How Do Individuals Perceive Diagnostic Labels and Explanations for Hip Pain? A Qualitative Study Among Adults With Persistent Hip Pain

Abstract

Background

Depending on how clinicians label and explain hip pain, patients may form different beliefs about hip pain and its management. When clinicians describe hip pain as a problem of passive “wear and tear,” patients may be more likely to believe that surgery is needed to “fix” hip pain than if it were explained as a dynamic, whole-joint condition or as a biopsychosocial problem. A qualitative study could inform health professionals on how to provide information about hip pain that meets patients’ expectations for information while also guiding them to use recommended nonsurgical care.

Questions/purposes

Qualitative methodology was used to explore: (1) how adults with hip pain perceive different diagnostic labels and explanations relating to the treatment of hip pain and (2) whether the different labels and explanations satisfy their expectations for diagnostic information.

Methods

This was a qualitative study using individual, semistructured interviews with an interview guide. Participants were recruited from metropolitan and rural Australia by social media advertising. Participants self-reported activity-related hip pain on most days in the past 3 months, were 45 years of age or older, and read and spoke in English. We sought to purposively sample a range of educational and health literacy levels. We interviewed 18 adults with hip pain (mean ± SD age was 64 ± 7 years, 13 of 18 patients were women) via video conferencing or telephone (based on preference). The labels and explanations were (1) hip osteoarthritis (explaining it as a dynamic, whole-joint condition), (2) persistent hip pain (explaining it as a biopsychosocial problem), and (3) hip degeneration (explaining it as passive wear and tear). Interviews were audio recorded and transcribed verbatim. Participants engaged in a think-aloud activity, in which we asked them to share their thoughts about three diagnostic labels and explanations as they read the relevant written information. Reflexive thematic analysis was used to analyze the data. This involved two authors first coding and identifying early themes in the data relating to our research questions (treatment beliefs relating to, and satisfaction with, information). Interpretations of data, including codes and themes, were discussed, challenged, and finalized through discussions among the research team. We ceased recruitment when we believed that our data set reached thematic saturation—that is, when it provided a sufficient understanding of our research question and the latest round of data collection had not led to substantial theme development or new themes.

Results

Participants varied in how they perceived different diagnostic labels and explanations for hip pain, informing wide-ranging treatment beliefs. For diagnostic labels of hip osteoarthritis and hip degeneration, they expressed preexisting beliefs that certain exercises (such as those involving weightbearing) could harm the hip and that surgery was a likely treatment for it. When provided with an explanation of hip osteoarthritis, most participants thought that exercise could help manage hip pain, but that the “right” exercises were needed. Participants were generally satisfied with an osteoarthritis explanation because they felt that it was technical and comprehensive. Participants were often dissatisfied with a biopsychosocial explanation of hip pain. They thought that it contradicted their beliefs that hip pain is a problem of degeneration and perceived that it was not personalized to their experiences.

Conclusion

Clinicians should consider explaining to patients that hip osteoarthritis is a dynamic condition (that is, involving ongoing joint changes and joint repair processes) affecting the whole joint rather than framing it as age-related degeneration. However, perceptions of diagnostic information varied considerably between individuals, informing wide-ranging and sometimes unhelpful treatment expectations. It is thus vital to check patients’ perceptions of this information (as with teach back) and address any unhelpful treatment beliefs that arise—particularly highlighting the potential benefits of all types of physical activity for hip osteoarthritis and that surgery is not an inevitable intervention for that diagnosis.

Clinical Relevance

Using the label “hip osteoarthritis” (explaining osteoarthritis as a dynamic, whole-joint condition) may foster more favorable beliefs about nonsurgical care. Because shifting entrenched beliefs is challenging, clinicians are encouraged to foster accurate beliefs about hip osteoarthritis and its care early in the patient’s healthcare journey. They should highlight the potential benefits of all types of physical activity and clarify that surgery is an optional, not inevitable, treatment for hip pain. Personalized education about biopsychosocial contributors to osteoarthritis hip pain (reflecting the patients’ narratives and experiences) could enhance patients’ openness to strategies that address these factors (such as improving sleep and mental health).

Introduction

Hip osteoarthritis is common, burdensome, and costly [1, 23, 37], with the number of people living with the condition projected to increase over the coming decades [49]. This increase is expected to drive rising rates of hip surgeries and associated costs, which may place unsustainable burdens on health systems globally [1, 33, 47]. While clinical practice guidelines recommend offering surgery only after first trialing recommended nonsurgical care (such as exercise) [42], these treatments are underused by, and under offered to, patients with hip pain [8, 27].

Numerous barriers hamper the uptake of recommended nonsurgical treatments for osteoarthritis (such as lack of access to facilities) [20]. One barrier is that clinicians often explain to patients that hip pain is a problem of age-related degeneration [25, 29]. This way of framing hip pain is inaccurate and can inform unhelpful treatment beliefs [25, 28]. Patients told that they have degenerative hip pain may underuse nonsurgical care for hip osteoarthritis because they think that only surgery can “fix” the “worn out” joint [13, 14, 25].

