Various causes of hip pain, and how to fix it

Hip pain is on the rise, even amongst the younger generation. What could be the underlying cause?

Well, we sit a lot more than we used to, and move with less diversity. I believe that this may trigger a chain reaction of postural and kinesiological alterations, which may in turn be responsible for the various types of hip pain.

This is a (relatively) simplified version of my other hip articles in norwegian.

Varieties of hip pain

By hip pain, I am generally talking about hip joint, hip bursitis and butt pain, i.e relational attachments and structures between the from the thigh bone (femur) and pelvis. The most common causes of hip pain that we see at the clinic, is either hip impingement, muscle pain, or bursitis in various locations. It is very important to identify which tissue in the hip region that is affected, to determine the proper strategy and rehabilitation process.

Let’s first have a quick look at the anatomy of the hip.

Relevant hip anatomy

Fig. 1

The thigh bone, or femur, has two attachment knobs called the greater and lesser trochanter. The head of the femur is a ball-shaped structure that fits into the hip socket of the pelvis, which is called the acetabulum. The surrounding hip muscles, generally connecting to the greater and lesser trochanter, will impact the femur’s movement, but also the femoral head’s articulation within the socket (intra articular movement).

When dealing with conditions such as hip impingement, which causes jamming of the femoral head within the acetabulum due to uneven muscular stabilization, it’s imperative to have knowledge of which muscles that do what action, especially with regards to intra articular joint movements. The muscles can also cause irritation of bursas, nerves, or even become inflammated themselves; you should therefore also be aware of the locations of these different structures.

Here are the most relevant muscles and their actions.

• Psoas – Pulls femoral head forward and inward, mildly decompresses the hip joint, hip external rotation, flexion
• Iliacus – Pulls femoral head forward, decompresses the hip joint, hip external rotation, flexion
• Tensor fascia latae – Pulls femoral head forward, decompresses the hip joint, hip internal rotation,  flexion & abduction
• Piriformis & Deep six – Pulls femoral head backward and inward, compresses the hip joint, hip rotator cuff, external rotation, horizontal abduction.
• Gluteus maximus – Pulls femoral head backward, compresses the hip joint, hip extension, external rotation
• Gluteus medius – Pulls femoral head backward and inward, compresses the hip joint, hip abduction, external rotation (posterior fibers)
• Pectineus – Pulls femoral head inward, compresses the hip joint, hip flexion, adduction, internal rotation

Find exercises for these muscles in my video library or on my youtube channel (treningogrehab).

Anterior femoral glide

Anterior femoral glide syndrome, or FAGS, is a term created by the renowned physiotherapist Shirley Sahrmann. It involves forward shearing forces in the hip that occur when the femoral head is forced forward in the joint socket. This forward jamming of the femoral head may damage the hip labrum, and potentially injure the acetabular edges. As seen in the quotes below, the main cause of FAGS is swayback posture. SBP involves hanging backward with the chest, and tucking the pelvis under, causing significant hyperextension of the hip joint. You can read more specific information about the correction of SBP and posterior pelvic tilt in posture HERE, but generally we’ll want to establish proper pelvic alignment (get out of posterior tilt, which is very veyr common), and also align the pelvis and chest vertically, so that it doesn’t hang backward.

Walking in the swayback posture resulted in a higher peak hip extension angle, hip flexor moment and hip flexion angular impulse compared to natural posture. Walking in a swayback posture may result in increased forces required of the anterior hip structures. – Lewis & Sahrmann, 2015

Another very common cause of anterior glide, is faulty technique in training. Especially in the deadlift and squat, where I see so many driving their backs backward and/or tucking the pelvis under, causing tremendous shearing forces in the hip joint. The fact is that most people aren’t able to “squeeze their glutes” without letting go over the lower back extensors, ultimately tucking the pelvis and causing shearing of the lumbar spine and hip joint.

It’s easily fixed – in theory – by optimizing pelvic alignment during the lift. It takes some practise to get it right, but both your hip and lower back will thank you greatly.

Fig. 2

Hip impingement

Hip impingement, also called femoroacetabular impingement (FAI), is often regarded as a difficult condition that can be hard to treat. Personally I’ve had high success rates treating hip impingement, using relatively simple biomechanical strategies that I will share in this article. Hip impingement involves malcompression within the joint, causing the femoral head to jam into the acetabular margin, which again may be causing cam or pincer lesions as well as labral injuries.

Fig. 3

There are mainly two types of hip impingement that you need to know about:

• External (posterior) impingement. Occurring in hip extension and external rotation.
• Internal (anterior) impingement. Occurring in hip flexion and internal rotation.

External (posterior) hip impingement

External FAI occurs when the femoral head is positioned and often locked to articulate too far forward in the acetabulum. If the hip flexors are too dominant in the movement and posture (rare!), this may lock the femoral head in anterior glide (forward glide) and decompression, causing the joint’s movement to become compromised, as the space increases on the backside of the femoral head and thus jams the posterior labrum.

