In this blog, I’m going to tell you why your hip hurts and what you should do about it!
Be sure to also check out our Hip Resilience Program!
Basic Hip Anatomy
The hip is a ball-and-socket joint where the head of the femur, or thigh bone, meets the acetabulum of the pelvis.
The labrum is a fibrocartilaginous ring that increases the depth of the socket and improves the stability of the hip.
Lastly, the hip is surrounded by a connective tissue known as the joint capsule and reinforced by the iliofemoral, pubofemoral, and ischiofemoral ligaments.
Intra-Articular vs Extra-Articular
Diagnoses of the hip are often categorized as intra-articular or extra-articular.
Anything within the capsule that affects the hip joint itself is known as intra-articular, such as osteoarthritis, femoroacetabular impingement, labral tears, dysplasia, and avascular necrosis.
Everything that occurs outside of the hip joint is labeled extra-articular, like adductor strains, gluteal tendinopathy, proximal hamstring tendinopathy, piriformis syndrome, and the other diagnoses I’m going to discuss.
Location of Symptoms
The location of symptoms can be helpful for differentiating between potential diagnoses. For example, symptoms of proximal hamstring tendinopathy will always present toward the back of the hip where the hamstrings attach to the pelvis. On the other hand, intra-articular problems frequently have a component of groin pain and individuals may use the “C-sign” to indicate their deep, anterior hip pain.
In anatomical terms, the front of the hip is anterior, the side of the hip is lateral, and the back of the hip is posterior.
Let’s begin with the intra-articular diagnoses.
Hip Osteoarthritis
Symptoms associated with hip osteoarthritis include:
- Morning stiffness
- Pain with climbing stairs or walking down slopes
- Pain on initial steps after rest
- Pain on walking
- and pain relieved by sitting
Additional findings may include:
- A limp with walking
- Hip muscle weakness when trying to stand on one leg
- Buttock pain while squatting
- Pain with resisted hip movements
- and decreased hip range of motion compared to the uninvolved side
This is not an all-inclusive list, but if you’re older, gradually start experiencing symptoms, and you’re noticing an associated decline in strength, range of motion, or overall function, hip osteoarthritis becomes higher on the list of possible diagnoses.
Although hip osteoarthritis is typically described as a degenerative joint disease related to “wear and tear” of the cartilage within the hip joint, it should be thought of as a systemic condition as other factors influence symptoms and the progression of the disease, such as genetics and metabolic health. Plus, many of the structural changes seen on imaging associated with hip osteoarthritis are often found in people with no symptoms.
Therefore, imaging is only recommended if surgery is a consideration or if there’s suspicion of an alternative diagnosis. Otherwise, a clinical examination by a medical doctor is sufficient.
Since the severity of symptoms can vary over time, non-operative management is considered the first line of treatment, including a regular exercise routine.
Want to learn more?
Check out our full blog about Hip Osteoarthritis!
Femoroacetabular Impingement (FAI)
“Femoroacetabular” refers to the hip joint, so you may also hear it be called hip impingement.
FAI was defined by Griffin et al in 2016 as a “motion-related clinical disorder of the hip with a triad of symptoms, clinical signs, and imaging findings. It represents symptomatic premature contact between the proximal femur [the thigh bone] and the acetabulum [the socket part of the pelvis].”
Symptoms include pain in the hip or groin, and in some cases, also the back, butt, or thigh. Additionally, people may experience clicking, catching, locking, stiffness, or limited range of motion. Symptoms commonly occur at the end ranges of an individual’s available hip range of motion, such as during a deep squat, deadlift, certain yoga poses, sitting for long durations, and various sporting activities.
Clinical signs involve the tests and measures that a physical therapist or medical doctor may perform during their examination. The most useful maneuver is bringing the hip into flexion, adduction, and internal rotation (FADIR). If a person does not experience symptoms, it is unlikely that they have FAI.
Flexion, abduction, and external rotation (FABER) may also be used to evaluate symptoms and differences in side-to-side range of motion.
