Review Article

Hip Muscle Atrophy and Hip Osteoarthritis-Evidence and

Continuing Challenges
Ray Marks1*
1Department
of Health and Behavior Studies, Columbia University, Teachers College, Box 114, 525W 120th Street, New York, NY 10027, USA
*Correspondence author: Ray Marks, Department of Health and Behavior Studies, Columbia University, Teachers College, Box 114, 525W 120 th Street, New
York, NY, USA; Email: [email protected]

Abstract
Citation: Ray M. Hip Muscle Background: Hip osteoarthritis, a highly disabling disease with no distinct cause, and a disease
Atrophy and Hip Osteoarthritis-
associated with high degrees of pain, stiffness, and disability continues to affect the lives of many
Evidence and Continuing
adults of all ages highly adversely and may be influenced adversely by some forms of muscle
Challenges. J Ortho Sci Res.
dysfunction, such as hip muscle atrophy.
2023;4(1):1-9.
Aim: To examine the prevailing research support for a mediating or causative role of muscle atrophy
https://doi.org/10.46889/JOSR.2023.
in hip osteoarthritis.
4105
Methods: An in-depth literature review focusing on hip osteoarthritis muscle atrophy associations
was conducted.
Received Date: 28-02-2023
Results: A fair number of past and recent research reports indicate efforts to examine and intervene
Accepted Date: 14-03-2023 to minimize one or more attributes of hip muscle atrophy appears promising in the context of efforts
Published Date: 21-03-2023 to foster improved outcomes of hip joint osteoarthritis, regardless of the application of high-tech
surgery.
Conclusion: Future research efforts are strongly indicated.

Copyright: © 2023 by the authors. Keywords: Arthroplasty; Muscle Atrophy; Hip Osteoarthritis; Pathology; Prevention; Surgery
Submitted for possible open access
publication under the terms and
conditions of the Creative
Introduction
Commons Attribution (CCBY)
license Osteoarthritis, a chronic painful disabling joint disorder, often impacting both hip joints and
(https://creativecommons.org/li where its slow progression often induces a high degree of progressive functional and social
censes/by/4.0/). disability is generally considered a disease of the cartilage tissue lining the joint, rather than any
other source. However, this commonly accepted belief fails to consider that mention has been
made to view osteoarthritis as a disease affecting the ‘whole joint’ rather than a single component
of the affected joint[s] [1,2]. As well, more emphasis in this regard has been placed for some time on its biomechanical origins
[3,4]. However, with no specific clearly defined agreed upon cause of this condition, and since cartilage is found poorly amenable
to intrinsic regeneration or healing processes, and may be impacted adversely by various drugs that have no meaningful disease
modifying effect [5,6], a host of non-pharmacologic approaches have been advocated. However, most are not universally
accepted as mainstream solutions, nor studied to the same degree as cartilage molecular and biochemistry approaches. As a
result, those who are most disabled may often suffer unduly perhaps, and must rely on various surgical interventions to replace
the damaged hip joint tissues with a metallic or artificial prosthesis to offset their pain if this is not contra indicated. However,
some recent discussions and findings that attempt to carefully examine osteoarthritis origins and progression, and that point to
a possible key or influential role of muscles, such as those surrounding the hip joint in mediating or moderating the disease
might be amenable to interventions that help improve joint status, or prevent it from worsening rapidly, regardless of the degree
and duration and extent of any underlying joint pathology [7].

This possible and biologically plausible role for muscle in the osteoarthritis disease context has thus been quite carefully
investigated of late as it appears that muscle abnormalities, for example those at the hip joint, may yet affect cartilage integrity,

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for example if abnormal physical stresses are placed on joints as a result of muscle weakness, uncoordinated muscular forces,
excessive muscular forces or by muscle contractile dysfunction [7,8]. In turn, damage caused by cartilage destruction that leads
to joint inflammation and declining motivation for movement may impact muscle adversely, thus leading to a decline in joint
protection mechanisms and hastening movement challenges that are more evident in cases with hip joint osteoarthritis than
controls [9].

