Myths in Hip Pain Treatment

Hip pain is a frequent problem, but the cause is often misdiagnosed. Patients often come in after having used rest, stretching, painkillers, massage, injections, or exercises they found online. These can be helpful for the right patient, but can also make recovery time longer if the actual cause is not identified.

The take home message: not all hip pain is “the hip joint.” The pain may be from the femoroacetabular joint, labrum, capsule, gluteal tendons, iliopsoas, adductors, sacroiliac joint, lumbar spine or peripheral nerves like lateral femoral cutaneous, iliohypogastric, ilioinguinal, femoral, obturator, genitofemoral nerves. The anterior, lateral and posterior hip pain all have different pathways to diagnosis and the same pain may be caused by multiple structures in the region.

Rest may be helpful for a brief time following acute overload, flare-up, fall or traumatic strain. Rest is seldom the sole treatment for hip pain. For many hip conditions, it is not necessary to completely unload the painful tissue, but rather modify the load.

Clinical nuance: a painful gluteus medius/minimus tendinopathy, for instance, could be exacerbated by continued compression of the lateral hip with side-lying, hip-adduction stretching, sitting cross-legged or aggressive IT-band work. However, it could also be exacerbated when the patient ceases to load the tendon at all. Progressive loading is required to restore capacity in tendons. A randomized clinical trial found that education plus exercise led to greater global improvement than corticosteroid injection at 52 weeks in patients with gluteal tendinopathy.

Example: runner complains of lateral hip pain and is prescribed to rest for 6 weeks. The pain subsides and as soon as they start running again, the pain comes back as the gluteal tendon, hip abductors, pelvic control, and stride mechanics are never rebuilt. Rest in this case decreased irritation but did not restore the capacity of the tissue.

When rest is detrimental: with FARS, labral inflammation, microinstability of the hip, or tendinopathy, prolonged periods of rest may lead to decreased hip strength, trunk control, gait tolerance, and confidence. This can lead to a less capacious hip that is more sensitive.

Better alternative: implement short term activity reduction and then implement guided motion, graded strengthening, gait correction, and load management based on the actual pain generator.

In some cases of symptomatic FAI and structural impingement, in particular, or of unstable labral pathology, mechanical catching, or failure of good-quality conservative treatment, surgery is required. Though it is important to not assume that hip pain is a surgical issue.

Clinical nuance: FAI is a true mechanical diagnosis, but more than an X-ray shape is required. The Warwick Agreement classifies FAI syndrome as a triad of symptoms, clinical signs and imaging findings. The morphology of the bone is not sufficient.

A young athlete with groin pain, positive FADIR, and limited flexion/internal rotation, with cam morphology and deep squat pain. This could be the case of true FAI syndrome. Yet another patient might have the same cam morphology on imaging and not really have intra-articular pain. In the second patient, pain can be due to adductor tendinopathy, iliopsoas irritation, lumbar referral or nerve entrapment.

Note: randomized trials have demonstrated that either arthroscopic surgery or a structured physiotherapy program can be effective in symptom improvement for FAI syndrome. There were some trials that preferred surgery for specific patients, but individual hip therapy also helped. But surgery is not necessarily bad, it should be tailored to the patient, not the imaging.

Better alternative: prior to surgery, identify the cause of pain – is it due to true bony impingement, labral instability, capsular laxity, tendinopathy, spine/SI referral, or kinetic-chain overload? When surgery is the most rational, the structural lesion is congruent with the clinical presentation.

The tissues change as we age, but pain does not have to be ignored as “just age.” There are many causes of hip pain in older people that can be treated, such as gluteal tendinopathy, early osteoarthritis, lumbar stenosis referral, SI joint pain, iliopsoas overload, abductor weakness, or altered gait mechanics.

Clinical nuance: imaging findings come with age; structural findings do not necessarily correlate with the pain source. Labral abnormalities and cartilage changes can occur even in asymptomatic hips. An MRI of asymptomatic people revealed abnormalities in 73% of hips and tears of the labrum in 69%.

Example: a 58-year old patient complains of pain in the lateral hip and is diagnosed with “arthritis” based on a mild degree of degenerative change seen on an X-ray. However, they are worse lying on their side, climbing up and down stairs and standing on one foot. This is more likely to be due to increased trochanteric pain syndrome or gluteal tendinopathy than primary hip joint arthritis.

Common error: assuming all older patients with hip pain are suffering from osteoarthritis may lead to clinicians overlooking treatable soft-tissue and nerve issues.

