Hip Dysplasia: What You Need to Know (and What Doctors Won't Tell You)

 (Image of Dysplasia from Wikimedia Commons)

If you have hip pain, someone may have told you that it's from hip dysplasia. In this article, we'll look at what hip dysplasia is, what surgeons believe about it, and what the science actually says.

If you're worried about hip pain and hip arthritis as a result of your hip dysplasia, read on to understand the myths and realities that even your physician might not know. 

Article Summary

• Hip Dysplasia, or shallow hip sockets, is common in the asymptomatic population.
• There are no known tests to determine whether dysplasia seen in an X-ray is the cause of a person's hip pain. 
• Long-term and large scale studies show no relationship between hip dysplasia, hip pain, and hip arthritis. 
• Long-term studies show that periacetabular osteotomy does reduce hip range of motion but has minimal effect on pain levels.
• PAO does not prevent future hip pain and osteoarthritis. More than 70% of PAO patients will see worsening of their hips in a 30 year time period. More than half ended up with full hip replacement within 30 years. 

You can watch the summary of this article in this Video on Hip Dysplasia 

What Is Hip Dysplasia?

In short, it's when your hip socket is considered too shallow. Surgeons say that this shallowness causes hypermobility and is a major risk factor for the development of hip pain and hip osteoarthritis.

To fix it, surgeons most often recommend PAO (periacetabular osteotomy). We'll dive more into PAO later in the article. 

How Common Is Hip Dysplasia?

Hip dysplasia is common in people without any symptoms at all. This is a key fact to keep in mind as we examine hip dysplasia and hip pain. 

A paper published in 2010 from Denmark showed that 4.3% of men and 3.6% of women with no symptoms have hip dysplasia.

A larger systematic review published in 2024 showed 3.8% in females and 2.7% in males. 

In 19 year old Norwegians, the prevalence ranges from 1.7-20% depending on how they defined dysplasia in a 2013 dysplasia study.

In Asian populations, asymptomatic hip dysplasia seems to be more prevalent. A Korean study showed a prevalence of 12.8 to 15% (depending on which metrics you use to identify hip dysplasia). 

In a Japanese study on the elderly, nearly 30% had hip dysplasia, and there was no correlation to hip osteoarthritis. 

In short, hip dysplasia is quite common even in people with absolutely no symptoms. 

Does Hip Dysplasia Cause Hip Pain and Hip Osteoarthritis?

As noted above, people often have dysplasia and no symptoms. If there were a strong correlation between dysplasia and hip pain, we would expect to see much higher incidences of hip pain and osteoarthritis in Asian populations. That is not the case.

Is there some way to tell that your hip dysplasia is causing your hip pain?

The answer is no. There are no definitive tests to determine whether your hip pain is from dysplasia. The only thing anyone can do is make a guess. Surgeons and physicians are trained to see dysplasia as a hip pain cause, but as shown by prevalence rates, there isn't enough evidence to make a convincing case. 

But what about osteoarthritis? 

Surgeons often claim that hip dysplasia will lead to hip pain and hip osteoarthritis. For example, this 2004 paper claims there is a strong correlation between hip dysplasia and the development of hip arthritis. 

However, there is more recent evidence that this isn't true.

A 2005 study examined the relationship between dysplasia, joint-space width, and hip pain. They followed volunteers with dysplasia and a control group for 10 years.  They "found no significant differences in the reduction of the joint space width at follow-up between subjects with dysplasia and the control subjects nor in self-reported pain in the hip."

In that 2010 study from Denmark we looked at earlier, researchers found "Acetabular dysplasia and the subject's sex were not found to be significant risk factors for the development of hip osteoarthritis."

And in a landmark study on hip health in senior age athletes published in 2016, researchers found no link between hip dysplasia and hip osteoarthritis: "radiographic findings of DDH (dysplasia) were not predictive of OA (osteoarthritis)."

Key points: Hip dysplasia is common in people with no symptoms. And studies show that hip dysplasia is not a risk factor for osteoarthritis or joint space narrowing - even if you're a senior-age athlete! 

How Effective Is Surgery for Hip Dysplasia?

