Hip Replacement Pain That Isn’t Settling

A hip replacement is meant to take away the pain that led you to surgery, and for most patients hip replacement surgery does exactly that. Hip replacement pain in the first weeks after surgery is usually normal and part of healing, but pain that plateaus, worsens, returns, or changes character months later is different and needs medical assessment.

If you have had hip replacement surgery and are dealing with ongoing or unusual pain after the operation, understanding the pattern of pain matters because persistent or new symptoms can point to treatable problems and change the best plan for recovery.

This page explains the normal healing pain pattern, the causes of persistent hip replacement pain from both implant and non-implant sources, how the problem is assessed, which treatments may help, and when revision surgery might be necessary.

At MTP Health, Dr Donald Cawthorne and our physiotherapy and exercise physiology team work together to identify the cause and plan the right next step.

Key Takeaways

• Pain that keeps improving, even slowly, is usually normal healing. Pain that stalls, worsens or appears as a new symptom deserves a review.
• Where the pain sits gives strong clues: groin and thigh, outer hip, buttock and leg, or the whole hip with warmth and night pain each point in a different direction.
• Only some causes involve the implant. Tendons, bursae, the lower back and leg length differences often explain pain in a hip that is otherwise sound.
• Assessment starts with examination and comparison of X-rays, moving to blood tests or aspiration only when infection needs to be excluded.
• Most non-implant causes are managed without further surgery. Revision is discussed only when a specific implant problem has been confirmed.

What Settling Pain Looks Like After Hip Replacement Surgery

In a hip that is recovering well, pain follows a downward trend. There may be setbacks after a long walk or a big day, but the overall direction is better each month, and the original deep arthritic ache from the damaged hip joint is gone. This is what normal pain looks like during hip replacement recovery, and most patients follow this curve over the first few months.

Three patterns break that trend: a plateau, where you are no better at four or six months than you were at two; worsening, or increased pain, where discomfort that had eased is now growing; and new pain in a spot that did not hurt before surgery. Any of these is a reason to be seen at an orthopaedic and physiotherapy clinic on Sydney’s North Shore, and the sooner it is looked at, the simpler the answer tends to be.

Where The Pain Is Matters

The location of your pain is the first thing Dr Cawthorne will ask about, because it narrows the possibilities quickly. Groin or front-of-thigh pain, especially on the first few steps after sitting, raises the question of the implant’s fixation or an irritated hip flexor tendon.

Outer hip pain when lying on that side or climbing stairs usually comes from the gluteal tendons and bursa rather than the joint. Pain that starts in the buttock or lower back and travels down the operated leg often has a spinal source.

A deep ache across the whole hip with warmth, night pain or a wound at the incision site that never fully settled needs infection excluded first. Feeling that one leg is now longer, with back or opposite-hip pain, points to a leg length difference. Any of these other symptoms is worth a mention at your medical review.

Problems With The Implant Itself

Loosening, or implant loosening, is the most talked-about cause, but it is uncommon in the early years. Early complications after hip surgery are uncommon, affecting fewer than 2% of patients. It tends to produce start-up pain in the groin or thigh that eases once you are walking, then returns after rest. Infection can develop early or years later, sometimes after an infection elsewhere in the body.

It may bring warmth, swelling and night pain, though a low-grade infection can be subtle and may not cause a fever. If you develop severe pain, spreading redness or fever, see a doctor immediately.

Joint instability, where the ball and socket of the new joint feels as if it may slip and hip dislocations can occur after total hip replacement, and pain related to how the components sit are less common. Surgery can also irritate soft tissues around the hip. Later on, implant wear and abnormal wear of the bearing surfaces can shed wear particles that irritate the tissues around the hip joint.

Each has a distinct pattern on examination and imaging, which is why a careful review is worthwhile before revision hip replacement or any surgical treatment is ever considered.

Pain From Outside The Joint

In many painful hip replacements, or after total hip replacement, the new hip joint is sound and the pain comes from the surrounding structures. The gluteal tendons and bursa on the outer hip can be tender after surgery, and the new joint itself can be sound while pain still comes from nearby tissues, or they may already be worn before it. The iliopsoas tendon at the front of the hip can rub against the edge of the socket joint, causing groin pain when lifting the leg into the car or up a step.

The lumbar spine and sacroiliac joint frequently refer pain to the buttock and thigh, and a change in walking pattern after surgery can stir up a back that was quietly coping before. Inflammatory conditions such as rheumatoid arthritis can also flare around the surgical site.