Rather than a passive process of wear and tear, contemporary evidence describes osteoarthritis as a dynamic, active condition [28]. Osteoarthritis is initiated by changes to joint cartilage (as with injury), which can stimulate joint responses that attempt to repair these changes (such as immune pathways) [19, 46, 55]. However, these responses can contribute to further whole-joint problems, such as further reducing cartilage integrity and reshaping joint tissues (for instance, bone growth) [19, 46, 55]. Joint pain and dysfunction can result when these joint responses fail to compensate for joint changes and/or themselves become maladaptive [19, 46, 55]. Painful osteoarthritis is also a biopsychosocial phenomenon, potentially influenced by an individual’s emotions, social context, and mental health [22, 28]. There is thus a global need to develop explanations that help patients understand hip pain accurately and guide them to actively manage it [30].

An earlier randomized control trial (RCT) that we performed found that providing patients with an osteoarthritis explanation or a biopsychosocial explanation led them to perceive that surgery was less necessary and exercise less harmful compared with explaining hip pain as degeneration [24]. However, participants were less satisfied with a biopsychosocial explanation of hip pain than a degeneration explanation [24]. This RCT cannot help us understand why people were most satisfied with a degenerative framing of hip pain even if it negatively influences treatment beliefs. To explore this tension, we need a qualitative study. Findings from a qualitative study can guide clinicians in fostering helpful beliefs about recommended nonsurgical care (such as exercise) while still satisfying patient expectations for diagnostic information.

Therefore, we performed this qualitative study to explore (1) how adults with hip pain perceive different diagnostic labels and explanations relating to the treatment of hip pain and (2) whether the different labels and explanations satisfy their expectations for diagnostic information.

Patients and Methods

Qualitative Approach and Research Paradigm

In this qualitative study, we used semistructured interviews via video conferencing and telephone to gather data. It was guided by a reflexive thematic analysis qualitative approach [9] and reported according to the Consolidated Criteria for Reporting Qualitative Research (COREQ) checklist [52]. This research was underpinned by an Interpretive Description paradigm [51]. It was designed and conducted by a team of (predominantly) clinician researchers who applied their expert lens to explore and analyze the subjective experiences of patients to generate knowledge that could inform clinical practice.

Context

Participants were recruited from the community across Australia (metropolitan and rural areas) with various healthcare experiences (had/had not engaged with a physician and/or orthopaedic surgeon).

Sampling Strategy

Participants self-reported activity-related hip pain on most days in the past 3 months, were 45 years of age or older, and read and spoke English (because the information and interviews were in English). Individuals with previous hip replacement(s) were excluded as these individuals may have had firmly held beliefs about surgery. We recruited participants by advertising with our center’s knowledge translation network and personal and social media accounts. Potentially interested participants provided information about themselves in a survey in Qualtrics. A study author (TH) contacted potentially interested participants via phone to confirm their details and eligibility. If eligible to participate, they were again provided with important information about the study and an electronic consent form to sign. We used purposive sampling, aiming to interview participants with varying educational and health literacy levels. Given that highly educated women were predominantly recruited in the first recruitment phase, we sought to balance this by seeking men and/or individuals who were nontertiary educated or reported a health literacy level lower than “easy.”

We ceased recruitment when we (1) believed that our analysis and interpretation adequately provided new, rich, and deep knowledge relating to our research aims [9, 39] and (2) the researchers (TH, RSH, MH, BJL, SJZ, FD) believed that the latest round of data collection had not led to considerable theme or new theme development—that is, when we reached thematic saturation. Overall, 18 individuals participated in this study, with a mean ± SD age of 64 ± 7 years, and 13 of 18 identified as women (Table 1). Of the participants, 12 of 18 identified their ethnicity as Australian/New Zealander, and 6 of 18 as European.

Table 1.

Participant characteristics

Participant code	Age in years	Gender	Health literacya	Highest education levelb	Diagnosis by healthcare professionalc	Pain intensityd	Pain interference with functione
1	60-64	Woman	Always easy	University or tertiary institute	No	7	7
2	55-59	Woman	Easy	High university degree	No	5	4
3	70-74	Man	Easy	High university degree	No	4	7
4	65-69	Woman	Always easy	University or tertiary institute	No	5	7
5	70-74	Woman	Easy	University or tertiary institute	No	6	2
6	60-64	Woman	Always easy	Higher university degree	Yes (arthritis)	5	4
7	50-54	Woman	Always easy	University or tertiary institute	Yes (osteoarthritis)	8	8
8	70-74	Woman	Always easy	University or tertiary institute	Yes (degeneration)	6	4
9	55-59	Woman	Neither easy nor difficult	Secondary school	Yes (compression [sic])	5	6
10	65-69	Man	Easy	University or tertiary institute	No	7	8
11	55-59	Woman	Easy	Secondary school	Yes (related to scoliosis)	7	6
12	65-69	Woman	Easy	University or tertiary institute	No	3	3
13	70-74	Woman	Always easy	Some education beyond high school	No	5	9
14	70-74	Woman	Neither easy nor difficult	University or tertiary institute	Yes (arthritis)	4	3
15	60-64	Woman	Always easy	Secondary school	Yes (degeneration, arthritis)	6	6
16	65-69	Man	Neither easy nor difficult	Some education beyond high school	Yes (osteoarthritis)	3	7
17	60-64	Man	Easy	Some education beyond high school	Yes (osteoarthritis)	6	8
18	60-64	Man	Always easy	Secondary school	Yes (arthritis, degeneration)	6	6

^aMeasured using a scale including “always easy,” “easy,” “neither easy nor difficult,” “difficult,” and “always difficult.”