If you've got hip dysplasia, you've most likely been recommended periacetabular osteotomy (PAO), as this is the most popular surgical treatment. 

PAO was first invented in 1984 by Dr. Reinhold Ganz. He and his team published a paper on this new surgical technique in 1987, and launched a whole new field of hip surgeries. 

With little science to back their claims, they popularized the belief that PAO could prevent hip pain and arthritis in the long-run. When we look at the results of the first groups of patients who underwent PAO, it's clear that there's something wrong with the theory and the surgery. We'll dive into that soon. 

PAO is an extremely invasive procedure. The surgeon makes huge cuts to create sections of your pelvis to reorient the acetabulum. They then use long screws to stabilize the new orientation of the sections. 

First, is PAO likely to give you full function and a pain-free life?

A 2024 paper analyzed the data from 62 studies on surgery for hip dysplasia. Researchers sorted through decades of papers to find the highest quality evidence possible. They applied a system called GRADE (Grades of Recommendation, Assessment, Development and Evaluation) to their recommendations. If they had good evidence for a conclusion, they would rate the recommendation high. If the evidence wasn't great, they'd rate it low (or very low). 

There are two important highlights in this analysis of surgery for hip dysplasia.

First, the claim that surgery is very helpful for hip dysplasia is not supported by high quality evidence. They say: "The improvements found across all subgroups from pre- to post- PAO surgery provide low level certainty that pain, ADL (activities of daily living), QOL (quality of life), sport and recreation, and symptoms improve following surgery. Despite the large magnitude of effect found, risk of bias of studies and inconsistency in data means the GRADE certainty rating remains at low." 

The second major point to note is that patients do not regain full pain-free function from PAO. From the conclusion: "Adults with DDH (hip dysplasia) undergoing PAO have more pain and worse function and QOL (quality of life) scores compared to healthy participants. Patients do improve following PAO surgery, and maintain this improvement, but they do not to the same level as their healthy participants."

In other words, with the evidence available, patients who undergo PAO do not get back to normal levels of function. 

Even in studies that strongly support PAO for hip dysplasia, you see similar results. The only difference is they engage in odd tricks to make the surgery seem better than it is. 

For example, in a 2020 paper on PAO, researchers claimed that "The majority of the patients...have no or low pain. The operation is effective with a good clinical outcome." 

But when you dig deeper, you see that they've done something very sneaky to bias the whole paper in favor of surgery.

They use something called HOOS to see how well patients did after surgery. HOOS stands for Hip disability and Osteoarthritis Outcome Score. They ask patients a bunch of questions and then add up all their answers to get a total score.

In the abstract, they note: "At the 2-year follow-up, HOOS pain improved by a mean of 26 points (CI 24–28) and a HOOS pain score > 50 was observed in 86%."

They are saying that the overwhelming majority of patients had a HOOS pain score above 50.

That sounds great! Right?

It only sounds good if you don't know that the best possible score is 100.

If you look at HOOS yourself, you can see that a score of 50 actually means you have a moderate level of pain. 

So if you underwent PAO and still had a moderate level of pain and regularly had to worry about your hip pain, that was still considered successful!

Buried deeper in the paper, they play an even dirtier trick. They say: "At 2 years’ follow-up, 86% of the preserved hips had no pain or a low pain score, defined by HOOS pain > 50."

Did you see what they did there? 

They lumped "no pain" and "low pain" together and then defined that one group with a HOOS pain score of greater than 50! As we now know, 50 is not the same as "no pain" or even "low pain." It's a state of moderate hip pain. 

This isn't outright lying, but it's deceptive redefinition of "no pain" at the very least. 

As you can see, PAO is not a guarantee you'll get full function back. And it's not a guarantee you'll be pain free.

If you underwent PAO surgery and still regularly felt moderate levels of hip pain, would you consider that a success? Unless you have truly severe, debilitating hip pain, the answer is probably no. 

Which leads us to the big question...

Can PAO Prevent Hip Pain and Osteoarthritis in the Long Run? 

Because PAO is often recommended to prevent hip osteoarthritis, some surgeons say it's a good idea to do the surgery on young patients in their teens. But what are the long term consequences? Will a surgery on a teenager to fix dysplasia mean they'll be pain free and problem free for life?

