How to treat and prevent hip pain for runners

Hip pain when running can be a real drag. Read our advice, get fixed up and be back running pain-free before you know it.

How to treat and prevent hip pain for runners

Hip pain can put you off your stride. While the pain is usually caused by strained or inflamed soft tissues, such as tendons, and can often clear up within a few days, it can also be one of the most frustrating injuries.

To get you running again PhysioMed have given us the lowdown on what causes hip pain and how best to treat and prevent it.

Causes of hip pain

Pain caused by a problem in the hip joint can be felt in the groin, down the front of the leg and in the knee. Sometimes knee pain is the only sign of a hip problem. This is called referred pain, and it’s fairly common.

Hip pain can also be felt in the buttock (although pain in this area can also be caused by problems with the lower back) or on the outside of the hip.

Osteoarthritis

Osteoarthritis - also known as joint ‘wear and tear’ - is common and mainly damages the joint cartilage, but there is often some inflammation as well.

It is one of the most common causes of hip pain in adults. Although it can often occur randomly, it’s often linked to earlier fractures, trauma, or childhood hip problems. Changes in the movement and alignment of the hip eventually lead to wear and tear on the joint surfaces. We don’t yet fully understand why osteoarthritis develops without any pre-existing problems, but it can cause a great deal of pain, restricted movement and a limp. In extreme situations, the leg can become shorter and the hip can become fixed in a bent position, making mobility significantly worse.

In osteoarthritis of the hip, the cartilage cushion is either thinner than normal (leaving bare spots on the bone), or completely absent. Bare bone on the head of the femur grinding against the bone of the pelvic socket causes mechanical pain. Small outgrowths called bone spurs or osteophytes may form in the joint. Fragments of cartilage floating in the joint may cause inflammation in the joint lining, and this is a second source of pain. 

X-rays show the ‘joint space’ to be narrowed and irregular in outline. An x-ray of the normal hip joint usually shows a ‘space’ between the ball and the socket because the cartilage does not show up on x-rays.

Trochanteric bursitis

Where friction occurs between muscles, tendons, and bones, there is usually a structure called a bursa. A bursa is a thin sac of tissue that contains fluid to lubricate the area and reduce friction and is completely normal. The body will even produce a bursa in response to friction. 

Sometimes a bursa can become inflamed (swollen and irritated) because of too much friction or because of an injury to the bursa. An inflamed bursa can cause pain because movement makes the structures around the bursa rub against it.

A common spot for bursitis is on the side of the hip. Here a large tendon passes over the bony bump on the side of the hip. Friction can start if the outer hip muscle (gluteus medius) is weak, if one leg is longer than the other, or if you run on banked (slanted) surfaces. This problem is common in older individuals but it may also occur in younger patients who are extremely active in exercises such as walking and running.

Torn acetabular labrum

The acetabular labrum is a thick ring of cartilage around the hip socket. It can be torn if the ball or socket of the hip is deformed. 

This can be the result of hip problems in childhood or changes to the shape of the hip as it develops, but in most cases the cause is unknown. Hip joint deformities are called cam lesions when the ball is affected and pincer lesions when the socket is affected.

Avascular necrosis (osteonecrosis)

Avascular necrosis is a condition that causes hip pain in young-to-middle-age adults. It’s often referred to as idiopathic, which means that it doesn’t have any clear cause. However, it’s also linked with the following:

  • Drinking too much alcohol
  • Using steroids
  • Sickle cell disease
  • Radiotherapy

Avascular necrosis can occur when the blood supply to the ball of the hip (the femoral head) is lost. This causes the bone tissue to die and the femoral head to collapse, which results in arthritis. If your doctor thinks you have avascular necrosis, it’s important that they refer you for an urgent MRI scan to confirm the diagnosis. As soon as you have a diagnosis, you can start treatment, which may stop the condition progressing and prevent arthritis developing.

Hip fractures

A fall onto the hip can result in a fracture. Most commonly this would happen in the elderly population and be in the neck of the femur. If the fracture is out of place it requires fixing to make the hip stable and this might be done with pins and screws or possibly with a full or partial hip replacement. If however, the fracture is stable it might be allowed to heal naturally and this would mean walking with crutches for four weeks gradually taking more weight on the leg the more comfortable and strong it feels.

Hip pain from back or local muscles

The nerves from the lower part of the back supply muscles that control the hip. A pinched nerve in the lower spine or the related muscles can cause pain to go down the front of the leg from the groin to the knee and make it feel like a hip pain.