^bSome education beyond high school includes undertaking education for a trade (such as a trade certificate).

^cDiagnosis self-reported by participants in the interview.

^dMeasured with numeric rating scale (0 to 10; higher scores indicate worse pain).

^eMeasured with numeric rating scale (0 to 10; higher scores indicate worse interference with function from pain).

Data Collection Methods

The interviews were conducted per the Three-Step Test-Interview method framework [11, 26]:

Stage 1: Thinking aloud. Participants were encouraged to verbalize their thoughts when reading the written diagnostic information (Fig. 1).

Fig. 1.

Diagnostic labels and their explanations.

Stage 2: Clarification. The interviewer asked questions to clarify participants’ verbalized thoughts (for example, why did you not like that word?) and observed behaviors (such as, why did you pause on that word?).

Stage 3: Debriefing. The interviewer explored the participants’ thoughts about the diagnostic information using a semistructured interview guide (Fig. 2), which was developed and discussed a priori among the research team.

Fig. 2.

Interview guide and diagnostic labels and their explanations.

We provided participants with written information for three diagnostic labels and associated explanations from our previous RCT [24]: (1) hip osteoarthritis, (2) persistent hip pain, and (3) hip degeneration (Table 1). We constructed the “hip osteoarthritis” explanation by adapting the definitions and explanations used by osteoarthritis organizations, such as Arthritis Australia [3], Osteoarthritis Research Society International [46], and Versus Arthritis [54]. We constructed the biopsychosocial explanation for persistent hip pain by adapting information from evidence-based definitions of persistent pain [17] and consumer information websites [2, 21]. We developed the explanation for hip degeneration based on consumer information websites [16, 41] and systematic review evidence of how healthcare professionals typically explain hip pain [25]. Further information on how these labels and explanations were developed has been provided (Appendix 1; http://links.lww.com/CORR/B406). During the interview, the participant read the labels and explanations for the first time and answered verbal questions about each label and explanation before proceeding to the next. We randomized the order in which participants read the labels and explanations.

Video conferencing (via Zoom or Microsoft Teams) or telephone interviews were used depending on the participant’s preference. Interviews lasted approximately 60 minutes, were audio recorded, and transcribed verbatim using the Microsoft Word transcription features. An author (TH) then manually reviewed the transcripts for accuracy, deidentified them, and assigned pseudonyms for confidentiality.

Researcher Characteristics and Reflexivity

A graduate researcher and clinical physiotherapist who identifies as a man (TH) and had no prior relationship with participants conducted the interviews. Other researchers included women physiotherapists (RSH, SJZ, MOK, FD), an exercise scientist (MH), a health scientist (BJL), and a social scientist and applied health researcher (CJ). All researchers have qualitative study training and experience.

Patient and Public Involvement

We sought feedback and piloted the interview guide and methods with two consumers (one man and one woman older than 45 years) with persistent hip pain. Minor changes were made to the interview schedule, namely reducing the number of questions. The diagnostic labels and explanations were also developed with consumer involvement.

Ethical Approval

We obtained ethical approval for this study from the University of Melbourne Institutional Human Research Ethics Committee (2023-27176-42744-3).

Analysis

We analyzed data with reflexive thematic analysis; this approach acknowledges that researchers actively generate themes informed by their subjectivity [9]. We used Microsoft Word to analyze the data. Data collection and analysis occurred concurrently, which allowed us to explore developing interpretations in subsequent interviews. Two authors (TH, SJZ) first inductively coded data individually, and then iteratively developed a coding framework focusing on perceptions of information relating to treatment beliefs and expectations relating to participant satisfaction with information. A third author (FD) also read a diverse sample of transcripts (that is, differing participants’ views and characteristics) to familiarize themselves with the raw data. Two authors (TH, SJZ) then collaboratively developed preliminary themes by identifying how perceptions across participants’ responses related to treatment beliefs (for instance, what perceptions of which language or concepts influenced beliefs and why) and why people were dissatisfied or satisfied with labels and explanations (for instance, based on their expectations for information) (Supplemental Tables 1 and 2; http://links.lww.com/CORR/B406). Treatment beliefs were also compared and contrasted across diagnostic labels and explanations. Incipient themes were first discussed, challenged, and refined with members of the research term (TH, RSH, MH, BJL, SJZ, FD) during data collection and analysis. Final themes were then agreed upon among the entire research team (TH, RSH, MH, BJL, SJZ, SB, CJ, MOK, FD).