A small leg length difference, scar sensitivity, excessive scar tissue and nerve irritation around the incision are other recognised sources: scar tissue formation is part of every recovery, but heavy scar tissue can tether tissues and keep causing pain. Surgery also disturbs soft tissues such as muscles and tendons, and after total hip replacement that can add to pain or stiffness during healing.

These problems respond to treatment, usually through targeted rehabilitation rather than another operation, and nerve irritation after surgery is recognised and can affect up to 30% of patients post-surgery.

How A Painful Hip Is Assessed

Dr Cawthorne begins with your story: when the pain started, where it sits, what brings it on and how it compares with the pain you had before your initial surgery, often done for osteoarthritis, the most common reason for hip replacement. Examination covers your gait, hip strength and range, tenderness over the tendons, and your back.

X-rays are then compared with the films taken immediately after your operation, because subtle changes around the implant, from loosening to implant failure, are far easier to see side by side. If infection is a possibility, blood tests for inflammatory markers come next, and a sample of joint fluid may be taken if those are raised.

Further imaging is reserved for questions the first steps cannot answer, a more targeted approach than the general hip replacement information most people read before surgery. Our physiotherapists add a movement and strength assessment, which often identifies the tendon or spinal contribution to your symptoms and points to the appropriate treatment, but accurate diagnosis is essential before choosing treatment or considering revision hip replacement surgery.

Treatment Depends On The Cause

When the source is a tendon, bursa or the back, treatment is led by the MTP physiotherapy and exercise physiology team. Physical therapy through a graded loading program for the gluteal tendons, hip flexor management, walking retraining and spine-focused work can settle symptoms over several weeks, and most patients can return to normal activities within a few months when recovery stays on track, with Dr Cawthorne reviewing progress alongside the team.

Simple measures help early: short-term pain medication for pain relief, keeping the leg elevated to reduce swelling, and pacing physical activity so pain levels stay manageable. Rehabilitation starts immediately after hip replacement surgery and progresses in stages to help reduce pain. Proper management like this resolves most non-implant pain and protects your quality of life. If everyday tasks become difficult, consult your GP.

A leg length difference is often managed with a small shoe adjustment and strengthening while the body adapts. Hip replacement implants typically last 15-20 years, so revision hip surgery is discussed only when an implant problem such as loosening, infection, recurrent instability, a hip fracture around the components or confirmed implant failure has been found.

Revision, a form of total hip arthroplasty done a second time, is a more complex surgical procedure than the first operation and carries higher risks than a first hip replacement, including deep vein thrombosis, blood clots that can travel to the lungs as a pulmonary embolism, and nerve damage.

An orthopaedic surgeon may offer this kind of joint replacement to relieve pain when the likely benefit clearly outweighs those risks, and it is paired with a structured prehab and rehab plan to give you the best chance of a successful recovery. The same principles apply across hip and knee conditions, so patients suffering ongoing pain after a knee replacement are assessed the same careful way.

Frequently Asked Questions (FAQs)

How long should pain last after a hip replacement?

Discomfort usually eases over the first weeks and keeps improving for up to a year. The direction of travel matters more than the calendar. Pain that is not improving by three to four months, or is getting worse, should be reviewed.

Is groin pain after a hip replacement a sign of loosening?

Groin pain can come from loosening, but in the early years it is more often caused by an irritated hip flexor tendon or referred pain from the spine. Comparing current X-rays with your post-operative films is the quickest way to tell the difference.

Can a hip replacement be infected without a fever?

Yes. Low-grade infections around an implant can cause persistent ache, night pain and stiffness without a temperature. Blood tests for inflammatory markers, and a joint fluid sample if needed, are used to confirm or exclude infection.

Why does my outer hip still hurt after hip replacement?

Outer hip pain usually comes from the gluteal tendons and bursa rather than the joint. These tendons can be tender after surgery or may have been worn before it. A physiotherapy-led loading program is the usual first treatment.

Does pain after a hip replacement mean I need revision surgery?

Most people with a painful hip replacement do not need revision, and hip replacement is commonly done for severe arthritis when other treatments have not relieved symptoms. Revision is considered when a specific implant problem such as loosening, infection or instability is confirmed. Soft tissue and spinal causes are managed with rehabilitation.

Conclusion

Ongoing pain after a hip replacement has a cause, and finding it is the first step towards moving comfortably again. Dr Cawthorne and the MTP Health team assess the implant, the tissues around it and your back together, so treatment matches the real problem. If your hip is not settling the way you expected, book an assessment with MTP Health or call (02) 9437 9794.