The muscle that flexes the hip is called the psoas muscle and it has a nerve supply from the femoral nerve. The gluteus maximus muscle extends the hip as you walk so that you can propel yourself forward and the gluteus medius muscle keeps the pelvis level when you stand on one leg. These are the spots where you might feel pain coming via the nerves that supply these muscles.

Poor biomechanics

Changes in the movement and alignment of the hip eventually lead to wear and tear on the joint surfaces.

  • A weakness of the muscles that pull the hip out and away from the other leg, or turn the thigh outward (hip abductor and external rotator muscles,) can lead to imbalances in the alignment of the entire leg including the knee. If you feel this is an issue, strengthen your hip muscles (use the exercises below) to correct the imbalance.
  • Muscles within the lower extremity might be too tight – e.g. quadriceps itself (front of thigh), hamstrings (back of thigh) and gastrocnemius (a calf muscle). If you feel that this is an issue, ensure adequate length of muscles and good range of movement at the knee by undertaking a regular stretching programme (use the stretches provided).
  • Poor foot control – flat feet or feet rolling inwards causes inward rotation of the leg and therefore poor positioning of the hip.

Activities

A sudden change in the type, nature, or loading of an activity can cause hip pain. This can also be affected by inappropriate clothing, accessories, surfaces and force generated.

  • A sudden introduction or escalation in hill / stair activity. 

Walk up stairs leading with your unaffected (pain free) leg, walk downstairs leading with your affected (painful) leg. If this is not possible within a work environment make use of escalators / lifts where possible and reduce over time to create the phased approach. Take regular short breaks and when safe to do so, walk backwards to change the biomechanical loading on your hip.
  • Prolonged postures such as sitting and getting up from prolonged sitting. 

Keep your legs moving when you are sitting down.

Ensure that your workstation is not cluttered and that you can stretch out your legs while you sit. 

Do not sit cross legged.

Raise your seat so that your hip is only bent to 90 degrees and it is easier to transition into sitting or standing.


  • Clothing/accessories

: poor footwear - unstable, not shock absorbing or not fit for the activity undertaken.

 Wear suitable shoes for the activity and also for your foot biomechanics (type, fit and condition of footwear).

 Restrictive clothing around the hips / knees e.g. tight pencil skirts.

 Wear suitable clothing for the activity that allows a good leg position.

 Weight (loading the hip). Being overweight (increased BMI) is a very significant contributing factor.

 Hip pain signs and symptoms
    Symptoms from hip problems vary. They depend on a person’s condition and which structures are affected. 



Some of the more common symptoms of hip problems are:

  • Hip pain/stiffness
  • Pain spreading into the back, groin, buttock and thigh regions
  • Pain radiating from the hip into the knee
  • Pain causing a limp
  • Pain accompanied by locking, catching, clicking
  • Pain upon weight bearing, sitting for long periods, walking or pivoting on the leg

Hip pain at-home recovery

When suffering from hip pain, it is recommended that you remain as active as your pain will comfortably allow and continue your daily activities as normal. Obviously if these activities are adding to the pain then modify or do not continue them, but getting back to work and keeping the area moving is often the best way to minimise the pain and aid recovery.

First aid advice (immediately after a hip injury)

Pain-relieving medication should help with the discomfort. Anti-inflammatory medications can help ease pain and swelling and get people back to activity sooner. These medications include common over-the-counter drugs such as ibuprofen. Talk to your doctor or pharmacist if you have specific questions about which pain reliever is right for you. Also see your GP if over the counter medication is not easing your pain after a day or two.

  • Apply hot or cold packs to the painful area. You may decide which the best approach is for you. You can buy hot  and cold packs from most pharmacies, but you can also use a hot water bottle or bags of ice or frozen peas (wrapped in a damp tea towel) will often be as good.

Both approaches help to reduce the pain sensation, but they also help to increase the blood flow to the area which brings oxygen and nutrients to the tissues to help them heal more quickly. Ice pack to be applied to the region for approximately 20 minutes every two hours. It is advised that you check the skin every 5-10 minutes to avoid the possibility of an ice burn from the cold temperature. Apply frequently in the first two days.
  • Position yourself in the most comfortable position and postures but try to change position every 30 minutes.  
  • Attempt gentle walking and movement to prevent ceasing up, if too painful use a walking stick or crutches to keep moving but reducing the load through the hip.
  • Sleep in the most naturally comfortable position on a comfortable surface. The best sleeping posture is lying either on your side or on your back. Support your hip with a pillow between your legs if side lying, or under your knees if lying on your back.