The better alternative is to not stop clinical reasoning when the patient ages. The exam should still address the following questions: is the pain intra-articular, tendinous, spinal, SI-driven, neural, vascular or kinetic-chain driven?

Hip clicking is normal. It can be caused by iliopsoas snapping, IT-band/gluteus maximus snapping over the greater trochanter, tendon movement, gas release or labral pathology. The meaning is dependent on whether the click is painful, reproducible, the click is caught, or the click is associated with instability.

Clinical nuance: snapping is frequently not associated with pain. Clicking and groin pain, locking, catching, giving way, apprehension is different. This could indicate labral pathology, FAI, capsular laxity, iliopsoas impingement or microinstability.

Example 1: benign click, a dancer experiences painless anterior hip snap during the transition from flexion to extension. In the absence of pain, no catching, and no loss of function this could be iliopsoas snapping without clinically significant pathology.

Example 2: a hockey player complains of deep anterior groin pain, painful catching, restricted internal rotation, and a positive impingement test. If so, the click could be a result of FAI/labral disease, not noise. Over time, abnormal contact between the femoral head-neck junction and the acetabulum can result in damage to the acetabulum cartilage and the labrum, caused by FAI.

Better alternative: don’t treat the sound. Evaluate the clinical pattern: pain location, pain provocation, pain instability, loss of ROM, strength deficits, and imaging congruence.

Stretching is one of the most popular self treatments for hip pain, and one of the easiest to get right and make wrong.

Important: not all painful hips are tight! Unstable, overloaded, sensitized, compressed, or compensating for poor lumbopelvic control are some of the painful hips.

Clinical nuance: aggressive hip flexion, adduction, and internal rotation stretching may be able to recreate impingement in FAI or in labral irritation. With gluteal tendinopathy, stretching into hip adduction may push the gluteal tendons against the greater trochanter. Microinstability may feel like it is relieving the stretch, but may lead to overloading passive structures that are already overloaded.

Example 1: FAI/labrum – a patient continues to do deep pigeon pose and hip flexor stretches with anterior groin pain. The hip becomes aggravated with the repeated end range positioning of the exercise. It is not lack of flexibility, but mechanical conflict and lack of control near the impingement zone.

Example 2: microinstability – hypermobile patient who complains of anterior hip pain feels “tight” in the front of the hip. They stretch the hip flexors very aggressively. This is followed by more anterior pinching as there is a lack of anterior capsular control and centration of the hip.

Example 3: lateral hip tendinopathy: a patient with gluteal tendinopathy stretches the IT band and sleeps with the painful leg crossing midline. Both act to increase compression across the lateral hip.

Better alternative: determine if the hip requires mobility, stability, tendon loading, motor control, nerve decompression, or spine/SI treatment. Stretching is only useful if the limitation is not instability or compression related, but mobility related.

X-rays are good for fractures, arthritis, dysplasia, cam/pincer morphology, joint-space narrowing and bony alignment. However, numerous painful hip conditions cannot be seen on simple x-rays.

This means that the X-ray may not directly demonstrate labral tears, early chondral injury, synovitis, gluteal tendinopathy, iliopsoas tendinopathy, peripheral nerve irritation, subtle capsular laxity or referred lumbar/SI pain. Normal x-ray does not exclude clinically significant hip disease.

Example 1: labrum, pain in the front of the groin, painful flexion/adduction/internal rotation, catching. The X-ray may be normal or only slightly abnormal, but MRI/MRA or diagnostic ultrasound guided injection may help determine if the labrum or joint is clinically significant.

Example 2: gluteal tendinopathy – a patient is complaining of lateral hip pain and weakness on single-leg stance. X-ray is normal. Gluteus medius/minimus tendinopathy or bursopathy may be demonstrated by ultrasound or MRI.

Example 3: nerve mimic. a patient has burning pain over the lateral thigh. Normal hip X-ray – the problem is not the hip joint – it may be irritation of the lateral femoral cutaneous nerve (meralgia paresthetica). Nerve entrapments around the hip have been reviewed as a neglected cause of hip-region pain.

Improved alternative: imaging should be tailored to the clinical question. X-ray provides answers to bony questions. Many tendon, bursa, dynamic and injection-guidance questions are answered with ultrasound. MRI/MRA provides answers to labral, cartilage, marrow and deeper intra-articular questions. The exam determines which question is important.

While pain relief is good, it is not the same as restoring the system that caused the pain. Treatment can be done with medication, rest, injection, massage, or passive therapy, which may help relieve symptoms without altering the underlying cause.