In view of these possibilities, and the very severe impact of hip joint osteoarthritis on the lives of many older adults, that appears
to extend to the underlying bone tissues and generates consistent findings of muscle force capacity declines but that the disease
symptoms do not correlate well with commonplace radiographic staged disease classifications, it thus seems plausible to examine
if researchers are pursuing this line of inquiry implicating muscle in some way in the current era of efforts to advance the idea
of joint and health protection rather than reliance on costly health interventions that do not account for upstream or salient
physiological factors that may predict future joint problems and others [1,8]. The rationale for considering the importance of the
muscle state at all stages of osteoarthritis disease as well as its prevention is the cross-cutting role played by muscle in generating
movement, as well as joint protection. Given the enormous burden of the disease, and the fact age and a ‘wear and tear’ theory
is often not a factor in explaining either the presence of the disease or why the disease manifests on one side and not the other,
and surgery to reduce pain does not help to uniformly restore joint function, in all older adults, especially if they are de-
conditioned it appears information on the state of the hip muscles in cases with varying complaints of persistent hip pain may
help to resolve some of this distress, while yielding one or more cost savings [10].

Because of the strong possibility that muscular disturbances at the hip or those that impact hip joint function in some way may
yet be implicated in the risk of incurring some degree of hip joint osteoarthritis, and/or a more detrimental outcome, especially
pain, and that may not be evidenced via standard radiological examination alone, this brief explores research that may provide
a clearer view of whether efforts to examine the possible role of muscle dysfunction at the hip joint has any bearing on the
manifestation of hip osteoarthritis disability, and if so in what respect [11]. Using the PUBMED, PubMed Central, and Google
Scholar data bases deemed to house salient representative data, and the terms hip muscle atrophy and hip osteoarthritis clinically
oriented articles dating largely from the most studied period of 2000-2023 and specifically related to muscle atrophy as opposed
to other forms of muscle dysfunction, this body of data was sought and carefully examined and reported in summary form only,
and regardless of muscle discussed or method of assessment. For an in-depth analysis of muscle related facts in the context of
hip osteoarthritis biomechanics, the discourse by Denham and the treatise by Maquet is highly recommended [4,12].

However, rather than any systematic analysis, this current scoping review of data that have emerged over the past 60 years was
designed to embrace all data linking muscle mass correlates with hip osteoarthritis. Since certain forms of study, while
conforming to solid design protocols may not capture all possibilities in this regard, this analysis accepted all forms of peer
reviewed research pertaining to the topics of muscle atrophy and hip osteoarthritis as valid. Excluded were studies highlighting
abnormal dynamic muscle forces and their manifestations, intervention associated studies and measurement studies, and foreign
non-English studies. Also excluded were studies pertaining to other possible hip osteoarthritis pathogenic factors such as
heredity, hormones, occupation, injury and diet, among other factors. The aim was to identify what the literature has revealed
over time as to the idea that a role for muscle atrophy at the diseased hip joint is a clinically relevant one; as well as related
research gaps, discrepancies and potential clinical and research opportunities. As outlined by Godziuk, et al., and despite more
than 100 years of study, hip osteoarthritis remains a highly painful disabling disease that strongly impacts the life quality and
independence of many older adults and is challenging to treat, hence efforts to understand its possible origins other than age
and injury continue to be highly salient [12]. This is increasingly so in light of data that reveal surgery, the most common form
of hip osteoarthritis treatment, is often not without risk, and may yet be delayed in the post COVID-19 period due to health
resource shortages and immense wait lists. Drugs too, may not be beneficial and lead to narcotic addictions and cartilage
destruction.