Further self-help

Be aware of hip positions and postures at work and home. The positions in which you work and relax each day have a great impact on the health of your hip. It is easy to compensate and allow yourself to develop poor postural habits. You will need to be consciously aware of postures and positions when you are performing tasks at home and work:


Think about how you are sitting in all situations:

  • Keep your legs moving when you are sitting down.
  • Ensure that your workstation is not cluttered and that you can stretch out your legs while you sit.
  • Do not sit cross legged.
  • Raise your seat so that your hip is only bent to 90 degrees and it is easier to transition into sitting or standing.
  • Driving the car: if this increases the pain, alter the seat distance from the pedals, seat height, back rest angle to see if a change of hip position or increasing the use of your feet rather than using your whole leg to use the pedals . Park with plenty of room to access and exit the vehicle with the door fully open to allow you to access the vehicle bottom first while stood on both legs, and exit it feet first with both feet concurrently.

Think about your standing posture, whether working at benches in your job or for household activities, be aware of your posture, symmetrical weight bearing, the surface on which you are standing and your footwear. 

  • Ensure the bench height allows you to work with a straight back, plenty of room for your feet (no twisting or reaching) and shoulders and arms relaxed.
  • Have objects close to you to avoid unnecessary reaching.
  • The standing surface should be cushioned (not just heard wood / concrete / tiles) and wear cushioned soles to your footwear. This reduces force and loading of your hip.
  • As much as sitting in one position is not good, prolonged standing can be fatiguing. Try to do some of your work while sitting, alternate your work or household tasks to vary your position.

Think about lifting and carrying

  • Think before you lift. Test the weight. Avoid reaching to lift objects or lifting awkwardly. Carry the object close to your body.
  • When lifting from ground level, stand close to the object with feet apart, bend using your knees and your back (about 50:50). Keep your chin in during the lift -think silverback gorilla posture!
  • Carry fewer bags of groceries from the car at a time. There will be more trips but less strain on your hip.  
  • Check the contents of your bags (e.g. handbag, gym bag, school bag). Lighten the load. 

  • When travelling, always use a suitcase with wheels, including hand luggage. Consider whether you need all those items that you have packed, especially footwear, which is heavy -lessen the load.
  • When going to and from work, carry your laptop or papers in a rucksack. Do not use a briefcase, or if you insist on not using a rucksack, alternate the side you carry your briefcase or laptop. If you need to carry extra paperwork, consider transporting it separately. Do not overload one side.
  • Specially designed laptop rucksacks are a more comfortable way of carrying computers.
  • Use a trolley to carry oversized or multiple items. At the supermarket, choose a trolley that steers easily when you push it.
  • When carrying children, regularly change sides. Use slings if comfortable, backpacks, prams or pushchairs.
  • When nursing or breastfeeding a baby, place the baby on a pillow on your lap to save having to hold the weight of the baby for prolonged periods.
  • Encourage children to climb onto your lap or into the car as soon as they are able.
  • Position their car seat to limit the amount of reaching you have to do to secure the child in the seat.

Household activities 

  • Spread chores out over a few days. You don’t have to do all the household tasks at once.
  • Change your routine and reduce the chance of hip strain.
  • Rotate the cleaning tasks and don’t do the same task all at once. Alternate lighter tasks with heavier tasks. For example, dust, hoover one room, do the washing up, and vacuum another room. Take breaks between each task. You do not have to do everything at once – be adaptable and pace yourself.
  • When doing laundry, lift fewer clothes from the washing machine at once. Place the basket up on a trolley to reduce the strain on your hip and shoulders while hanging out the clothes. Dry heavy items on a clothes rack / radiator if necessary.
  • In the kitchen, place items that you use regularly at bench height so that you don’t have to do unnecessary bending or reaching.
  • If using heavy saucepans or pans, draw them close to you first and lift with two hands. To lessen the weight, let them rest on the sink as you drain the contents.
  • Don’t start new projects such as painting a skirting board or projects involving heavy lifting until your hip has recovered. Get help to carry heavy loads or to do heavy tasks.
  • In the garden, vary your activities and positions. Do some weeding then some raking, then some trimming. Rotate your activities.
  • Weed the garden kneeling on your hands and knees or in a half kneeling position with one knee bent up.
  • Use a wheelbarrow to take weeds to the compost bin.