Unfortunately, the answer is a resounding no.

A paper published in 2017 showed disturbing outcomes over a 30 year time frame. 

"Thirty years postoperatively...more than 70% will develop progressive osteoarthritis, pain, and/or undergo THA (total hip arthroplasty/hip replacement)."

More specifically, 56% of patients ended up with hip replacement within the 30 year window. 

In addition, the pain relief from the surgery doesn't last for the majority of patients. "After improvement of the clinical scores at 10-year followup, both the Merle d’Aubigné-Postel score and the HHS (Harris Hip Score) decreased to the preoperative values at 30 years followup."

In other words, patients might see some improvement in the first ten years, but by the thirty year mark, their pain levels go back to where they were pre-surgery. This is despite the fact that the surgery seems to successfully reduce range of motion (i.e. make the hips more stable). 

They found that "typically excessive ROM in dysplastic hips is decreased to a normal level after PAO" and that the decrease in range of motion lasted over 30 years. But that did not translate into healthy, pain-free hips. 

This should lead you to question the assertion that the reduction in range of motion will solve your hip pain. 

In summary, periacetabular osteotomy is not a guarantee that you'll fix hip pain in the short term. It won't prevent future hip pain. And, over a 30 year time frame, more than 70% will see worsening in their hips with over half getting total hip replacement. 

That means PAO does not prevent hip arthritis, hip pain, or hip degradation in any reliable way. 

Can You Fix Hip Pain Without Surgery? 

The short answer is yes. I've seen it with clients, online students, and commenters on my YouTube channel. Erica and Jacqueline are two great success stories. 

But it's not necessarily going to be easy. The hardest step requires you to make a big mental shift.

Instead of fixating on the orthopedic diagnosis of hip dysplasia, you need to focus on your muscles. Instead of searching for the surgeon who has the most experience doing PAOs, you want to take responsibility for healing yourself.

You have to believe you can fix yourself.

This starts with understanding a few key concepts.

Your muscles move your bones. If your muscles don't function right, you don't feel right.

From there, you start training your hip, core, and leg muscles so you can move right.

This means shifting from a medical diagnosis mindset to the ATM theory (Always Think Muscles).

By retraining your muscles, you can make your daily life more comfortable and improve your overall function. As you learn how to train your muscles, the results will become obvious on a daily, weekly, and monthly basis.

There are no nasty side effects besides soreness in weak muscles. There are no medications. And there are no invasive incisions to leave scar tissue behind.

There is no debate that exercise can improve muscle size and function. There is no debate that you can change the way muscles interact to move your bones. So if your hips feel loose, unstable, or just plain painful, learning to retrain your muscles should be the very first step.

In my totally non-medical opinion, opting for a surgery with poorly studied outcomes (and well-established poor outcomes) should be the absolute last resort. 

How Do You Fix Hip Pain from Hip Dysplasia?

First, it's important to remember that hip pain is unlikely to be from the bone shapes. Otherwise you'd see a lot more hip problems in Asia and in aging athletes with dysplasic hip bones.

People who get the dysplasia diagnosis are often very mobile in their hips. So PAO aims to reduce range of motion by reorienting parts of your pelvis. As we've seen, this doesn't provide long term pain relief.

Instead, if you place your attention on training the muscles around the hip to be stronger throughout the full available range of motion, you can relieve your hip pain.

The details of the process may be different for each individual, but the overall process is the same.

You identify muscles that are weak, and you strengthen them all in a balanced way.

Now, you might be thinking "how is that going to fix my shallow hip socket?!"

Consider that the socket of your shoulder joint is extremely shallow. It's far more shallow than the socket of dysplasic hips.

^{The red area is the shoulder socket, known as the glenoid fossa.}

How do you keep your shoulder joint intact? How are humans able to do downward dogs, push-ups, handstands, and cartwheels without the arm bone slipping inside a super shallow socket?

The answer is muscles. The muscles around the shoulder joint create stability of the shoulder joint at many different angles.

But maintaining that stability in every possible angle doesn't come naturally. It only comes if you train it. That's why not everyone can easily flip upside down into a handstand!