Primary and Secondary Study Outcomes

Our primary study outcome was to explore individuals’ perceptions of diagnostic labels and explanations related to beliefs about hip pain. We sought to develop themes that increased our understanding of how diagnostic information (terms and concepts) informed beliefs about the benefits and/or harms of treatments for hip pain and the reasons for this. This analysis occurred in iterative, concurrent rounds of interviewing participants, analyzing data within and then across participants, and finally, challenging and refining themes collaboratively within our team. We identified three key themes: (1) labeling hip pain as osteoarthritis or degeneration can evoke existing beliefs that exercise is harmful and surgery is necessary, (2) “hip osteoarthritis” explanation prompted diverse beliefs about what is appropriate treatment, and (3) a biopsychosocial explanation of hip pain informs beliefs that biopsychosocial treatments could be beneficial.

Our secondary study outcome was to explore whether the different labels and explanations satisfied participants’ expectations for diagnostic information. Using methods similar to those for our primary outcome, we sought to develop themes that increased our understanding of which diagnostic terms and concepts satisfy peoples’ expectations for information about hip pain and why. We identified two key themes: (1) satisfaction is increased with a medical label and technical explanation, and (2) a hip osteoarthritis explanation could benefit from tailored psychosocial information. Our findings are described below, with each theme supported with participant quotes and indexed with an identification number, age, and gender (for instance, Participant 1, 60 to 66 years, woman).

Results

How Do Adults With Hip Pain Perceive Different Diagnostic Labels and Explanations About the Treatment of Hip Pain?

Treatment expectations for hip pain differed based on the diagnostic labels and explanations provided and how individuals perceived this information. We developed three key themes that we believe could help clinicians guide patients to form favorable beliefs about nonsurgical treatments for hip pain (Table 2). We have illustrated the key similarities and differences in treatment expectations arising from different diagnostic information (Fig. 3). Additional information on themes and related treatment beliefs has been provided (Supplemental Table 3; http://links.lww.com/CORR/B406).

Table 2.

Themes, treatment beliefs, and the diagnostic information informing these for the “hip osteoarthritis” and “hip degeneration” label and explanation