Exercise 

  • Act as usual: it is normal to experience some discomfort during recovery but don’t stress your hip to a painful level. Try to participate in most of your normal activities. If your normal activities or sports place high strains on your hip, adapt them or build up to them gradually as your hip recovers.
  • Be active: perform general exercise and activity to maintain your wellbeing and health.
  • Undertake a specific exercise regime to improve your movement and flexibility and restore muscle control and support to your hip.
  • Walking is a very good form of general exercise. You need good supportive shoes with good shock absorbing insoles. Trainers are good for walking on dry flat surfaces and have some of the best shock absorbing material in the soles of the shoes. You should walk at a normal pace that you are comfortable with and walk for about 30-40 minutes 3-4 times a week. Too much walking might aggravate an uncomfortable hip so try to keep within limits and do not cause pain. When you come home do some of the stretches below.
  • The best all-around exercise for the hip is swimming. The water reduces the body weight going through your legs and relieves the stress on your hip as you “walk” about in the shallow end of the pool. Swimming is excellent – it involves the use of most of your body muscles. However avoid breaststroke legs as this can aggravate the hip.
  • Bicycling (stationary or mobile) is also a good form of exercise as it works the leg muscles to make them strong but full body weight does not go through the legs.
  • Undertake the hip rehabilitation exercises. The exercises in this leaflet were chosen specifically to assist you to improve your level of hip movement and flexibility. The exercises will also help restore the muscle control necessary to support your hip during normal activities. Muscle control means pain control.
  • Exercise to reduce your pain.
  • If you are overweight, then look to reduce stress on the hip by losing weight.

Hip pain stretches

Lengthening tight muscles is important to reduce pain and speed healing, as tense muscles have a reduced blood supply. Blood carries oxygen and nutrients that the muscles need to heal.

Piriformis

One of the main muscles affected during episodes of hip pain, this is a strap like muscle passing from your sacrum to the greater trochanter. It both abducts the femur at the hip and also externally rotates the thigh. As this muscle becomes tight it causes both pain in the buttock region and over the greater trochanter (see previous anatomy section) but it can also cause pain in the leg as it can compress the sciatic nerve which passes underneath it (called piriformis syndrome).

As with all the stretches, do this gently and carefully until you feel a stretch sensation that is not overly painful.

Sit on a chair with your feet on the floor

  • Take your left leg up and place your left heel on your right knee, then push the left knee gently down and outwards with your hand (men sometimes sit in this position when relaxing)
  • Sit up tall and if you can, slightly lean forwards with a flat back
  • You should feel the stretch in your left buttock just behind your hip
  • Do the stretch on both sides
  • Hold the stretch for 30 seconds and repeat

Quadriceps stretch

The Quadriceps is the large muscle group on the front of the thigh. It attaches to your pelvis and then below the knee (via the patella tendon) at the top of the shin bone. This muscle group (comprising of 4 muscles) both moves the hip and the knee.

  • While lying on your stomach with your legs straight and knees together, bend your knee so that you bring your heel towards your bottom
  • Grab hold of your foot with the hand of the same side and pull your heel nearer to your bottom until you feel a comfortable stretch on the front of the thigh
  • Hold the stretch for 30 seconds, return to the start position and repeat
  • Once you have done this repeat on the other side

Hamstring stretch

The hamstring is the large muscle at the back of the thigh. It actually attaches to your pelvis and then below the knee at the top of the shin bone. This muscle group, comprising of three muscles, both moves and stabilises the hip and the knee.

  • While standing, place one foot on a small step or stool and then whilst keeping your back straight and your head up (fix your gaze high on the wall opposite) lean forwards until you feel a stretch in the back of the thigh
  • Hold the stretch for 30 seconds, return to the start position and repeat
  • Once you have done this repeat on the other side
  • Please remember to keep the back upright and straight whilst performing this exercise.  Keeping you back straight is helped by keeping your gaze high.

Stretching the inside of the thigh/hip

This simple exercise will stretch the tissue around the inside of the hip and thigh and maintain the movement in this area. Although this may seem like just a hip exercise, some of the muscles attach on the inside of the knee so you may feel a stretch here as well.

  • Stand with a wide stance
  • Lean towards one side creating a straight leg on the opposite side
  • You should feel a stretch along the inside of the leg
  • Hold the stretch for 30 seconds, return to the start position and repeat
  • Once you have done this repeat on the other hip
  • Please remember to keep the back upright whilst performing this exercise

Stretching the outside of the hip

This simple exercise will stretch the tissue around the outside of the hip and buttock and maintain the movement in this area.