Clinical nuance: a corticosteroid injection can alleviate pain from bursitis, synovitis or inflammation in the tendon area, but if the patient returns to the same gait mechanics, hip adduction collapse, pelvic drop, lumbar compensation or sport overload, the pain will likely return. Education and exercise was the only treatment that had sustained benefits in gluteal tendinopathy.

Example 1: lateral hip pain. A patient is given a trochanteric bursa injection and is better for three weeks. However, they still have a pelvic drop, weak abductors, poor trunk control and compressive sleeping positions. The injection was given for pain and not for the mechanical environment.

Example 2: labral pain: an intra-articular injection alleviates groin pain. That confirms the joint is overloaded, but not why: FAI, dysplasia, capsular laxity, microinstability, rotational sports demand, or lack of kinetic-chain control.

Better alternative: pain relief as a window to restore capacity: strength, gait, hip centration, trunk-pelvis control, tendon loading and sport-specific mechanics.

Discomfort during rehab is OK. Sharp, worsening, catching, unstable, burning or neurologic pain is no more to be ignored.

The clinical nuance is that hip pain should be differentiated between “acceptable tissue loading discomfort” and “warning pain.” Although strengthening can cause some mild controlled pain, tendinopathy can cope with this. Repeated end-range impingement may be intolerable to FAI/labral pathology. Nervous pain gets worse during compression, traction, and/or holding a sensitizing position.

Example 1: tendinopathy – if there is mild discomfort in the lateral hip during controlled movements of the adductor, it can be tolerated if it settles by 24 hours and function improves.

Example 2: labral/FAI warning pain with loaded squats catching in the deep groin – should not be pushed through. The patient might be impinging or loading the impingement/labral zone again. Nerve involvement is suggested by the following examples: warning pain in nerves (nerves may feel warm, tingle, numb, electric, or may radiate into the thigh). Lateral femoral cutaneous, iliohypogastric, ilioinguinal, genitofemoral, obturator or femoral nerve entrapment can be mistaken for hip pathology.

Improved alternative: make progress in line with tissue response. Sharp, progressive, neurologic, giving way or not responding to exercise pain should be reviewed.

Groin pain is nonspecific and is indicative of intra-articular hip pathology. FAI, labral tear, iliopsoas tendinopathy, adductor-related groin pain, sports hernia/inguinal disruption, lumbar referral, SI joint referral, femoral nerve irritation, obturator nerve irritation and genitofemoral/ilioinguinal neuralgia are all included in the differential.

Clinical nuance: The hip joint is a frequent source of pain in the groin area, but the lumbar spine, SI joint, abdominal wall, pelvic structures, and nerves can all be sources of groin pain. The pain from the SI joint may radiate to the lumbar disc or leg and the referral patterns are not restricted to the buttock.

For instance, anterior hip/groin pain following abdominal surgery or heavy core exercises. When the pain is burning, superficial and runs down the lower abdominal/inguinal region, the iliohypogastric or ilioinguinal nerve may be affected instead of the hip joint.

Better alternative: Groin pain should lead to a layered exam: hip joint tests, resisted adduction, iliopsoas testing, abdominal wall/inguinal evaluation, lumbar screen, SI provocation, and peripheral nerve mapping.

Labral tear is very relevant or incidental. Labral tears are common in people who do not have any symptoms. One study showed that 69% of asymptomatic hips had a labral tear. Another study revealed that many asymptomatic volunteers had either articular cartilage or labral defects, but more in the symptomatic patients.

The question isn’t “is there a labral tear?” The real question is: is this labral tear clinically relevant and mechanically active? Clues include painful catching, giving way, reproducible groin pain, positive impingement testing, loss of internal rotation, matching FAI/dysplasia/microinstability morphology and response to diagnostic intra-articular injection.

Example: 45 year old patient with a labral tear on MRI, with pain predominantly lateral, exacerbated by lying on the side, and exacerbated by single leg stance. The labral tear could be incidental; the gluteal tendinopathy could be the main pain generator.

Clinical risk: If every MRI labral tear is considered the primary diagnosis, there may be unnecessary surgery or missed diagnosis of tendinopathy, nerve entrapment, SI pain or lumbar referral.

Alternative: relate the labrum to the symptoms, exam, biomechanics and diagnostic injection response.

The hip is a region of force transfer between the foot, knee, pelvis, SI joint, lumbar spine and trunk. A local hip diagnosis can be true, but a driver can be regional or kinetic-chain.

Hip loading can be altered by poor dorsiflexion, excessive pronation/supination of the foot, knee valgus, pelvic drop, trunk lean, thoracolumbar stiffness, or poor control of abdominal pressure. This is particularly important in the case of adductor overload, FAI, gluteal tendinopathy and hip microinstability.

