Written by:
Sean Rimmer, Physical Therapist &
Run Coach at Run Potential Rehab & Performance
Unfortunately, as runners we are bound to deal with some sort of running-related injury. Though we may place close attention to our training program (frequency, duration, and intensity of runs), nutrition, sleep, and recovery tactics, there's still a good chance an injury can show its face. Most commonly, we see running-related injuries come on within the lower body due to the loading demands of running. One of the more common running-related injuries I see in patients is hip pain. Hip pain can be caused by mechanical (movement related) or non-mechanical related injury, but for the purpose of this article, I'll review common reasons for mechanical hip pain seen in runners.
In runners, I often see hip pain in the following 3 regions:
Groin pain
Lateral (outer) hip pain
Buttock pain
Though a runner's pain may be experienced in the regions listed above, the first step is to figure out is where the pain is truly originating from (though this can be tricky at times). So, to truly understand what tissue or structure is involved it's important to understand the runner's history (i.e. Recent training, previous injuries, recent nutrition, training environment, etc.) and how the symptoms behave (i.e. How does the pain act with running and other activity). These details will begin to tell the story of which tissue/structure may be involved. From there, the final pieces can be put together with a thorough assessment by an experienced medical professional (shameless plug) to provide a proper diagnosis. With that being said, every runner with hip pain does not need to see a medical professional, but if symptoms continue to progress and/or become concerning to the runner, seek out help!
Where Hip Pain is Perceived
It's important to note, you may perceive pain in the region of the hip, but it could actually be stemming from another area. This could be secondary to referred pain. I commonly see individuals with referred pain to the groin or thigh when the actual area of involvement is stemming from the lower back. A second note to consider is perceived depth of pain. if an individual's perceived depth of pain is impaired, an individual may perceive pain in the superficial myofascial tissue though symptoms could actually be stemming from the internal joint or femoral head/neck. Again, a sound history, symptom behavior, and assessment can determine the issue. I often see runners complaining of straining their hip flexor and rarely it actually is strained, as muscle strains tend to have a mechanism of injury or occur at high velocity speeds (i.e. sprinting) rather than relative sub-maximal speeds seen in distance running.
Symptom History
Symptom history is crucial! Asking questions to understand when symptoms begin is imperative. For instance, did symptoms come on gradually or from a mechanism like a fall while running? Are there any previous injuries or pain in the region of the hip? Did the pain start in the hip or somewhere else? When did you first notice the pain? What has your training looked like leading up to the hip pain? The list goes on. The more questions asked, the more details begin to open up which can help identify what tissue/structure is involved.
Symptom Behavior
When we discuss symptom behavior, this specifically includes how the symptoms act from the start to finish of a run, post run, with day-to-day activity, and other forms of movement/exercise. It's often a concerning sign if symptoms get worse as you run longer and potentially linger post run, than if symptoms "warm up" during your run and feel better throughout the run. For example, soft tissue related symptoms have the potential to warm up depending on how reactive the symptoms are, bone related pain tends to get worse with more running/loading, and nerve related pain is a bit more variable sometimes symptoms get worse, sometimes there's no pain, and sometimes the pain remains the same.
Common Tissues Involved in Runners with Hip Pain
Unless there's been a previous hip injury (i.e. labral tear) or congenital condition (i.e. hip dysplasia), the most common tissues involved in hip pain I see in runners are as follows (in no particular order):
Tendinopathy of the Gluteus Medius, proximal hamstring, and less commonly, Iliopsoas (hip flexor) at the lesser trochanter.
Femoral neck bone stress injury
Greater trochanteric pain syndrome
Referred pain from the lumbar spine & nerve related pain
These areas are often affected due to the demands of running which require repetitive sub-maximal single leg loading and energy storage and release from muscle-tendon units. We also need to consider nutrition and energy-availability specifically when it comes to trabecular bone like the femoral neck. I will briefly discuss each tissue above as it pertains to runners with hip pain.
Tendinopathies of the hip region
To put in simple terms, tendinopathies stem from pain within the structural tendon unit. Typically, tendinopathic pain tends to remain local to a specific area of the tendon. For example, Gluteus Medius tendinopathies are felt on the lateral (outside) portion of the hip between the muscle and the greater trochanter, proximal hamstring tendinopathies are felt on the underside of the buttock near the insertion of the pelvis, and iliopsoas tendinopathies are usually felt just underneath the groin and upper portion of the inner thigh. Tendinopathies usually come a long when there is a weakness within the muscle tendon-unit, over-compensation in the muscle tendon-unit, and/or training error (consistent tissue stress>tissue recovery). Tendinopathies are okay to run with if pain is tolerable or warms up, though in a reactive state running may need to be reduced or modified until symptoms improve.
Femoral neck bone stress injury (BSI)
The femoral neck is the junction between the femur and the femoral head (ball of hip). This area needs to be able to handle both tensile and compressive forces at the hip when we run. Typically, these injuries come on gradually with minimal and intermittent pain from running but can eventually become worse with running and potentially even walking. Symptoms are often experienced in the groin or lateral hip specifically with running & single leg hopping. Bone stress injuries are graded 1-4 on a continuum, with a grade 1 being the mildest (stress reaction) and a grade 4 as a stress fracture with a visualized fracture line seen on MRI. Femoral neck bone stress injuries are something we really want to try to catch early on as a runner, as this region of the bone is a high-risk site; meaning that the bone in this region has a poor blood supply which can impair and prolong healing time.
Greater Trochanteric Pain Syndrome
The greater trochanter is a bony prominence on the most lateral aspect of the femur near the hip. This bony landmark provides host for a multitude of muscle-tendon attachments around the hip. This area between the bone and outer most skin is rather thin and can become compressed. There are bursae (fluid filled sacs) in the region of the greater trochanter which provide lubrication to the motion in this region.
However, this region can become painful when the outer part of the bone becomes chronically compressed due to impaired running mechanics (i.e. over-striding and long ground contact times) and impaired pelvic mobility. Often times, if we change the mechanical faults and allow some reduced loading to this region, it often gets better rather quickly.
Referred Pain from the Lumber Spine & Nerve Pain
Pain stemming from the lumbar spine can be variable as it pertains to pain around the hip. Pain can be experienced in the front, back, or side of hip. Symptoms can stay in one place but can also move around and vary in intensity based on position or movement. Unfortunately, the pattern is not always consistent like that of tendon or bone related pain. Potentially, there can also be symptoms of numbness, paresthesia, or weakness within certain muscles of the leg. I often see these symptoms come on when individuals have reduced lumbar spine mobility and often with a sedentary occupation outside of running. Depending on the severity of symptoms, this is often something a type of pain we can run with if it's tolerable and symptoms often begin to resolve when the lumbar spine is addressed specifically.
Closing Thoughts
In closing, this is by no means an exhaustive list of hip pain diagnoses, but rather the most common diagnoses I've seen in runners in my practice. If someone's had a previous hip or lumbar spine related traumatic injury, previous surgery, or congenital hip dysplasia, there could be a possibility for other hip pathology involved. When it comes to the aforementioned diagnoses, pain can range from mild to severe for all of the diagnoses, but the one tissue we need to be the most concerned with is the femoral neck. As progression of damage to this tissue can lead to a potentially long recovery, and worst-case scenario, not running again.
So, if hip pain comes on, pay attention. Pay attention to how the pain came on, how it behaves, and where the pain is located. And if there's a sense of initial concern, seek out professional help! The last thing I ever want to see is a runner not be able to run and be set back for an extended period of time!