Theme and treatment beliefs	Diagnostic information evoking and informing beliefs	Quotes
Labeling hip pain as osteoarthritis or degeneration can evoke existing beliefs that exercise is harmful and surgery is necessary
Only low-impact or nonweightbearing exercise is appropriate for hip osteoarthritis	“Hip osteoarthritis” label (evoked preexisting belief)a	Participant 15, 60-64 years, woman: “Yeah, again resting, stretching, just doing things at slower pace, but still being active, not stopping and I’ve gotta hip pain and I can’t do anything.” Participant 18, 60-54 years, man: “So I would do things to help myself as well, but cutting back on certain things as well, you know, training it hard. You gotta stop, you gotta stop running it, you’ve gotta go jogging on ovals. Not, not pavement. If you want to play and continue to play, go do things smarter and better and less of it.”
Surgery is a likely or necessary treatment for hip osteoarthritis	“Hip osteoarthritis” label (evoked preexisting belief)a	bParticipant 9, 65-69 years, woman: “Yeah, if I was told I had hip osteoarthritis and I’ve got that explanation, I think I probably would think I would eventually do that [surgery]. Yeah, I mean, I’m XXc now, but like in, I’m talking in years, you know, in years’ time, I’m thinking, I’d be thinking in the back of my mind, yeah, I can see that coming. TH: What do you think informs that expectation? Participant 9: Just hearing from other people. Yeah, yeah. TH: That have had osteoarthritis? Participant 9: That have had hip replacements who are who are older but fit, you know. So you know, you do kind of think well, if they if it’s happening to them, well, it’s gonna eventually happen to me.” Participant 5, 70-74 years, woman: “And then if you can’t live with it, then I feel from my personal knowledge and experience through friends and family that hip replacement. But I’d hope that I wouldn’t get that far, but it’s it is, it’s on the list, you know, for many people, yeah.”
Low-impact exercise appropriate for hip degeneration (minimize wear and tear)	“Hip degeneration” label (evoked preexisting belief)a	Participant 12, 65-69 years, woman: “… but if I do that in the pool or if I walk on soft grass or something like that I get the steps up and the pain is not on bad. That was why I was just thinking, maybe nonweightbearing. Yeah, I know that’s still weightbearing, but that’s not as rough on the joints.” Participant 6, 60-64 years, woman: “So, I think it could be harmful… but it also, I’m sure, does improve the muscle, which is supporting those bones.”
Medications and/or injections to manage degenerative hip pain	“Hip degeneration” label (evoked preexisting belief)a Hip degeneration explanation: hip pain is a problem of wear and tear and cartilage breakdown (that is, bone on bone)	Participant 8, 70-74 years, woman: “Medications, I guess… I’d probably ask her if it would be worth having an injection into my hip.” Participant 11, 5-59 years, woman: “You know, is that where you’ve got to start taking the painkiller drugs to be able to just to be able to get through walking upstairs or, you know, doing your everyday walking or anything like that because the pain of bone on bone. With no cartilage in that there. Yeah, that won’t, it won’t be won’t be much fun whatsoever.”
Perceived inevitable deterioration with hip degeneration	“Hip degeneration” label (evoked preexisting belief)a Hip degeneration explanation: hip pain is a problem of wear and tear and cartilage breakdown (that is, bone on bone)	Participant 4, 65-69 years, woman: “To me this would be, it’s pretty scary stuff [hip degeneration], thinking how can I walk and am I going to be in a wheelchair.” Participant 11, 55-59 years, woman: “Degeneration means it’s going. It’s on its way out. It’s whittling away. It’s slowly disappearing. Yeah, which is not what you want at the end of the day because it’s sort of like you know yeah, it’s gonna go, you know, like the ball and socket or something like that. If it starts degenerating, then you’re gonna possibly end up with even more pain.… But I know down the track eventually it will probably get me. It’ll get the better of me eventually, and I’ll have to give up my horses and stop riding and things like that…”
Surgery is required to “fix” the cartilage loss	“Hip degeneration” label (evoked preexisting belief)a Hip degeneration explanation: hip pain is a problem of wear and tear and cartilage breakdown (that is, bone on bone)	Participant 3, 70-74 years, man: “I guess the first thing that comes into mind is hip replacement.” Participant 2, 55-59 years, woman: “I sort of feel though with this statement I would think that it’s marching forward to possibly eventual surgery, yeah.” Participant 6, 60-64 years, woman: “But it’s not going to fix it. It’s not gonna, it doesn’t take it away. Yes, it makes your muscles stronger, but it’s not gonna actually change the bones now degenerated, rough and whatever it is you know, got lumps and bumps on it or whatever. It doesn’t. Nothing’s going to change it apart from surgery.”
“Hip osteoarthritis” explanation prompted diverse beliefs about what is appropriate treatment
Specific (“right”) exercises could help treat hip osteoarthritis (that is, facilitate repair)	Hip osteoarthritis explanation: osteoarthritis is a process of joint changes and failed joint repair responses	Participant 6, 60-65 years, woman: “… what would I be able to do to help repair then you know, and exercise, but you know, that will have to be very in a very controlled way with an expert’s guidance.”
Certain medications or supplements may help treat hip osteoarthritis (that is, facilitate repair)	Hip osteoarthritis explanation: osteoarthritis is a process of joint changes and failed joint repair responses	Participant 11, 55-59 years, woman: “I don’t know if there is a medication that could help, you know, to repair ligaments or to help repair bone, you know, calcium’s good for bones and things like that. But I don’t know if that could help that or not at the end of the day.”
Nonsurgical treatments could help avoid or delay surgery	Hip osteoarthritis explanation: osteoarthritis is a process of joint changes and failed joint repair responses	Participant 9, 55-59 years, woman: “Yeah, thinking that you should probably do more of it [exercise]. I’m not great at doing that. You know, I really have to push myself. Yeah, I’m thinking that I need to take more, get more vitamins, fish, oil, vitamins, things like that, you know, so last thing in the world I want to happen. I want to be able to enjoy life for a very long time, you know.”
Osteoarthritis affecting the whole joint would be difficult to treat	Hip osteoarthritis explanation: osteoarthritis is a whole-joint condition (that is, affecting cartilage, bones, ligaments, and muscles)	Participant 14, 70-74 years, woman: “Yeah, it doesn’t sound like there’s a magic bullet for it, that’s for sure. Well, especially if this is true [whole-joint disease], and it’s affecting so many different types of tissue.”

^aPreexisting beliefs denote the fact that participants expressed these beliefs for a given diagnostic label before they were asked to consider its accompanying explanation.

^bThese responses include a dialogue between the interviewer (TH) and the participant (denoted by the participant code).

^cParticipant’s age redacted to maintain confidentiality.

Fig. 3.

Key similarities and differences across diagnostic labels and explanations. A color image accompanies the online version of this article.

Theme 1: Labeling Hip Pain as Osteoarthritis or Degeneration Can Evoke Existing Beliefs That Exercise Is Harmful and Surgery Is Necessary

Many participants perceived the label “hip osteoarthritis” to indicate wear and tear to the hip, even though this phrase was not included in the osteoarthritis explanation. Informed by this belief, people with hip pain believed that only low-impact or nonweightbearing exercises (such as swimming and yoga) were appropriate to treat hip pain and that other types of exercise (such as running) would “wear out” the joint further (Table 2). A patient offered this observation on this theme: “Yes, well, it might be one of the only few exercises you can actually do [walking] that doesn’t, you know, impose too much damage on your body—but in terms of wear and tear, it’s gotta be wear and tear. But it’s not happening at a greater degree” (Participant 10, 65 to 69 years, man).