Additionally, hip range of motion is independently assessed, with an emphasis placed on hip internal rotation when the hip is flexed to 90 degrees.
Along with symptoms and clinical findings, imaging is necessary to diagnose FAI. X-rays can be performed to assess changes in the shape of the hip bones. Cam morphology refers to changes of the femoral head, pincer morphology refers to changes of the acetabulum, and mixed morphology describes a combination of the two.
Imaging findings, clinical signs, AND symptoms are all required to make the diagnosis because it is possible to have changes on imaging without symptoms.
Therefore, imaging is necessary to definitively diagnose FAI, especially if surgery is a consideration, but it is not required to initiate rehab because in most cases, 3-6 months of rehabilitation is recommended first since surgery doesn’t guarantee a return to normalcy, the monetary cost is higher, and there are more risks involved.
Want to learn more?
Check out our full blog about Femoroacetabular Impingement (FAI) Rehab!
Hip Dysplasia
Hip dysplasia can be thought of as a “shallow” socket that does not provide sufficient coverage of the femoral head.
As stated in a recent paper by Evans et al, Developmental Dysplasia of the Hip (DDH) refers to the condition in infancy and Acetabular Hip Dysplasia (AHD) refers to an adolescent or young adult onset.
In the same paper, the authors developed the ALPHA alert mnemonic to increase the diagnostic awareness of acetabular hip dysplasia.
- A stands for Age of symptom onset as it is expected in adolescents or young adults; predominantly females.
- L stands for Limp on examination or patient-reported with the potential for a leg length discrepancy or hip weakness.
- P stands for Pain that is progressive in nature with no known cause. Deep hip flexion is frequently problematic.
- H stands for History, such as any childhood hip concerns or a family history of hip issues.
- A stands for Articulation. Individuals will often report hypermobility, feelings of instability, hip joint sounds, and difficulty with sitting cross-legged.
A combination of these features may warrant X-rays for further evaluation.
Like the previous two diagnoses, imaging findings indicative of hip dysplasia may be present in individuals with little to no symptoms, so non-operative management is often the first line of care when it is detected early.
Want to learn more?
Check out our podcast episode about Hip Dysplasia!
Labral Tears
Labral tears rarely occur in isolation. Instead, they frequently coincide with other conditions like hip dysplasia and FAI. As you may have guessed by now, labral tears are also often found in individuals without symptoms. For this reason, rehabilitation is usually the first step in management.
Avascular Necrosis
Avascular necrosis, or osteonecrosis, of the femoral head is essentially bone tissue death due to a lack of blood supply. Traumatic causes involve fractures and dislocations while the most common non-traumatic causes are corticosteroid use and excessive alcohol intake. Depending on symptoms and the stage of the condition, management may range from rehabilitation to pharmacological treatments to core decompression to a total hip replacement.
Extra-Articular Sources of Groin Pain
Aside from the hip joint-related groin pain that I’ve already discussed, there are several extra-articular sources of groin pain: adductor-related, iliopsoas-related, inguinal-related, and pubic-related. Generally, pain or tenderness localized to one of these structures, in addition to a reproduction of pain through contracting or stretching that specific structure, can help determine the source of symptoms. Notably, the pain felt with resistance testing must be in the location of that structure being tested.
Adductor-Related Groin Pain
Adductor-related groin pain is common in athletes who participate in sports that involve kicking and cutting. It is identified by the presence of pain or tenderness in the adductor area with palpation, as well as resistance testing that reproduces pain in the adductors. It is more likely the culprit of groin pain if symptoms are also present with stretching the adductors.
The most commonly affected muscle is the adductor longus, and it is usually strained from kicking or changing direction.
Iliopsoas-Related Groin Pain
Iliopsoas-related groin pain refers to pain and tenderness at the front of the thigh, along the iliopsoas, that is reproduced with resisted hip flexion and/or stretching of the hip flexors.
The rectus femoris, which also falls under this category, is most commonly strained during sprinting and kicking while the iliacus and psoas can become strained from change of direction movements.