External FAI is identified by having the patient supine, and externally rotating the femur while it is extended / straight. A FABER test may also be used, but it’s not as valuable diagnostically as the first test. When positive, the patient will feel like the joint is jamming up, and it’s usually painful. A little more complicated, but you can also force the femoral head backward by pushing the proximal femur posteriorly, and while you’re testing. This should resolve or dramatically reduce the symptoms, which anecdotally confirms what I am claiming in this article with regards to the causes of hip impingement, as the hip joint glides posteriorly and compresses, improving intrajointal articulation. Likewise, increased pain and reduced ROM will occur if you force the femoral head further forward during the test, because it jams the hip joint up even more.

Fig. 4 – Test for posterior (external) FAI

The true underlying cause of this condition is usually a lack of pelvic rotation in gait, or habitual internal femoral rotation in posture, ultimately weakening the muscles that rotate the femur and pull it backward. The cure, though, is relatively simple, once you know what’s actually going on inside the joint. We have to strengthen the muscles that pull the femur backward (posterior glide and medial translation) to adequately compress the joint! Sometimes, especially common with women, the patient will be required to stop ‘hanging in’ with the knees, to avoid habitual internal femoral rotation, as this inhibits the gluteal complex.

As seen in the hip anatomy list, these muscles include the piriformis and deep six muscles, the gluteus maximus, the gluteus medius, and sometimes the psoas (as the psoas will often calm down the tension of the iliacus, as it is its synergist and is often weak).

Internal (anterior) hip impingement

Internal FAI occurs as the direct opposite to external FAI; the femur is locked too far back and medially in the acetabulum, i.e the joint is overly compressed. This condition is relatively common, and is something I see often at my clinic. Internal FAI usually happens as a chain reaction to swayback posture, as I’ve written about before. Swayback posture will force the femoral head forward due to the upper body’s backward swaying, hyperextending the hip joint. The body will compensate by hyperactivating the muscles that pull the femoral head back, to hinder unbearable jamming into the anterior surface of the acetabulum.

In other words, there will both be anterior shearing forces when the legs are stationary and loaded (standing), and posterior glide with excessive joint compression (including excessive medial translation) of the femoral head once the leg is unloaded, causing internal impingement when the femoral head is not able to come forward during hip flexion and internal rotation.

To identify this condition, have the patient in supine with the knee and hip flexed to 90 degrees. Internally rotate the femur. When the test is positive, the joint will feel jammed and painful. You can force the femoral head forward by pulling the femur anteriorly from the knee, while you’re testing. This should, once again, dramatically reduce the symptoms, increase internal rotation and prove my claim that the femoral head is locked in posterior glide in anterior FAI.

Fig. 5 – Test for anterior (internal) FAI

To cure this condition, both the swayback posture (root of the problem) and the posteriorly locked femoral head (symptom) has to be addressed. By correcting the swayback posture, the body will no longer need to hyperactivate the muscles that pull the femoral head backward, as the anterior shearing forces have ceased. Additionally, the hip flexors (that pull the femoral head forward) has to be strengthened, to help the femoral head forward during hip flexion.

Sometimes, the patient has a habit of leaning the knees inward (internal rotation), similar to those with external FAI, which inhibits the hip flexors and external rotators. This is an issue with great inhibitory potential, and may in tougher cases retard or even cancel out the beneficial effects of the exercises that I have mentioned in this article. In such case, the patient will need to learn to gently outwardly rotate the femur in posture, generally just a quarter of an inch, and avoid them to knock in during standing, walking, etc. This is relevant for both internal and external hip impingement scenarios.

Once again, refer to the anatomy list higher up in the article, and strengthen the muscles that pull the femur forward in the acetabulum (anterior glide). They’ll often require significant strengthening, so be patient.

Butt (muscle) pain

With, or without sciatica, the butt pain often stems from the deep six hip rotators or the gluteus medius.

It’s pretty easy to check, by using palpation, specific exercises (or manual muscle testing) and pressure into the muscle. If someone comes in with butt pain at my clinic, I ask them for the specific location. They’ll usually point to the piriformis, to the sciatic nerve (same area), or to the posterior fibers of the gluteus medius.

By pushing into the muscle or area that’s affected, you want to reproduce the person’s exact symptoms. If you can, that means this is the right spot, and next you’ll need to find out whether the muscle you are compressing is over or under active. An under active (inhibited) muscle is usually to blame for muscular pain and/or muscularly related nerve pain, in my experience. This is why so many get temporary relief, at best, by massages and similar muscle release strategies; they do not check whether muscle is under- or over active. Stiff, tight or painful does NOT equal overactive!