Many participants believed that surgery was likely for hip pain when diagnostically labeled as hip osteoarthritis—this belief was informed by their own and others’ healthcare experiences. Beliefs about the harms of exercise and surgery often persisted even after being presented with an explanation of osteoarthritis: “I suppose I do [think surgery is inevitable]. Because, you know, everyone’s got a next-door neighbor, a friend, you know, the lady next door is 5’ 2” and probably 50 kilos, and she’s just had both hips done, so it’s a bit of a genetic lottery and lifestyle. So yeah, I possibly think it is inevitable” (Participant 2, 55 to 59 years, woman).

When hip pain was labeled and explained as degeneration, participants believed that exercise could only compensate for the hip’s structural damage and that medications were needed to manage the pain. This belief was often strongly linked to participants’ perception that degeneration would inevitably progress (to “bone on bone”), leading to worsening pain, disability, and thus, inevitably, surgery to “fix” the hip (Table 2): “So, the wear and tear that you occur is like a tire, and I keep it relating to a tire in a car. Once the tire gone to a certain level, you can’t get it better to the same level, you have to replace it with a new tire” (Participant 10, 65 to 69 years, man).

Theme 2: “Hip Osteoarthritis” Explanation Prompted Diverse Beliefs About What Is Appropriate Treatment

While participants perceived an explanation of osteoarthritis to suggest that exercise could help manage hip pain, some perceived that specific medications or exercises would be needed to favorably facilitate joint repair processes (Table 2): “… because if there’s repair work for the body to do certain types of exercise may be, or certain activities or treatments may be conducive to that, and others may not” (Participant 7, 50 to 54 years, woman).

Some participants, perceiving the explanation this way (that is, as suggesting that joint repair could be facilitated), believed that surgery for hip osteoarthritis could be avoided or delayed: “… so that body will try and repair these changes. Then she [general practitioner] goes on to say… so, the repair, doesn’t to me suggest surgery because she’s [general practitioner] saying the body can do the repair” (Participant 8, 70 to 74 years, woman).

In contrast, some participants perceived the “whole-joint” explanation of hip osteoarthritis to mean that it was actually a more severe condition than wear and tear (that is, cartilage loss). This understanding informed the belief that osteoarthritis was less amenable to nonsurgical treatments: “Well, yeah. Then it’s like, oh, shit, it’s my whole leg. Like my whole legs bucked (sic), like basically. It makes it sound pretty bad. Ohh, what am I gonna do now? I’ve got you know ligaments and muscles, you know. It probably all of those things are involved, but I didn’t think that’s what it was” (Participant 11, 55 to 59 years, woman).

Theme 3: A Biopsychosocial Explanation of Hip Pain Informs Beliefs That Biopsychosocial Treatments Could Be Beneficial

When hip pain was framed as a biopsychosocial problem, some participants believed that biopsychosocial treatment strategies might help manage contributing factors to hip pain (Table 3). For some, having previously engaged with mental health strategies made them receptive to this explanation of hip pain: “I mean, I do like meditation and relaxing and stuff like that because I do have a stress problem. You know, I try to relax and stuff like that. So, I suppose that’s gonna help it some, that’s gonna help that too if I reduce my stress levels” (Participant 9, 55 to 59 years, woman).

Table 3.

The theme, treatment beliefs, and diagnostic information informing these for the “persistent hip pain” label and explanation

Theme and treatment beliefs	Diagnostic information evoking and informing beliefs	Quotes
A biopsychosocial explanation of hip pain informs beliefs that biopsychosocial treatments could be beneficial
Biopsychosocial strategies to manage stress, sleep, and mental health could help treat hip pain	Persistent hip pain explanation: pain is a biopsychosocial problem influenced by genetics, poor sleep, life stress, and emotions	Participant 3, 70-74 years, man: “… you know, talking about poor sleep. So yeah. How is my sleep? How is my stress level? How are my emotions? Am I fearful of my pain? So yeah, it’s almost like a counselling style I feel, which, you know, would be a good start. Because you gotta get to know the person and work with their attitudes towards stress.” Participant 6, 60-64 years, woman: “I mean, I guess the fact that I have sought out a psychologist, partly it is to do to deal with the, you know, chronic pain. But there’s other things that have flicked (sic) into that to do with past experiences and you know, just general stress you know. So you know. I have actually for me personally, I have sought help with that because I can recognize that some of those things could be true.”
Reduced perceived need for surgery to treat hip pain	Persistent hip pain explanation: pain is a biopsychosocial problem influenced by genetics, poor sleep, life stress, and emotions	aParticipant 9, 55-59 years, woman: TH: “With this explanation, how do you see your future, with the hip pain?” Participant 9: “Well, I mean. that hopefully it’s gonna, it gets better when I try it work on my stress more then. But as I say, I know that this is that, that that’s who I am, and that’ll be with me forever, you know, so I have to just control as best I can.” TH: “Is this explanation suggesting to you surgery?” Participant 9: “Ohh no no, no. I don't think so, no. I mean I’m fearful of the pain because it’s limiting, not getting any younger. You know what I mean?! So, you think you do sometimes think ohh, what’s ahead of me, you know. But I’m not thinking about surgery. Yeah. I would go to great extremes before I would get surgery.”