Two things I want to mention here:
- Contrary to popular belief, the hip flexors are rarely the cause of, or answer to, all of your hip-related problems.
- An irritated hip flexor is more commonly a symptom of an underlying intra-articular pathology as opposed to being the primary issue itself.
Inguinal-Related Groin Pain
Inguinal-related groin pain is characterized by pain in the inguinal area which is between the lower abdominals, pubic bone, and the bone at the front of the hip called the anterior superior iliac spine, or ASIS. Symptoms may be reproduced with coughing, sneezing, and resisted trunk flexion.
Although it can initially be difficult to differentiate inguinal-related groin pain from adductor-related groin pain, adductor-related groin pain will typically improve with adductor-specific exercises. Inguinal-related groin pain, however, will not improve and may in fact worsen with adductor-specific exercises or with increases in activity in general.
It’s important to note that an inguinal hernia does not fall under this category of groin pain. Therefore, a palpable bulge should not be present.
Pubic-Related Groin Pain
Pain at the pubic symphysis, which is where the left and right sides of the pelvis come together, and the bones next to it is the hallmark sign of pubic-related groin pain. There are no specific resistance tests for pubic-related groin pain, but it can be more likely if both resisted trunk flexion and resisted hip adduction reproduce symptoms in the pubic area.
Imaging is usually unnecessary for these sources of groin pain and structured rehabilitation is typically the initial focus.
Want to learn more?
Check out our full blog about Groin Pain Rehab!
Gluteal Tendinopathy / Hip Bursitis
If you put your hand on the side of your hip, you should feel a bony prominence known as the greater trochanter, which is part of your femur. The greater trochanter serves as an attachment site for the gluteus medius and gluteus minimus tendons.
In a non-weight bearing position, these two glute muscles act to abduct the hip. More importantly though, they stabilize the pelvis when standing on a single leg, such as when walking, running, and going up stairs.
There is also a trochanteric bursa, which is a fluid-filled sac that serves to cushion and reduce friction in this area. Over the top of these structures lies the iliotibial (IT) band.
Hip bursitis, the diagnosis often provided to people experiencing pain in this region, generally refers to inflammation of the trochanteric bursa. However, research spanning across 20 years (Bird et al 2001, Connell et al 2003, Kong et al 2007, Silva et al 2008, Blankenbaker et al 2008, Woodley et al 2008, Fearon et al 2010, Long et al 2013, Lange et al 2022) has determined that bursitis is actually unlikely to be the primary contributing factor to symptoms.
In fact, MRIs often find bursitis in hips that are completely pain-free.
Much of the same research found that the tendons of the gluteus medius and minimus are more often involved. Therefore, gluteal tendinopathy, which refers to pain and impaired function associated with the loading of these tendons, has been proposed as the preferred diagnosis.
Having said that, it’s important to point out that tendon changes seen on MRI are also common in people without symptoms.
Since these “pathological” findings are present in individuals with and without symptoms, imaging is unnecessary in most instances.
The diagnosis is most common in older, less active perimenopausal women, but it can also occur in a younger, more active population like runners.
In addition to reporting symptoms with sleeping on the affected side or with activities that load the gluteal tendons, such as walking, running, and climbing up stairs, a study by Grimaldi et al in 2017 concluded that “…a patient who reports lateral hip pain within 30 seconds of single-leg-standing is very likely to have gluteal tendinopathy.”
Alternatively, if pain isn’t elicited when pressing on the greater trochanter, gluteal tendinopathy is unlikely.
With that information in mind, the naming of a diagnosis matters in how it informs management.
Many people associate bursitis with the need for ice, complete rest, and anti-inflammatory medication, and that sometimes creates the idea that management of their symptoms is out of their control.
Gluteal tendinopathy provides more options for self-management, including activity modifications and exercise therapy as needed. It’s also been well-documented that other lifestyle and metabolic factors influence the health of tendons, such as diabetes, hypercholesterolemia, adiposity, and certain medication usage like statins and antibiotics. Therefore, any lifestyle interventions to improve overall health (like regular physical activity) can be considered a component of rehab.