Search Results
Among the literature retrieved from the aforementioned data bases, a thematic analysis of all previously published clinical
articles revealed a limited albeit diverse body of approximately 100 works referring to muscle attributes that began in the 1950s,
and only truly increased substantively in publication numbers as of 2020, but yet remains limited in scope and importance when

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considering the term ‘osteoarthritis’ alone current yields 110,508 PUBMED listings that began in 1885 with 1683 of these alone in
2023. Of the 265 hip osteoarthritis listings highlighted between Jan 1 and February 27, 2023, only 19 refer specifically to muscle
attributes. These as well as those published over time are highly diverse however, and include, but are not limited to studies
examining aspects of muscle measurements, muscular strength deficits, aberrant movement patterns, muscle fat infiltration, and
intervention studies. Various studies discussing muscle atrophy in the context of one or more hip muscles and that may have
implications for hip osteoarthritis prevention and intervention do however prevail, for example studies that discuss atrophy of
the iliopsoas muscle or the hip abductor muscles in hip osteoarthritis realms [14-17].

The discussions here do not focus on the nature of the research design to any degree, but rather focus on either what appears to
be the impact of hip osteoarthritis on one or more surrounding muscles as manifest by changes in muscle size and composition,
or the less well accepted idea of muscle mass and its properties as a causative or hip osteoarthritis mediating factor [15,18].
Although increasing numbers of articles have discussed other aspects of muscle rather than muscle mass or size, it was assumed
muscle atrophy and/or its association with joint instability, muscle fibrosis and fat infiltration may be an understudied albeit
clinically important contributing factors to hip osteoarthritis pathology that may also be expected to produce disturbances of
cartilage metabolism and consequent manifestations of joint degeneration [19-26].

As per Godzink, et al., one aspect that is additionally pertinent in this context is that muscle mass alterations, are relevant to
study because these muscle mass losses are commonly associated with aging, a well-established probable correlate of disabling
hip joint osteoarthritis [13]. In this regard, recent data does specifically show the presence of a sarcopenic obesity phenotype,
characterized by high adiposity and low skeletal muscle mass is associated with higher infection rates, poorer function, and
slower recovery after surgery in various populations, as well as possibly in adults with hip osteoarthritis and low skeletal muscle
mass. Although not well studied, de Ceuninck, et al., argue that altered joint stability, maladapted postures and defective
neuromuscular features in hip osteoarthritis for example, that may ensue if muscle force capacity is reduced when needed, could
impact cartilage cells at the cellular and molecular levels negatively and significantly [24]. A parallel idea supported by Wu, et
al., is that as far as senescent skeletal cells and synovial cells are concerned, they are able to communicate and may well be
influenced by the muscle quality and prevailing degree of muscle protection [26].

Current work by Iwasa, et al., who did find fatty degeneration of the hamstrings, iliopsoas, and hip adductor muscles to be
significantly related to health quality of life in patients with hip osteoarthritis tended to support a role for muscle fat infiltration
in the osteoarthritis pain and disability cycle [27]. They also implied these muscles should be targeted accordingly during
conservative rehabilitation for hip osteoarthritis as well as in the context of rehabilitation efforts following hip joint surgical
replacement. In support of this idea, Peires, et al., found a greater cross-sectional area of hip adductors was associated with better
function and quality of life in individuals with mild-to-moderate hip osteoarthritis [28]. In addition, it appeared a greater cross-
sectional area of hip flexors might be associated with better quality of life. To the contrary, a further recent report has shown hip
abductor muscle fat is associated with markers of cartilage degeneration [29].

Kivle, et al., who examined data from patients with end-stage osteoarthritis and matched healthy controls found the gluteus
minimus muscle was significantly smaller in the osteoarthritis-group compared to the control group [30]. Higher levels of fatty
infiltration were identified in the anterior segment of the muscle along with the anterior and middle segments of the gluteus
medius muscle in the osteoarthritis group. Overall, their findings showed end stage osteoarthritis was associated with significant
atrophy of the gluteus minimus and higher levels of fatty infiltration, particularly in the anterior segments of both the gluteus
minimus and medius. As well, even though minor fatty infiltration of the anterior segment of gluteus minimus appeared to be a
normal part of ageing, a different pattern of atrophy and fatty infiltration was observed between patients with end-stage
osteoarthritis and their healthy matched peers.

