Hip Pain

MY HIP FLEXORS ARE TIGHT…”

At The Injury Hub, we’ve been fortunate to work with some of the country’s finest professional dancers—artists from Sadler’s Wells, ZooNation, the Royal Ballet, and backing dancers for the likes of Kylie Minogue, Robbie Williams, JLS, Take That, and a long list of Saturday night TV shows.

For years, dancers have been coming to us complaining of a “hip flexor strain.” And it’s not just dancers—the local Cross Fitter, Pilates enthusiast, runner, or desk-bound office worker will often walk in having confidently self-diagnosed a “tight hip flexor.”

Quite often, someone else has told them this—a trainer, a therapist—or they’re body-aware enough to know that the hip flexor muscles pass through the front of the hip, so they make the logical assumption that the pain in that region must be coming from tightness.

Here’s the thing: in over 25 years of clinical practice, we can count the number of true symptomatic “tight hip flexors” I’ve seen on one hand. Genuinely maybe three.

As someone with a special interest in radiology, and now working as a musculoskeletal sonographer, I’ve scanned hundreds of dancers and athletes with so-called “tight hip flexors.” The overwhelming conclusion? The real cause of their symptoms is a condition called Femoroacetabular Impingement or FAI.

Understanding Femoroacetabular Impingement (FAI)

Femoroacetabular Impingement (FAI)

FAI is a condition where there is abnormal contact between the ball and socket of the hip joint. It usually starts with a minor anatomical difference either a small bump of bone on the neck of the thigh bone (a CAM lesion), or a slight overhang on the rim of the hip socket (a Pincer lesion). These subtle shape differences can significantly alter the way the hip joint moves and loads (Ganz et al., 2003).

Between these two bones sits the labrum, a ring of cartilage that cushions the joint, deepens the socket, and helps keep the femoral head in place. It surrounds the outer rim of the acetabulum, not deep within the joint itself. This is important, because if the labrum becomes irritated or torn, it does not necessarily indicate arthritis or deep joint damage. In fact, many people have labral tears without any degenerative change in the hip socket itself (Register et al., 2012).

Problems develop when a person with a CAM or Pincer lesion repeatedly moves the hip into flexion, such as during running, squatting, standing from a chair, or hugging the knees to the chest. That extra bit of bone begins to rub against the labrum, causing irritation and, over time, fraying or tearing of the cartilage (Agricola et al., 2013).

Symptoms often begin as a vague, dull ache during or after activity and can progress to sharper catching or clicking sensations deep in the groin. In some cases, it may feel like the hip is sticking or giving way. These symptoms can significantly limit sport, work, and daily activities if not addressed.

FAI is usually straightforward to identify with the right examination. At The Injury Hub, we use a combination of targeted clinical testing and onsite diagnostic ultrasound to assess for impingement and labral irritation. If further detail is required, an MRI scan can be arranged to confirm the diagnosis and assess any associated cartilage involvement. MRI with arthrography remains the gold standard for evaluating labral tears and cartilage damage (Naraghi and White, 2014).

Treatment Options

Treatment depends on the severity of symptoms and duration of the problem. At The Injury Hub, management begins with conservative care, including hands-on manual therapy and traction-based techniques to decompress the hip joint, combined with guided rehabilitation and strength and conditioning to optimise movement control. Ultrasound-guided injections may also be used to reduce inflammation and irritation around the joint.

Recent research highlights the importance of rehabilitation in FAI. A 2019 randomised controlled trial demonstrated that structured physiotherapy focusing on movement retraining and strengthening can provide significant improvements in pain and function, even in patients with structural CAM or Pincer lesions (Griffin et al., 2019).

For more persistent cases, particularly where there is a significant labral tear or marked structural abnormality, onward referral to a hip specialist may be appropriate. Surgical options, such as arthroscopic labral repair or bony reshaping (osteoplasty), have been shown to reduce symptoms and improve function in carefully selected patients (Palmer et al., 2019; Yeung et al., 2022).