Example 1: FAI – poor squat mechanics, a limited ankle dorsiflexion, posterior pelvic tilt, or excessive hip internal rotation may all cause the hip to come into the FAI impingement zone repeatedly and lead to symptoms.

Example 2: gluteal tendinopathy – lateral hip pain can present with excessive hip adduction and pelvic drop during walking. The tendon is not only “inflamed,” it is being compressed and overloaded thousands of times a day.

Example 3: SI referral. A patient with posterior hip pain may have SI joint pain due to poor force closure, gait deviations, previous ankle injury, increased laxity due to pregnancy, or lumbar-pelvic control deficits.

Improved alternative: assess hip as a movement system: foot, ankle, knee, pelvis, Lumbar spine, Trunk control, breathing/IAP, sport-specific mechanics.

The symptoms from nerve pain in the hip do not always occur in the classic sciatica pattern. Peripheral nerves around the pelvis and hip may refer pain to the hip joint, tendons or SI.

Clinical nuance: Burning or numbness over the anterolateral thigh may develop from the lateral femoral cutaneous nerve. Iliohypogastric and ilioinguinal nerves can send pain into the lower abdomen, groin, iliac crest or inguinal area. Medial groin/adductor pain can be confused with pain from the obturator nerve. The femoral nerve can produce pain, discomfort, and weakness in the front of the thigh. Nerve entrapments around the hip have been singled out by reviews as sources of regional pain that have been neglected.

Example 1: LFCN mimic – a patient complains of “hip pain” over the lateral/anterior thigh, the pain is burning and superficial, and worse with belts, tight clothing, prolonged standing, or hip extension. That is more sinister for irritation of the lateral femoral cutaneous nerve than hip arthritis.

Example 2: iliohypogastric/ilioinguinal mimic. After abdominal surgery, intensive core work or fascial restriction around the abdomen, a patient experiences pain in the lower abdomen, inguinal canal, anterior hip, or near the iliac crest. Though the MRI of the hip may be normal, as the main problem is neural/fascial, rather than intra-articular.

Example 3: obturator mimic: medial groin pain with adductor guarding may be attributed to adductor tendinopathy, however, the same regional symptoms may be produced by obturator nerve irritation.

Improved alternative: map the quality of alternatives and territory. Nerve related findings such as pain from burning, tingling, numbness, electric pain, or pain from nerve tension/compression should prompt a nerve-related examination.

While most hip pain is not an emergency, it is important to get a prompt assessment of the following: severe pain following a fall, inability to put any weight on the hip, obvious deformity, fever, large swollen hip, gradual weakness, numbness, worsening pain in the night, unexplained weight loss, or pain that fails to settle despite reasonable self-care.

Avoid delayed referral if the symptoms include neurologic signs, inability to walk, traumatic onset, or systemic signs.

Scans show structure. They are not meant to illustrate how the patient uses the hip, how the pelvis is controlled, how the gluteals are used, how the lumbar spine is used for compensation, or how a nerve is affected by movement.

When evaluating the hip, the following should be asked:

Does pain occur in the joint? Consider F.A.I., labrum, chondral injury, synovitis, arthritis, dysplasia and microinstability.

Is it extra-articular? Consider a gluteal tendinopathy, iliopsoas, rectus femoris, adductors, proximal hamstring, bursopathy or fascial overload.

Is it referred to? Consider the lumbar spine, SI joint, pelvic ring, abdominal wall, or thoracolumbar junction.

Is it neural? Consider the lateral femoral cutaneous, iliohypogastric, ilioinguinal, genitofemoral, obturator, femoral, sciatic or cluneal nerves.

Does it involve the kinetic chain? Consider foot/ankle restriction, knee valgus, pelvic drop, trunk lean, poor IAP, poor lumbopelvic control, or sport-specific overload.

There is no universal solution for hip pain treatment. The most common error is treatment of the location of the symptom rather than the pain generator. Rest might be insufficient. Stretching could be the wrong way. Over-calling incidental imaging findings or under-calling soft tissue, nerve and movement causes. Treatment for pain can help, but doesn’t guarantee a solution.

Accurate diagnosis is best – hip joint, labrum, FAI, tendon, capsule, microinstability, SI joint, lumbar spine, nerve or kinetic-chain overload. Once the actual driver is determined, treatment can be much more precise.

This article is meant for educational purposes only and should not be used as a substitute for professional medical advice, diagnosis or treatment.