But everyone can gradually train to be able to do it.

To maintain joint stability in a shallow socket, your muscles must work.

Your hip sockets, even if they're dysplasic, are still deeper than your shoulder sockets! As in your shoulder joints, the real stability comes from the muscles of your hip joint. 

So to make your hips feel more stable, you want to train your hip muscles to control the full range of motion.

You want to strengthen your glutes, hamstrings, adductors, hip flexors, and hip rotators. You'll discover that some of them are weak in specific orientations. You'll want to improve strength in those orientations.

You want to strengthen your core muscles as well, making sure they can engage properly when you need them to stabilize your pelvis.

It'll be a journey, but the odds of exercise stabilizing your hips and relieving hip pain are far better than what the current evidence shows for PAO. And there are far fewer downside risks. 

What Exercises Should You Do for Hip Dysplasia? 

As mentioned earlier, it can vary a lot by person, and the process of learning what your body needs will be highly individualized.

However, I would start with the glutes and hip flexors.

Here's one video that will help you improve your glute strength.

Then this video will help you strengthen your hip flexors. 

Then strengthen the inner and outer hips. This follow along video includes beginner level exercises to strengthen your inner and outer hips.  

Also, don't be afraid to add resistance when you feel ready for it. For people with hypermobile hips, it's crucial to use resistance to build more tension in the muscles. Some people will never feel stable and comfortable until they add resistance to their hip training. And some people need a lot of resistance to feel stable.  

For some, it's as simple as adding a heavier kettlebell to the deadlift. For others, it means adding ankle weights to a bunch of different exercises at different angles.

Just remember to stay within a controllable, pain-free level of resistance and range of motion.

Follow-Along Workout for More Hip Stability

 This free workout comes from my Healthy Hips program with a slight twist. It includes several exercises to improve your hip stability as well as detailed instructions for an extremely important hip strengthening exercise at the end.  

See also: How to Fix Muscle Imbalances

What About Massage and Stretching for Hip Dysplasia? 

If you already have hypermobile hips, massage and stretching are highly unlikely to fix the sense of tightness and tension in your hips. To relieve that tightness and tension, you need to strengthen your hip muscles.

This is counter-intuitive, and that's why it creates so much frustration for people with flexible, painful hips.

More flexibility does not solve hip pain. More stretching and relaxation will not remove all forms of "tightness."

If you've already been trying to stretch and massage your hip pain away and find it futile, STOP. It's time to build strength in your hips as mentioned in the previous section.

If, on the other hand, you are stiff and inflexible, stretching and massage might be helpful. It's worth exploring these strategies more, but remember not to put all your eggs into the relaxation basket. To feel comfortable, your muscles need to be strong.

You can't make strong muscles by massaging and stretching them all the time. 

See also: When Massage Makes Your Pain Worse

Final Thoughts on Dysplasia and PAO

Surgeons in the late 1900s popularized the belief that dysplasia was a clear cause of hip pain and osteoarthritis. They believed newly pioneered surgical techniques could fix and prevent hip pain and arthritis. In the years since, research has shown no consistent link between dysplasia and hip arthritis and hip pain. Research has also shown that periacetabular osteotomy is not a reliable way to prevent hip pain and osteoarthritis in the long term.

The most cost-effective, least invasive method to deal with hip pain is smart exercise. While it can sometimes be frustrating, it is worth trying before going with an invasive surgery with ambiguous benefits and clear downsides. 

Need More Help with Your Hips? 

I sincerely hope that the exercise recommendations I've made in this article help you. And when you feel like you need more or are ready for more, I encourage you to check out the Healthy Hips program.

I created this comprehensive hip training program to help people with hip pain. I've had all kinds of hip pain. I've had hip pain from strengthening some muscles too much. I've had hip pain from allowing muscles to get too weak and loose. I've seen the many different variations of hip pain in myself and others, so I made a flexible program to address as many scenarios as possible.

My goal was to create a program that anyone can use to create stronger, healthier, happier hips. And I wanted to do it in a risk-free way for people around the world. While I can't guarantee it'll be the perfect answer for EVERY case of hip pain, I can guarantee that if you try it, and it doesn't work for you, you'll get your money back!