Want to learn more?
Check out our full blog about Gluteal Tendinopathy Rehab!
Snapping Hip Syndrome
Snapping hip syndrome refers to a snapping sensation felt on the front or side of the hip that occurs with various motions. The snapping can be painful or painless, and loud, quiet, or completely inaudible. There are 2 primary types: internal and external.
Internal snapping, also sometimes called “Dancer’s Hip”, refers to the iliopsoas tendon (hip flexor) snapping over one of two locations: the head of the femur or a bony prominence on the front of the pelvis known as the iliopectineal eminence. It can be felt when the hip is moved from flexion, abduction, and external rotation to a more extended, adducted, and internally rotated position.
It’s somewhat confusing, but internal snapping is NOT intra-articular although there are other causes of intra-articular joint noises and sensations, such as labral tears and loose bodies.
External snapping is usually attributed to the IT band or gluteus maximus moving back and forth over the greater trochanter. It can be felt during side lying flexion and extension of the hip, or during different weight bearing movements, such as a single leg deadlift.
Whether someone notices the snapping develop randomly or shortly after an injury, it’s typically nothing to worry about. Snapping is common, often happens in people without any pain, and does not mean that anything is wrong with the hip or that issues will arise in the future.
I like this quote from world-renowned hip specialist, Dr. Thomas Byrd – “For most patients, the treatment is then little more than assurance that this is a normal variant and that the snapping is not indicative of future problems.” For this reason, I prefer to drop the word “syndrome” because it makes snapping hip sound scarier than it is.
With all that being said, I do understand that pain isn’t the only concern for some people. For example, here’s a top comment from our video about the topic: “It just feels jarring… Like nails on a chalkboard feeling in my body. I know my nails on the chalkboard aren’t harming me, but it makes me feel like I’m going [to] be sick…”
Sometimes that snapping sensation goes away on its own and sometimes activity modifications and a dedicated exercise plan can help.
Want to learn more?
Check out our full blog about Snapping Hip Rehab!
Since I’ve discussed symptoms toward the front of the hip and the side of the hip, let’s shift the focus to the back of the hip.
Proximal Hamstring Tendinopathy
The hamstring muscles originate on the ischial tuberosity, also referred to as the sit bone, and consist of 3 muscles: the semimembranosus, semitendinosus, and the long head of the biceps femoris. They insert onto the lower leg and primarily contribute to knee flexion and hip extension.
Similar to other tendinopathies, proximal hamstring tendinopathy is characterized by persistent tendon pain and loss of function related to mechanical loading.
This pain is located around the lower gluteal region, which may or may not radiate down the back of the thigh and often occurs during activities and positions that place more stretch, load, and/or compression through the proximal portion of the hamstring tendon. Examples include running uphill, sprinting, movements involving deeper hip flexion (like squatting or lunging), stretching, and sitting for prolonged periods of time.
A sudden increase in some of these activities may be a contributing factor as to why this condition developed in the first place. A simplified explanation is that the loads placed on the affected hamstring tendon through different positions and movements may have exceeded its capacity to recover and adapt appropriately. Think of it as doing “too much, too soon.”
This load is often associated with external factors, such as the intensity, volume, and frequency of training.
For example:
- Recently incorporating uphill running and sprint intervals into training sessions
- Or practicing yoga and including more stretching at the end range of hip flexion
This is why rehabilitation is the focus of management.
Also, it is worth noting that since hamstring tendon pathology is common in people without pain, imaging is usually not required.
Want to learn more?
Check out our full blog about Proximal Hamstring Tendinopathy Rehab!
Piriformis Syndrome
Trying to neatly categorize other conditions contributing to posterior hip symptoms is, well, a pain in the butt. Oftentimes, symptoms in this region are quickly labeled as “piriformis syndrome.”
However, except in very rare cases, piriformis syndrome probably doesn’t exist in the way that most people think it does. In most instances, it is more likely that irritation of a nerve or structure in the lower back is contributing to symptoms in your butt, thigh, or down the back of your leg. There are different medical terms for this, such as referred pain, radicular pain, and radiculopathy.