  • Lay down on your back with your knees bent and your feet on the surface.
  • Cross one leg over the other so that the foot is resting on the knee of the other leg. Let your crossing leg relax so that the knee drops sideways.
  • Reach forward with both hands and pull the thigh of the ‘crossed’ leg towards you until you feel a comfortable stretch in the buttock/hip of the crossing leg.
  • Hold the stretch for 30 seconds, return to the start position and repeat on the other leg.

Hip loosening exercises

Leg slides

A gentle hip and knee movement to get you moving when feeling very stiff.

  • Lie on your back on your bed or floor with straight legs.
  • Slowly slide one leg up to bend your hip and knee, keep your foot on the bed.
  • Then slowly slide it back down again to its original position.
  • Repeat the movement on each leg 5-10 times and do the exercise three times a day.

Knee and hip sideways pivot

A gentle hip and knee movement to get you moving when feeling very stiff, pairs well with the leg slides.

  • Lie on your back on your bed or the floor with both feet together.
  • Slowly pivot one knee out to the side a short distance, keeping your feet on the bed.
  • Then slowly return it back to its original position.
  • Repeat the movement on each leg 5-10 times and do the exercise three times a day.

Hip and knee hugging

This is a great, general exercise for the hip which will help to maintain the movement in the joint whilst also stretching the muscles around the back of the hip joint.

  • Lie on your back with your legs straight and your back in a slightly arched position.
  • Lift one leg towards your chest, bending at the knee and hold it there at the end of the movement or until a gentle stretch is felt.
  • Hold the stretch for 30 seconds and repeat.
  • Then repeat on the other hip.
  • Please remember to do this exercise slowly and stop if you feel any pinching in the front of the hip.

Stretching the front of the hip

Again, this is a great, general exercise for the hip which will help to maintain the movement in the joint whilst also stretching the muscle in the front of the hip. When you sit regularly or perform repetitive activities such as walking or running, the ligaments and muscles at the front of the hip can get tight, which can lead to pain and stiffness in the front of the hip. This simple exercise stretches the ligaments and muscles in the front of the hip and also helps to maintain the movement in the hip joint.

  • Place a stable chair in front of a wall so that it cannot move.
  • Stand in front of the chair and place the unaffected foot on the chair.
  • Bring your weight forward as you extend the hip of the standing leg as far as you can.
  • Hold the stretch for 30 seconds, return to the start position and repeat.
  • Once you have done this repeat on the other hip.
  • Please remember to keep the back upright whilst performing this exercise.

Exercises for muscle control and hip pain relief

Kneeling leg slides

This is a gentle exercise that works your hip flexors and extensors with minimal effort. 

  • Kneel on your hands and knees on the floor or stable surface - place your hands right under your shoulders and you knees under your hips.
  • Make sure that your weight is evenly balanced between hands and knees.
  • Slowly slide your right leg backwards along the floor and bring it back again.
  • Repeat this with your left leg.
  • Repeat this exercise 5-10 times with each leg

Bridging

This exercise will help to strengthen your buttocks and core muscles which are very important in hip extension and walking.

  • Lie on your back with knees bent and feet on the floor.
  • Slowly curl your back off the floor hold for three seconds.
  • Curl back down to the floor.
  • Repeat this exercise 10 times.
  • To progress this exercise, place the fingertips of both hands on your pubic bone and then slide them left and right along the pelvic bone until you find a big bony lump (with each hand) above your hips. In fact we generally put our hands there when we put our hands on our hips!
  • Place two fingers on each bony prominence. Your aim is to keep these bones stable as you curl your back off the floor and also as you curl it back down!

Hip side left

  • Maintaining the strength around the hip is very important and people are often surprised to find that the strength around their hip may not be as good as they expected.
  • Lie on your side, on a comfortable surface with both legs slightly bent at the knee.
  • Place your upper hand over your pelvis to maintain its position during the exercise – do not roll backwards.
  • Lift up the top leg keeping the knee slightly bent, foot facing forward and the pelvis stable.
  • You may feel the muscles working on the outside of the hip.
  • Return to the start position and repeat five times.
  • Make sure that you stay on your side and do not roll backwards.
  • Once you have done this repeat on the other side

Hip flexion

  • Hold on to a chair or table and lift your knee up to the level of you hip
  • Do not lift too high or cause any pain
  • Do the movement 5-10 times on each leg

Remember to follow this advice under the guidance of your physiotherapist.

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