You’ll hear and read a lot about knee pain in runners but what about hip pain? Hip pain is less common than knee pain but no less annoying or troublesome. So, what are the main causes of hip pain in runners? How do you know what’s causing your hip pain? And, importantly, what should you do if you’re a runner with hip pain?
First up let’s have a quick look at the hip joint. As I always say, the more you understand what’s going on inside you, the easier it is to overcome problems.
The hip is a ball and socket joint. The femur is the thigh bone and it has a big knobbly head which sits inside the hip socket. The socket is a cup on the pelvis called the acetabulum. Both the femoral head and the acetabulum have a coating of cartilage on them to protect the joint. Synovial fluid within the joint helps it to move smoothly too.
A ball and socket joint means that the hip can move in all directions. To move forwards, backwards, sideways and rotate requires a host of different muscles. Flexion of the hip is carried out by iliopsoas, rectus femoris, sartorius and pectineus. Extension is carried out by gluteus maximus and the hamstrings. Other muscles are also involved with sideways movement and rotation. These muscles surround the hip and help to add stability. More stability comes from hip ligaments (ligaments attach bone to bone).
The hip has a rich supply of blood vessels. Some purely supply blood to the hip while others are passing through to supply blood to the lower legs. The main nerves in the hip are the sciatic, femoral and obturator nerves.
Causes of hip pain in runners
Many structures inside the hip can cause pain. It can come from bones, cartilage, muscles, tendons, ligaments, nerves and more. Sometimes the source can be from elsewhere in the body but the pain is felt in the hip. It’s all pretty confusing. Here are some common causes of hip pain in runners:
The iliotibial band (ITB) is a thick band of fibrous tissue which runs down the outer thigh, from the pelvis to the knee. It helps to stabilise the hip and knee and it works with the hip muscles during movement. ITB pain is usually felt in the knee but it can present with hip pain too. Typically the pain comes on during running (usually at around the same distance) and is often worse when running downhill.
Greater trochanteric pain syndrome (GTPS)
Often called trochanteric bursitis, GTPS is a common cause of hip pain in runners, particularly women between age 40 to 50. Pain is usually felt on the outside of the hip and is worse when you lie on your side, sit with your legs crossed or when running. It’s unclear what causes it but rather than pure inflammation, it’s thought to be lots of small injuries to the muscles and tendons around the trochanter.
Pulled or tight muscles
Any of the muscles and tendons surrounding the hip joint can be overstretched or tight. It’s common to strain the top of the hamstrings, the hip flexors or the adductors (which move the leg towards the body). Injuries usually happen when you make a sudden and big increase in your training volume, frequency or intensity. Pain can come on gradually or suddenly and is usually quite localised to the injured area. Having good all round, balanced muscle strength will help to prevent injury.
The labrum is the cartilage inside the hip joint and if it gets torn it can cause clicking and catching in the hip as well as a dull, burning pain which is often felt in the groin. Hip mobility can be limited and stiffness is common too. You might have no or very few symptoms and hardly know it’s happened or you can be unable to run for months. Symptomatic and troublesome labral tears require surgery to fix them.
When you get a bony overgrowth within the hip joint, either on the femur or on the acetabulum, it stops the smooth gliding of the joint. This can lead to the structures around the joint getting squashed and ‘impinged’. It can also cause damage to the cartilage including labral tears (see above). This is also called femoral acetabular impingement (FAI). It tends to affect younger athletes. Pain is usually a dull ache with occasional sharp shooting pains with certain movements. There can be clicking in the joint too. Surgery is sometimes required to shave off the bony overgrowths.
In the same way that you can have stress fractures in your shins and feet from running, you can get them in your hips too. They’re usually associated with over use and increasing training too quickly but they can also be linked to low bone density meaning that older women are more at risk. The pain tends to be in the front of the thigh or groin, it’s worse when you lie down and when you run. They usually heal within three months with rest and strengthening exercises.
Gradually increasing hip pain in older runners could be due to osteoarthritis (OA). Remember that sensible, recreational running doesn’t cause OA. You are more likely to have problems with your joints if you are inactive. Your genetics play the largest part in whether you will have OA and how much it will affect you. The hip can become stiff and cause pain during running and afterwards too. There might be a grating or crackling noise when you move. Symptoms can flare up from time to time or be constant.
The nerves in the hip come from the spine and many of them travel down to the lower legs. This means that pain can be confusing and not be felt at the site of the problem. Hip pain could be coming from a nerve in the back or from a problem with the knee or foot. It’s important to keep this in mind if your pain is not settling.
What to do if you have hip pain
Hip pain is not always straightforward and working out the cause can be real detective work. With all the causes of pain above, the first step is to rest. Stop running and give your body some time to recover and heal. If you have severe pain, a sudden loss of mobility or a high temperature, get an urgent medical assessment. If things seem to ease up with rest, try returning to your activity slowly. If you have pain which is recurrent or doesn’t resolve with rest, you need to see a health care professional to get a diagnosis. This isn’t the time to be diagnosing yourself. Hips are complicated and a proper examination and possibly x-rays and scans are required to determine the cause.
Preventing hip pain
Accidents and injuries aren’t always preventable but there are plenty of things we can do to reduce our risk of developing hip pain:
- Train sensibly, increase your running distances gradually
- Schedule plenty of rest days to allow your hips to recover and adapt to your training
- Do regular strength and mobility exercises to keep healthy muscle balance
- Watch your posture and running form
- Avoid sitting crossed legged or standing ‘sunk into’ one hip
- Don’t run when injured; your biomechanics will be affected
- Mix up your surfaces; spend time on and off road
- Wear the right shoes for your feet
- Eat well to give your body the nutrients it needs for healthy joints and to maintain a healthy weight
You can learn more about what’s going on in your body and how to overcome common running problems in my book Run Well: Essential health question and answers for runners, published by Bloomsbury and available from all good booksellers.