^aThese responses include a dialogue between the interviewer (TH) and the participant (denoted by the participant code).

Some participants perceived that a biopsychosocial explanation suggested that surgery was potentially not needed for hip pain given that other strategies (as described in the previous paragraph) may help manage its psychosocial contributing factors: “Ah, because… it’s inferring that, you know, there may be other influences of genetics, poor sleep, life, stress, emotions, how fearful you are. So, I’d be going, OK, let’s work on all that first, let’s try everything we can, yeah…” (Participant 3, 70 to 74 years, man).

How Do the Different Labels and Explanations Satisfy Participant Expectations for Diagnostic Information?

Participants were often satisfied with a diagnostic label of osteoarthritis and its accompanying explanation, particularly when they felt that it offered a technical explanation of how structural processes contribute to hip pain. We developed two key themes that could guide health professionals in providing an explanation that satisfies patients’ expectations for information. Additional participant quotes informing these themes have been provided (Supplemental Table 4; http://links.lww.com/CORR/B406).

Theme 1: Satisfaction Is Increased With a Medical Label and Technical Explanation

Participants often desired a legitimate (that is, scientific) medical diagnostic label for their hip pain. Many felt that “hip osteoarthritis” provided such a label, while the label “persistent hip pain” did not: “All that’s doing again is reinforcing the actual symptoms. That’s all you’re doing. You’re describing the symptom. That’s our job… so, for you to turn around and say you’ve got persistent hip pain—excuse me, you’ve gone to university, you’ve got how many degrees to repeat what I’ve just told you?” (Participant 1, 60 to 65 years, woman).

Participants were often satisfied with the “hip osteoarthritis” explanation because they felt that it provided the most technical and comprehensive information. Some were satisfied with the amount of information provided. Others wanted more detailed information about the biological processes underpinning osteoarthritis and what they mean for treatment. Participants were generally dissatisfied with a biopsychosocial explanation of hip pain. They often perceived that it was unclear, irrelevant to their experiences of pain, or contradicted their belief that hip pain is a problem of degeneration: “Well, it’s [hip osteoarthritis] less wishy-washy than you know past experiences, life stress, fearful of pain [persistent hip pain]. And the degeneration is a bit limited, just looking at cartilage damage. The hip osteoarthritis is like all you can eat buffet—it’s giving the patient an idea of the complexity of the situation” (Participant 14, 70 to 74 years, woman).

Theme 2: An Osteoarthritis Explanation Could Benefit From Tailored Psychosocial Information

When reflecting on the persistent hip pain explanation, participants acknowledged psychosocial aspects to their hip pain and recognized that psychosocial factors could influence it—even participants who wholly attributed their pain to physical causes: “It does affect mental [health]… so then my body is under stress, and maybe then it goes to those parts that are probably a little bit vulnerable, and it’s sort of saying to me if you’re not going to listen to me, I’m going to sit you down” (Participant 13, 70 to 74 years, woman).

Participants suggested that including information about psychosocial contributors to hip pain could make an osteoarthritis explanation more comprehensive. However, they suggested that clinicians should personalize this information to a patient’s circumstances and expectations for such information.

Discussion

Labeling and explaining joint pain as a degenerative, structural problem (such as “wear and tear”) can negatively influence beliefs about it and its treatments [25, 44, 45, 57]. However, clinicians often explain hip pain this way to patients [25, 45]. To guide patient education about hip pain, we conducted a qualitative study addressing two aims: first, to understand how peoples’ perceptions of different diagnostic labels and explanations of hip pain influence their treatment beliefs, and second, to understand to what extent people were satisfied with different types of diagnostic information and why. Key findings were that a diagnostic label of hip osteoarthritis or hip degeneration elicited preexisting unhelpful beliefs—particularly that exercise is harmful and surgery is inevitable. These beliefs potentially impede individuals from using nonsurgical treatments that may help them live better with hip pain. An evidence-based osteoarthritis explanation generally informed more helpful treatment beliefs. Participants were also mostly satisfied with this explanation and a diagnostic label of “hip osteoarthritis.” Clinicians should thus label and explain hip pain as hip osteoarthritis (that is, a dynamic process of joint changes and attempted repair) and avoid framing it as a problem of passive degeneration. Checking how patients understand diagnostic information is vital to identifying and responding to any unhelpful perceptions or treatment beliefs that arise (for instance, that only certain types of exercise are appropriate to treat hip pain).

Limitations

A potential limitation of this study was its small sample size, which included only Australian participants. Our findings may not necessarily represent the perspectives of people with more diverse cultural and ethnic backgrounds or from other countries. Furthermore, no participants rated their ability to understand written health information as “difficult” or “very difficult”; thus, our findings may not transfer to people with lower levels of health literacy. Despite these potential limitations, we believe that our findings may apply across various contexts. We found that participants’ perceptions of diagnostic information were more greatly influenced by prior beliefs (such as those informed by healthcare experiences) than participant characteristics (such as educational levels). Relatedly, a key reason we ceased sampling participants was that later rounds of data collection, which included more men and participants with lower educational levels, did not lead to new or substantial development of themes.