Fig. 6

Severe, excruciating trigger points in the posterior portion of the gluteus medius or even in the groin or anterior thigh regions, are often attributed to nerve irritation issues. For the gluteus medius, the clunial nerve (also spelled “clunial” nerve) entrapment may be the cause, and if so, mere strengthening exercises for the gluteus medius won’t suffice nor resolve the condition. Clunial, genitofemoral (groin), obtruator (inner thigh) and similar nerve entrapment syndromes are almost always just referred pain from the lumbar plexus, in which the plexus (lower back’s nerve bundle) is caught within the psoas major’s fibers and may generate many diffuse and weird issues.

This topic is too great to elaborate upon in this simplified article, but if you suspect that your pains are stemming from nerve entrapment issues, please read my lumbar plexus compresson syndrome article. Common signs of LPCS is that the pain spreads out, it’s hard to really point out where it is exactly and what kind of pain it is, it gets worse when standing up (as this stretches the psoas), and so on.

Fig.  7

In practice

Say you push into the piriformis and it reproduces a mild sciatica; that’s a confirmation that the piriformis and sciatica symptoms are linked together. The next step is to figure out the strength of that piriformis. This can easily be done by trying to strengthen it; the patient will feel whether the muscle is indeed strong or not, pretty fast, unless they’re doing the exercise wrong. You can also use manual muscle testing, if you’re familiar with it.

Fig. 7

If the muscle is weak, keep strengthening it 3-4 times per week and the symptoms will eventually go away. The sciatica or muscle pain is caused by weakness of the piriformis or deep six muscles, which is a very common scenario. The same goes for the gluteus medius (or almost any type of true muscle pain, to be honest). If they feel super strong, which is very rare, it’s probably hyperactive for a nearby structure, such as the psoas, adductors or gluteus maximus. In such case, release it (the painful, strong muscle) and strengthen the weakest nearby muscle of relevance.

9.5 out of 10 times, a weak muscle will be the cause of muscular pain, and muscular nerve entrapment. This is because weak muscles become very stiff and abrasive, which has a tremendously higher potential of irritating the surrounding structures, such as nerves or bursas. These muscles will usually get worse if you release them (massage, stretch, needling), so stick to a strict strengthening protocol and it’ll get better in a few weeks. It usually gets worse at first, but that’s just something you’ll have to get through in order to make the muscle healthy again. I recognize that this is the opposite of what almost everybody else are saying, but the results I am having with this approach are very positive.

Hip bursitis

With regards to bursitis, the two most common locations of pain, are the trochanteric bursa and the iliopsoas bursa. The latter is also called iliopectineal bursa. As with the muscularly based nerve entrapments, bursas also become more susceptible to irritation when an inhibited, stiff and abrasive muscle is rubbing against it.

Fig. 8

The following relations are the most common things to look for.

• The trochanteric bursa can be irritated by the gluteus maximus and tensor fascia latae, which both inserts into the iliotibial band which is lying on top of the bursa. Usually the TFL is weak, causing irritation of the trochanteric bursa. Walking is usually one of the triggers of this condition. In 9 of 10 cases, the TFL is weak and requires strengthening along with the gluteus medius and maximus, to stabilise the hip and thus stop the irritation of the bursa.

• The iliopsoas bursa is covered by the psoas and iliacus muscles. It’s relatively rarely affected by these two muscles, but if it is, the pain occurs during hip extension. The cause is usually weakness of the psoas and posterior pelvic tilt, which chronically hyperextends the hip joints.

• The iliopectineal bursa is covered by the pectineus muscle. Groin pain in the bottom of a squat, when bending or sitting in full hip flexion, are common triggers. The pectineus can be both over- and under active and will need to be assessed with a strengthening exercise. If it feels very strong, release it and strengthen the psoas and abductors. If it’s weak, strengthen it.

Fig. 9

In conclusion

In my experience, the most common hip injuries are: hip impingement, femoral anterior glide (often in combination with anterior hip impingement), gluteal region pain, trochanteric bursitis, and iliopectineal bursitis.

Underlying dysfunction with regards to postural/habitual and movement strategies are usually the true causes, which may cause common muscle imbalances that lead to improper articulation of the hip joint, labral tears, irritation of gluteal muscles, nerves, bursas, etc. By correcting one’s posture, and strengthening the right muscles, these aforementioned conditions will usually resolve. That is, if assessed and rehabilitated properly.

Summary

• Swayback posture and posterior pelvic tilt will cause anterior femoral glide and inhibit the hip flexors, potentially leading to hip impingement.
• One must differentiate between anterior and posterior hip impingement, as they have somewhat opposite rehab approaches.
• Muscular, nerve or bursa-related pain is usually caused by “weak and tight” muscles that need strengthening. By using palpation, strength tests and pressure, you can figure out which structure that needs what.