The Relationship Between Hip Strength and Lower Extremity Overuse Injuries


Among the physical therapy and rehab community, it is well understood that musculoskeletal pain in one area of the body often has its roots in weakness or dysfunction of another area. For example, knee pain can arise from foot or ankle dysfunction, or shoulder pain may occur due to imbalanced muscles in the torso. It is not surprising, then, that Achilles tendon pain may have its origins elsewhere.

In a recent study published in the journal Physical Therapy in Sport (Habets et al., 2017), researchers set out to determine if a relationship exists between deficits in hip strength and Achilles tendinitis in middle-aged male runners.

Does Hip Weakness Cause Achilles Tendinitis?

For this study, researchers designed a controlled trial with a study population of 24 middle aged male runners, 12 of whom displayed symptoms of Achilles tendinitis, and 12 who were asymptomatic.

Here are the details:

  • Both the injured and uninjured legs of the symptomatic subjects were tested, using isometric strength tests for hip extension, abduction and external rotation, and a single leg squat test.
  • Results were compared to those of the asymptomatic control group.
  • Test results showed deficits in isometric hip strength ranging from 28% to 34% when comparing the injured leg of the symptomatic group to leg strength of the control group.
  • The uninjured legs of the symptomatic group were also found to be weaker than the control group, and about as weak as the injured leg.
  • Results of the single leg squat test showed no significant difference between the control group, the non-injured limb, and the injured limb.
  • The research team concluded that deficits in hip strength can cause dysfunction and symptoms throughout various tissues of the lower extremity.

The study results raise the question of why injuries only occurred in one leg of the symptomatic group, when both hips were weakened.

Other Factors Contributing to Lower Extremity Injuries

It is often the case that a combination of factors contribute to athletic overuse injuries, and no single factor can be isolated as the underlying cause. In the above-mentioned study, hip weakness appeared to affect Achilles tendon function, but the study only looked at hip strength, and neglected to consider other factors such as knee, foot and ankle strength and function.

Moreover, the test results of the study showed isometric strength deficits in the injured group, but found no such deficits in the single leg squat test, a functional test that requires posterior-lateral hip strength.

When attempting to single out a cause of lower extremity overuse injuries, it is important to remember that human movement requires integration of multiple systems in order to complete any task. Dysfunction or strength deficits in any one area can force other areas to take up the slack, and that can lead to overuse and injury.

Consideration of other factors, such as patellar alignment, quadriceps strength, foot posture, and fear-avoidance behaviors, should be made as well, to ensure that rehabilitation does not focus on one area to the neglect of other potential causes.

Overuse Injury Treatment in NYC

Getting at the source of injury and correcting it to restore function is our overriding mission at NYDNRehab. Ignoring overuse injuries and pain can lead to more serious injuries down the road, that can take you out of the game altogether.

If you intend to maintain a physically active lifestyle, the sports medicine pros at NYDNR can help, Our unique high-tech gait lab is designed to identify and quantify motor deficits and correct them before injuries occur. Contact us today, and achieve your peak performance potential while reducing your risk of injury. At NYDNR, movement is life!


Habets, B, et al. (2017). Hip muscle strength is decreased in middle-aged recreational male athletes with midportion Achilles tendinopathy: a cross-sectional study. Physical Therapy in Sport, 25, 55-61.



A clinical exam and diagnostic ultrasound imaging can help your therapist pinpoint the exact location and cause of your hip and groin pain.

Ultrasound enables you and your therapist to view the hip and groin region in real time, while in motion. In addition to ultrasound, video gait analysis can help us identify faulty movement mechanics that contribute to hip and groin pain. Once the exact cause is determined, an effective treatment plan can be initiated.


Explore more advanced diagnostic tools available only at NYDNRehab:


In this instance, an athlete was originally diagnosed with minor quadriceps muscle strain and was treated for four weeks, with unsatisfactory results. When he came to our clinic, the muscle was not healing, and the patients’ muscle tissue had already begun to atrophy.

Upon examination using MSUS, we discovered that he had a full muscle thickness tear that had been overlooked by his previous provider. To mitigate damage and promote healing, surgery should have been performed immediately after the injury occurred. Because of misdiagnosis and inappropriate treatment, the patient now has permanent damage that cannot be corrected.

The most important advantage of Ultrasound over MRI imaging is its ability to zero in on the symptomatic region and obtain imaging, with active participation and feedback from the patient. Using dynamic MSUS, we can see what happens when patients contract their muscles, something that cannot be done with MRI. From a diagnostic perspective, this interaction is invaluable.

Dynamic ultrasonography examination demonstrating
the full thickness tear and already occurring muscle atrophy
due to misdiagnosis and not referring the patient
to proper diagnostic workup

Demonstration of how very small muscle defect is made and revealed
to be a complete tear with muscle contraction
under diagnostic sonography (not possible with MRI)


Complete tear of rectus femoris
with large hematoma (blood)


Separation of muscle ends due to tear elicited
on dynamic sonography examination

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