Several other studies conducted since 2000 have concluded the presence of muscle atrophy in one or more of the muscles
surrounding the hip may not only contribute to the magnitude and progression of hip osteoarthritis disability, but may persist
in the operated limb of some patients with advanced or complicated hip osteoarthritis manifestations even after surgical
reconstruction [20,31]. Mak, et al., who strove to determine if there is significant psoas muscle atrophy as indicated by muscle
cross-sectional area and a high degree of fat infiltration in post-unilateral hip arthroplasty cases over an eight-year period found

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the cross-sectional area of the psoas muscle on the implant side was significantly smaller than that on the non-operative side
[32]. There was also an association between the cross-sectional area differences and the fat grade of the implant side, results that
aligned somewhat with those of Lee, et al., [16].

Loureiro, et al., concluded that atrophic, bilateral hip and knee muscle weakness is a feature of individuals with mild-to-moderate
hip osteoarthritis and that early interventions to target muscle weakness and prevent the development of strength asymmetries
that are characteristic of advanced hip osteoarthritis appear warranted [33]. This idea, while far from robust, does seem to have
considerable support despite the fact one review tended to discount any muscle mass involvement in the realm of hip
osteoarthritis, despite obvious strength declines [34].

However, Marshall, et al., did not specifically assess muscle size issues to any degree, and an earlier study of men with hip
osteoarthritis did show a significantly lower abduction, adduction, and flexion set of muscle strength measures than those of
controls [34]. The finding of a decrease of muscle size in those cases with severe signs of hip osteoarthritis and hip pain may
contribute to the overall decrease of muscle strength in those with hip osteoarthritis as time progresses, although other possible
underlying causes of the muscle weakness need to be studied.

As per Lawrenson, et al., while there is some low-quality evidence that specific hip muscles are smaller in unilateral hip
osteoarthritis, variation in the magnitude of differences indicate the observed changes in size that have been noted are not
necessarily uniform across all muscles or stages of pathology [35]. As noted by Grimaldi, et al., what is demonstrated may depend
on what is measured and how and at what disease stage, thus definitive conclusions must await further study [36]. Uemura, et
al., agree that hip osteoarthritis can however lead to atrophy of the gluteal and thigh muscles, even though they report the muscle
volume of these can recover even though this may take for up to two years after hip joint replacement surgery [37]. However,
their 2016 data may not reflect that occurring currently in 2023, for example in cases who are non-Japanese, in higher age ranges,
and with multiple chronic health challenges that limit activity, including long COVID-19 syndrome, unanticipated cuts in health
services, and persistent severe obesity.

Other researchers indicate cases in the older age ranges with signs of hip osteoarthritis may well exhibit age associated general
muscle mass declines, and possible joint instability and with this, pain that if untreated at its source may further muscle mass
losses, as well as increase the risk for poor walking ability and possible falls injuries [21,38,39]. Studies in larger cohorts
investigating muscle size and composition across the spectrum of articular pathologies and age ranges are however clearly
required here to arrive at a consensus about a role for hip muscle mass, and possible decreases in their contractile tissue features
that affect muscle function [40].

As well, while the current research appears promising for helping to reduce the suffering attributable to hip osteoarthritis, the
use of single rather than multiple measures or theorizing about-but not measuring muscle mass attributes in any way- may fail
to clearly depict the presence and implications of any actual degree of excess muscle atrophy as far as this could markedly impact
muscle function and possible joint physiology [41,42]. Moreover, while Vadala, et al., indicate a possible negative role for muscle
intrinisc structures and fatty infiltration of the muscle in the context of hip osteoarthritis, what the role of muscles other than
those studied may play in this regard or whether the observed tendon pathology that was observed was the cause or consequence
of the severe hip joint damage that emerged over time could not be discerned from the limited muscle analysis [43]. In addition,
the role of pain, as well as measurement approach, injury and age could not be discerned among the study findings and that
could possibly explain the observed fatty infiltration of the contra-lateral pre- and post-operative muscles as well as the post-
operative operated muscle. Other data show that older females with lower than desired muscle mass tend to have a greater
chance of having hip joint osteoarthritis that may reflect a deficit in joint protection ability of the remaining muscle mass,
regardless of whether this effect is a cause or an outcome of the disease, but why not all older people sustain the disease, or why
the disease is often more evident on one side of the body or affects one muscle but not others remain unclear [44].

