gradually.  

“The damage from inflammation goes quite quickly,” says Dr. Bekele. “One study found that 50 percent of patients who had significant hip involvement required joint replacement within that five-year period,” Dr. Bekele notes.  

Bring up any new pain, including discomfort in your hips, with your rheumatologist. “If this is early hip involvement or spinal involvement, early diagnosis and treatment is the best way to prevent or to reduce the risk of severe inflammation causing joint damage and progression,” notes Dr. Bekele. In the end, identifying the problem early may even save your hips. 

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