The low back should be the top consideration for symptoms in this area until proven otherwise.
And if not the lower back, the second most common culprit is frequently the hip joint itself. Buttock pain can be a symptom of the intra-articular diagnoses I mentioned earlier, such as osteoarthritis, FAI, and hip dysplasia.
Want to learn more?
Check out our full blog about Piriformis Syndrome Rehab!
Deep Gluteal Syndrome
That doesn’t mean that all posterior hip pain is stemming from the lumbar spine or hip joint, but if you read through the literature or speak to different clinicians, the definitions, explanations, and understanding of symptoms in this region can vary considerably.
Deep gluteal syndrome was introduced in 1999 by McCrory and Bell as a catch-all phrase to account for any structure contributing to symptoms in this area, including the piriformis, and it’s become much more popular in recent years. As stated by Park et al in 2020, deep gluteal syndrome is “defined as compression of the sciatic or pudendal nerve by any anatomical structure in the deep gluteal space.” If we could see through or pull back the gluteus maximus, that’s essentially the deep gluteal space.
Park and colleagues include the following diagnoses in deep gluteal syndrome:
- Piriformis syndrome
- Gemelli-obturator internus syndrome, named for the gemellus superior, gemellus inferior, and obturator internus muscles
- Proximal hamstring syndrome, in which irritation of the hamstrings and sciatic nerve co-exist because of their close proximity and
- Ischiofemoral impingement syndrome, resulting from compression of the sciatic nerve and/or quadratus femoris muscle between the ischial tuberosity and lesser trochanter of the femur when the hip is extended, such as during a long stride when walking or running.
There is no universal consensus, though. Some authors include different diagnoses and syndromes, while others don’t include ischiofemoral impingement as a subset of deep gluteal syndrome at all.
Nerves
Having said that, I don’t want to diminish your current experience or a previous experience you’ve had. I’m also not trying to neglect the role that nerves play in contributing to symptoms. There are a lot of nerves innervating the hip and pelvis, and it’s possible for an irritation of one of these nerves to contribute to tingling, burning, numbness, weakness, etc.
However, I encourage clinicians to always perform a thorough examination of the lumbar spine, and for patients to hold their providers accountable for examining their low back so the piriformis muscle isn’t blamed too hastily.
Sacroiliac Joint Pain
Sacroiliac joint pain is another entity that can be confused with posterior hip pain.
Sacroiliac joint pain is typically characterized by one sided pain below the level of the lumbar spine that may radiate into the buttock or thigh. Fortin 1994, Slipman 2000, Young 2003, Han 2023, Szadek 2023
It can follow a traumatic event, such as a motor vehicle accident or fall onto the buttock. It can also result from repetitive activities, such as lifting or running. In some cases, the cause of symptoms is unknown. However, sacroiliac joint pain is most commonly related to pregnancy. Ostgaard 1991, Chou 2004, Gutke 2006
Want to learn more?
Check out our full blog about Sacroiliac Joint Pain Rehab!
Fall-Related Fractures & Stress Fractures
Perhaps the most impactful issue I haven’t mentioned yet is fall-related fractures in older adults as the consequences can be severe. Fortunately, many of these falls are preventable. I highly recommend watching our video on how to improve balance and prevent falls.
Stress fractures can also be quite impactful. The following information is taken from a recent consensus statement by Hoenig et al:
- Stress fractures fall under the umbrella of bone stress injuries, which are overuse injuries to bone resulting from “repetitive loading coupled with inadequate time for tissue recovery.”
- These injuries are most frequent in military personnel and athletes, particularly runners.
- “Bone stress injuries in athletes can be termed as low-risk or high-risk based on their anatomical location and risk for progression and/or healing complications.” With regards to the hip, the superior cortex of the femoral neck is considered high risk whereas the femoral shaft is not.
- Some risk factors for developing a bone stress injury include increases in training volume or intensity, previous history of a bone stress injury, low body mass index, poor bone health, and insufficient caloric intake to meet energy demands.