Thus, while findings from most published data on this topic imply a mediating or moderating or causative role of persistent
muscle atrophy at the hip in the progression of unilateral hip osteoarthritis that warrants attention, it appears prudent to await
further insightful well-designed research that can yield more solid conclusions. In the interim, it seems clear that surgical hip

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replacement does not always attenuate muscle atrophy in any immediate manner in all cases, suggesting either a preexistent
problem or one invoked by surgery or both. Indeed, cases exhibiting the presence of poor hand grip strength before hip surgery,
which may denote, muscle mass or general sarcopenic deficiencies, have been found to be have poorer than anticipated post-
surgery outcomes than stronger cases with similar pathology [37,45,46]. More recently, the high percentage of fat observed in
various hip joint muscles in cases undergoing surgery could explain the observed link between obesity and hip joint
osteoarthritis, while a deficient pre surgical or post-surgical muscle strength loss could be expected to induce more adverse
outcomes than not, including higher levels of obesity if activity is suboptimal [47]. In addition, the presence of a type II muscle
fiber deficit that impacts joint loading mechanisms detrimentally, as well as weightbearing endurance may be an additional
pathogenic factor that additively fosters cartilage injury or additional trauma to the already affected joint[s] if untreated because
muscle response times may be duly delayed or slowed due to this particular selective muscle fiber loss [41,48].

Discussion
Osteoarthritis, a widespread joint disorder resulting in dysfunction of one or more freely moving joints such as the hip joint, is
presently not reversible, and invariably leads to various degrees of intractable pain, disability and loss of independence in the
older population in particular. As with aging, the disease may be accompanied by various degrees of muscle mass declines,
sarcopenia, and muscle fiber atrophy. Moreover, in the absence of any explanation for the disease and its origins, muscle wasting
has been suggested to be a probable factor affecting and being influenced by the stability of the joints such as the hip, wherein a
loss of mobility, or impaired mobility patterns, can lead to gradual articular cartilage degeneration [49].

This brief examined this hypothetical unproven scenario in the belief that if it is a possible pathogenic factor, early identification
of hip muscle atrophy may help clinicians to develop effective exercise programs to counter hip osteoarthritis onset and
progression or at least its severity. Although negative findings may not be published, or may emerge in the future, and only a
small percentage of the many muscles at the hip have been studied, most prevailing observations indicate that where present,
atrophy of one or more key hip muscles, which are important in hip joint and pelvic stability, may alter hip joint function quite
measurably during gait and functional tasks, even if not commonly detected in substantive numbers of hip osteoarthritis cases
[50,51]. Clinicians treating patients with intra-articular hip joint pathology may hence need to assess their clients very thoroughly
and if indicated prescribe exercises targeting the specific muscles that may be vulnerable to atrophy or are already atrophic
carefully and using best practices. The finding that muscle mass deficits even if not present before surgery, may prevail for
extended periods after successful reconstruction surgery of the osteoarthritis hip joint implies a further need for vigilance both
before and after hip joint arthroplasty surgery [52]. Observations that fatty atrophy of one or more hip muscles may increase the
extent of hip osteoarthritis pathology, further suggests efforts to control weight may be a highly salient management approach
in those with hip pain, given that preoperatively, muscular atrophy and fatty infiltration has been demonstrated in the diseased
hip [53]. A role for suboptimal muscle volumes, which appear associated with the extent of pathology and walking ability in
cases complaining of hip pain has also been put forth [54] and may well foster or exacerbate any inadvertent surgically induced
neuromuscular adaptations such as marked muscle wasting, weakness, and deterioration in muscle grade or preexisting gluteal
muscle weakness and a limping type gait that may impact post-surgical outcomes adversely and negatively [55-59].