References

• Agricola, R. et al. (2013) ‘Cam impingement causes osteoarthritis of the hip: a nationwide prospective cohort study (CHECK)’, Annals of the Rheumatic Diseases, 72(6), pp. 918–923.

• Ganz, R. et al. (2003) ‘Femoroacetabular impingement: a cause for osteoarthritis of the hip’, Clinical Orthopaedics and Related Research, 417, pp. 112–120.

• Griffin, D.R. et al. (2019) ‘Hip arthroscopy versus best conservative care for the treatment of femoroacetabular impingement syndrome: multicentre randomised controlled trial (UK FASHIoN)’, BMJ, 364, l185.

• Naraghi, A. and White, L.M. (2014) ‘MRI of labral and chondral lesions of the hip’, AJR American Journal of Roentgenology, 202(3), pp. 497–510.

• Palmer, A.J.R. et al. (2019) ‘Arthroscopic hip surgery compared with physiotherapy and activity modification for the treatment of symptomatic femoroacetabular impingement: systematic review and meta-analysis’, BMJ Open, 9(8), e031073.

• Register, B. et al. (2012) ‘Prevalence of abnormal hip findings in asymptomatic participants: a prospective, blinded study’, American Journal of Sports Medicine, 40(12), pp. 2720–2724.

• Yeung, M. et al. (2022) ‘Outcomes of hip arthroscopy for femoroacetabular impingement: a systematic review and meta-analysis’, Journal of Bone and Joint Surgery American, 104(16), pp. 1431–1442.

Gluteal tendinopathy is one of the most common causes of pain on the outside of the hip, yet it is often mistaken for trochanteric bursitis. Research now shows that in the majority of cases diagnosed as “bursitis,” the underlying issue is actually a tendinopathy affecting one or more of the gluteal muscles, most often the gluteus medius and gluteus minimus (Fearon et al., 2013).

These tendons attach onto the greater trochanter, the prominent bony point felt on the outer side of the hip. Over time, the tendons can undergo microscopic degeneration, thickening, and sometimes partial tearing. This is usually the result of repeated compression and tensile loading rather than inflammation alone (Grimaldi et al., 2015). The condition is particularly common in women over the age of 40, although it can affect both men and women at any age.

Patients typically report pain when lying on the affected side in bed, walking long distances, climbing stairs, or after prolonged standing. Movements such as squats and lunges may aggravate symptoms. In some cases, pain may radiate down the outside of the thigh, which can be mistaken for sciatica (Mellor et al., 2018).

Whereas trochanteric bursitis involves inflammation of the fluid-filled sac between the tendon and bone, gluteal tendinopathy is a degenerative condition of the tendon itself. Bursitis can occur alongside tendinopathy, but on its own it is much less common than previously thought.

Diagnosis is straightforward with the right assessment. At The Injury Hub, we combine targeted orthopaedic testing with onsite diagnostic ultrasound to assess tendon structure, detect partial tears, and identify any associated bursal inflammation.

Treatment Options

Management of gluteal tendinopathy has shifted significantly in recent years. While rest and anti-inflammatory medications may provide short-term relief, research consistently shows that the most effective long-term treatment is a progressive, controlled loading program for the tendon. This usually involves eccentric or heavy slow resistance exercises targeting the gluteus medius and minimus (Mellor et al., 2018; Ganderton et al., 2018). The aim is to gradually strengthen the tendon and improve its tolerance to load.

At The Injury Hub, our onsite strength and conditioning coach provides tailored progressive programs to ensure patients load the tendon safely and effectively for recovery. Exercise is combined with education to avoid positions that compress the tendon, such as sitting with crossed legs or standing with the hip dropped to one side (Grimaldi et al., 2015).

In more persistent cases, additional therapies can be used. Shockwave therapy has been shown to promote tendon healing and reduce pain in chronic cases (Furia et al., 2009; Rompe et al., 2009). Ultrasound-guided injection therapy may also be considered depending on the pathology. Corticosteroid injections can provide short-term relief where bursitis is present, but they are less effective for tendinopathy and best used selectively (Brinks et al., 2011). For pure tendinopathy, regenerative injections such as platelet-rich plasma (PRP) or prolotherapy may be more appropriate, with emerging evidence suggesting they can stimulate tissue repair (Fitzpatrick et al., 2019).