- “Treatment approaches include activity modification, protected weight-bearing, immobilisation, physical therapy, nutritional counselling and, in some cases, surgical fixation.” The experts in this consensus statement largely agreed that most stress fractures should be initially managed non-surgically.
Pediatric / Childhood Conditions
Although I briefly mentioned Developmental Dysplasia of the Hip (DDH), pediatric, or childhood, conditions are not the focus of this blog. However, here are three diagnoses to be aware of:
- Legg-Calve-Perthes Disease, which is basically a type of avascular necrosis that occurs in young children. Its name comes from the 3 surgeons who first described it.
- Slipped Capital Femoral Epiphysis (SCFE), often referred to by its acronym – SCFE, most commonly happens in adolescents. According to Gholve et al “SCFE occurs when the capital femoral epiphysis (the femoral head) displaces posteriorly on the femoral neck at the level of the physis (the growth plate). [However] SCFE is a misnomer because it is actually the femoral neck metaphysis that displaces anteriorly and superiorly in relation to the capital femoral epiphysis.”
- Apophyseal Avulsion Fractures, which typically occur when a rapid and forceful contraction of a muscle pulls off part of the bone where it is attached. A study by Ferraro et al in 2023 reported the following: “The average patient age was 14.6, and 78% of the fractures occurred in male patients. The anterior inferior iliac spine (33.4%), anterior superior iliac spine (30.5%), and ischial tuberosity (19.4%) were the most common fracture sites. The most common injury mechanisms were running (27.8%), kicking (26.7%), and falls (8.8%). The most common sports at the time of injury were soccer (38.1%), football (11.2%), and baseball (10.5%).”
Cancer, Infection, & Pelvic Floor
The list of diagnoses I have mentioned so far is not all-inclusive and there are non-musculoskeletal causes of hip pain that must always be on the radar of healthcare providers, such as cancer, infections, and organ-related issues.
There can also be a link between pelvic floor problems and hip symptoms. We have a 30 minute video on the topic if you’d like to learn more.
Hopefully all of the information up to this point helps you appreciate the complexity of the hip and the importance of a thorough assessment from a licensed healthcare provider.
How To Rehab Your Hip
Before I outline my general recommendations for rehab, I want you to keep in mind that not every problem can be solved with exercise alone. There are times when surgery is necessary for hip osteoarthritis or another diagnosis, and it can be life-changing. Similarly, sometimes bone stress injuries require a period of unloading or immobilization. For the most part, though, rehab is going to have some overarching themes. Here are 5 things most people should consider doing:
- Modify aggravating factors, whether that’s related to the gym, recreational and sporting pursuits, or day-to-day tasks. Some discomfort is usually acceptable during rehab, but if you’re consistently pushing into unbearable pain and experiencing flare-ups, you probably need to temporarily scale back whatever it is that’s giving you problems. Think of it as taking 1 step back so you can eventually take 2 steps forward. On the other hand, if you’re a person who has restricted yourself from all exercise and activities for fear of worsening your condition, you might just need to give yourself permission to move.
- Identify if there’s anything you can do that would positively influence your overall health. Sleep, stress, nutrition, alcohol intake, medication usage, and anything else that influences your health and well-being can also influence the onset and persistence of symptoms. My advice would be to reach for the lowest hanging fruit, start small, and write down your intentions so you can reflect on your progress each week.
- Implement targeted exercises to address any deficits in your strength, range of motion, confidence, etc. Exercise can also be used to improve your tolerance to specific activities, such as walking, stair climbing, running, or playing sports. It doesn’t have to be overly complicated. Oftentimes, 1-3 exercises performed a few times per week is a great starting point.
- Use feel good treatments as needed, but you’ll probably get the most benefit from the things that challenge you.
- Recognize that there’s rarely a quick fix. Rehab often takes significant time, effort, and consistency.
Do you want a structured plan that’s going to provide you with the knowledge and tools to feel more confident, capable, and resilient than ever before? Check out our Hip Resilience Program!
Thanks for reading. Check out the video and please leave any questions or comments below.