Momose, et al., further conclude that an increase in muscle volume, plus allowing for the recovery of any muscle degeneration,
may help to improve limping in patients with hip osteoarthritis [59]. Additionally, appropriate exercise may help as well if
applied early on and pursued because as indicated by Zacharius, et al., a higher degree of gluteal muscles atrophy along with
fatty infiltration of these muscles and others is quite strongly associated with hip osteoarthritis clinical severity [53,60]. In
addition, if this possible linkage between muscle size and composition and hip osteoarthritis joint changes can be further
supported in the future, it would, at least, provide a possible avenue for supporting more targeted intervention opportunities to
reduce muscle atrophy due to hip osteoarthritis. This in turn might mitigate or reduce any fatty infiltration of one or more hip
muscles more effectively than not, thus potentially yielding more optimal surgical outcomes as well as possible non-surgical
functional outcomes for adults with osteoarthritis of the hip than is presently observed [65,66]. Indeed, as outlined by de Ceunink,
et al., the consistent body of evidence showing that a decline in lower limb muscle strength is associated with hip osteoarthritis
may lead one to conclude that chondrocytes and myoblasts may indeed share common pathological targets and pathways and
that the potential advantage of understanding this association has far reaching clinical implications [23]. Muscles may also
undergo property changes that induce muscle atrophy due to hip surgical approaches that should not be ignored and thus unless

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this is acknowledged, it may be difficult to improve function capacity and ease, in general, even after corrective joint surgery
[61].

In the interim, it appears due consideration of all possible pathogenic factors including the structure and composition of muscles
surrounding the hip joints may well help to eliminate or minimize much suffering, and/or delay the need for harmful drugs and
surgery. Cases assessed accordingly after surgery may likewise benefit [24]. Since different muscles or patterns of muscle mass
loss may yield different pre-or post-surgical hip osteoarthritis functional responses and pathomechanics, researchers can
potentially help to vastly advance this field by conducting more elaborate and carefully construed multipronged studies.
Clinicians in the interim are urged to assess their clients muscle status periodically and carefully so as to apply appropriately
tailored treatment approaches rather than generic approaches that can impact muscle size and fiber type composition and its
shock absorbing properties favorably, while helping to control or eliminate biomechanical disruptions of the joint due to excess
fat infiltration and associated age and other factors that impact skeletal muscle mass, composition, and elasticity [62-64,67-69].
Surgeons too can continue to examine how various forms of surgery impact muscle degeneration or recovery at the osteoarthritic
hip and report these potentially revealing data using advanced and multiple functional measures [70].

Concluding Remarks
In summarizing what we know about the possible interaction of hip muscle atrophy and its presence or impact in the realm of
hip joint osteoarthritis in the older adult population, and while this work is possibly not all inclusive or reflective of emerging
data, it appears safe to say:

1. Hip osteoarthritis a widespread health condition that continues to induce high degrees of disablement among many older
adults in all parts of the world may be impacted negatively by various biomechanical influences attributable to declines in muscle
size, among other muscle correlates
2. The disease, while largely impervious to the sole application of various drugs, may yet be impacted favorably by concomitant
or independent efforts of clinicians to carefully examine the status of the muscles at the hip joint for any signs of muscle mass or
volume losses and to intervene accordingly to improve any atrophic presence that is evidenced through well accepted
conservative approaches, regardless of surgery
3. Researchers can greatly help to advance this line of inquiry urgently needed to allay suffering and health costs by concerted
efforts to study the nature and role of muscle atrophy and fatty infiltration of those muscles at the hip that may lead to muscle
weakness in the context of the vulnerable older individual in a careful comprehensive manner over time
4. How muscle mass at the hip varies or manifests when using advanced technology and radionuclide scintigraphy to examine
any parallel bone and synovium changes, along with biochemical markers of cartilage destruction is especially indicated
5. Until more research is forthcoming, the application of carefully construed muscle-oriented approaches should still become
more mainstream especially for safely modifying pain, instability, stiffness, function, but must be carefully tailored and
insightfully targeted, rather than attempting to rely solely on aggregated approaches and understandings from systematic
reviews
6. Older overweight adults should be encouraged to lose weight so as to avert any damaging muscle fat infiltration build up

Conflict of Interest
The authors have no conflict of interest to declare.

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