Another potential limitation is that our beliefs and experiences as scientists and physical therapists led us to prioritize what we believe are helpful treatments, such as exercise. However, we sought to follow clinical guidelines for osteoarthritis in offering these interpretations of the data [4, 42]. Acknowledging this potential limitation, we presented our analysis transparently by making our code and theme development available to the reader. We also strove to explore alternative interpretations of the data by discussing and challenging our interpretations among our international research team with diverse research and clinical experiences.

Discussion of Key Findings

Although “hip osteoarthritis” met most participants’ expectations for a medical diagnostic label, the explanation of hip osteoarthritis prompted participants to express several misconceptions about osteoarthritis. Misconceptions about osteoarthritis and its treatment appeared to originate from their prior interactions with health professionals and public discourse (such as discussions with friends) rather than the written explanation provided. These misconceptions, namely that osteoarthritis is a “wear and tear” and “bone on bone” problem, lead patients away from healthy behaviors and first-line nonsurgical care [6, 13, 14, 18, 24, 25]. Clinicians should avoid framing hip pain as a problem of passive, age-related degeneration. Doing so may foster more accurate and helpful beliefs about hip pain. Changing beliefs about hip pain may empower patients to use recommended nonsurgical treatments and to live better with hip pain [48].

Our findings revealed several specific opportunities for clinicians to change patient beliefs about osteoarthritis and its treatment. Participants often believed they would need the “right” or “correct” exercises for osteoarthritis. This belief may impede patients from types of exercise that could benefit them. Clinical guidelines recommend various types of exercise, including weightbearing and nonweightbearing, with similar benefits and (low) risks of harm across them [4, 34, 42]. We encourage clinicians thus to explain to patients that all types of exercise are potentially safe and beneficial for treating hip pain [43], that they do not appear to progress structural changes in the joint [10], and that they may provide benefits beyond the hip (such as to mental health) [29]. Clinicians should also educate patients that surgery for hip osteoarthritis is not “needed,” “required,” or “inevitable” [15, 42]. They should engage patients in shared decision-making, framing surgery as an optional treatment for those who have tried and not sufficiently benefitted from nonsurgical care [42]. Indeed, most individuals with hip osteoarthritis do not undergo total hip replacement surgery, and hip pain and related physical disability do not progressively worsen over time for many individuals [7, 15].

To foster more helpful treatment beliefs about osteoarthritis, clinicians should ask patients about their understanding of the provided information, for example, using teach back, which is simple to implement (that is, asking patients to teach back to clinicians the provided information) and can improve patient outcomes (such as satisfaction) [50, 56]. Clinicians could then address unmet expectations for information (such as level of detail) and identify and respond to any misconceptions and preexisting unhelpful treatment beliefs, such as those outlined in the above paragraph. Importantly, patients often form beliefs about hip pain during early healthcare encounters [25]. However, changing existing beliefs with health education is challenging [31, 32, 48]. Our findings show that simply providing people with evidence-based information about hip pain does not necessarily change inaccurate beliefs about hip pain. For these reasons, health professionals should seek to instill helpful, accurate beliefs about osteoarthritis early in a patient’s clinical journey [30].

Participants were often dissatisfied with a biopsychosocial explanation of hip pain. People often seek biomedical explanations to validate joint pain and guide the way to “fixing it” [5, 36, 38, 40, 53]. However, they also recognize that pain can relate to other factors such as sleep, personal relationships, and mood [5, 32, 45, 53]. While reconciling this tension is challenging [12, 31, 35], our findings suggest that clinicians can support patients to understand hip pain as an active, biological joint condition, but also recognize psychological factors contributing to it. They can do this by asking patients to reflect on the circumstances and experiences influencing their pain (such as times of poor sleep). Clinicians could then incorporate this patient narrative into the education they provide. This type of participatory education may better help patients make positive changes in beliefs and behavior [18, 30, 48]. Indeed, our findings suggest that educating individuals in this way may help them become more open to actively managing biopsychosocial contributors to hip pain. Future research is needed that engages consumers in codeveloping and evaluating educational approaches, which aim to empower diverse individuals and communities to actively manage and live better with hip pain [30, 48].

Conclusion

Clinicians should consider providing patients with contemporary information about osteoarthritis that frames it as a dynamic condition (that is, involving ongoing joint changes and joint repair processes) affecting the whole joint rather than as passive, age-related degeneration. However, perceptions of diagnostic information varied considerably between individuals, informing wide-ranging and sometimes unhelpful treatment expectations. It is thus vital to check patient perceptions of this information (for instance, using teach back) and address any unhelpful treatment beliefs that arise—particularly highlighting the potential benefits of all types of physical activity for hip osteoarthritis and that surgery is not inevitable for all patients with that diagnosis.