With accurate diagnosis, a structured loading program, and the right combination of adjunct therapies, most cases of gluteal tendinopathy improve significantly, allowing patients to return to normal activities without pain.

References

• Brinks, A. et al. (2011) ‘Corticosteroid injections for greater trochanteric pain syndrome: a randomized controlled trial in primary care’, Annals of Family Medicine, 9(3), pp. 226–234.

• Fearon, A.M. et al. (2013) ‘Greater trochanteric pain syndrome: defining the clinical syndrome’, British Journal of Sports Medicine, 47(10), pp. 649–653.

• Fitzpatrick, J. et al. (2019) ‘Leukocyte-rich platelet-rich plasma treatment of gluteal tendinopathy: a double-blind randomized controlled trial with 2-year follow-up’, American Journal of Sports Medicine, 47(5), pp. 1130–1137.

• Furia, J.P. et al. (2009) ‘High-energy extracorporeal shock wave therapy as a treatment for greater trochanteric pain syndrome’, American Journal of Sports Medicine, 37(9), pp. 1806–1813.

• Ganderton, C. et al. (2018) ‘Education plus exercise versus corticosteroid injection use for gluteal tendinopathy: clinical outcomes from a randomized clinical trial at 52-week follow-up’, Journal of Orthopaedic & Sports Physical Therapy, 48(6), pp. 489–499.

• Grimaldi, A. et al. (2015) ‘Gluteal tendinopathy: a review of mechanisms, assessment and management’, Sports Medicine, 45(8), pp. 1107–1119.

• Mellor, R. et al. (2018) ‘Exercise and load modification versus corticosteroid injection versus wait and see for persistent gluteal tendinopathy: a randomized clinical trial’, BMJ, 361, k1662.

• Rompe, J.D. et al. (2009) ‘Home training, local corticosteroid injection, or radial shock wave therapy for greater trochanteric pain syndrome’, American Journal of Sports Medicine, 37(10), pp. 1981–1990.

Trochanteric bursitis describes irritation of the bursa that sits over the greater trochanter, the bony prominence on the outside of the hip (the part that presses into the mattress when you lie on your side). While many people are told they have “bursitis,” it is now widely recognised that the bursa is often irritated secondarily to an underlying gluteal tendinopathy. In other words, the tendon pathology is usually the main driver, and the bursa becomes inflamed as a consequence. That said, isolated bursitis does occur and can be extremely painful (Grimaldi and Fearon, 2015).

Typical symptoms include pain when lying on the affected side, discomfort during long walks, hills or stairs, and pain when squatting or rising from low chairs. Pain is usually localised to the lateral hip but can radiate down the outside of the thigh, which sometimes leads patients to confuse it with sciatica (Fearon et al., 2013).

The bursa’s role is to reduce friction between the gluteal tendons and the bone. When the overlying gluteal muscles are tight or the tendons overloaded, the bursa can be compressed and irritated. Postural factors such as increased lumbar lordosis (an exaggerated lower-back curve) or a habitual “hip hitch” stance can further increase lateral hip compression (Ganderton et al., 2017). Spinal or lumbopelvic dysfunction may also contribute by increasing gluteal muscle tension across the bursa.

Diagnosis is usually straightforward with a thorough clinical assessment. At The Injury Hub, ultrasound is frequently used to confirm whether the bursa is inflamed, to assess for co-existing gluteal tendinopathy or partial tears, and to guide any interventions with precision.

Management is most effective when it addresses both bursal irritation and any underlying tendon overload. Strategies include:

Load and posture management are key early steps. Reducing side-lying compression (for example, lying on the non-painful side with a pillow between the knees), avoiding prolonged legs-crossed sitting, and limiting hill walking or stair climbing can reduce bursal irritation. Gait modifications and standing with weight evenly distributed can also prevent lateral hip pinching.

Hands-on therapy can be beneficial in releasing tight gluteal tissues and improving lumbopelvic stiffness, thereby reducing compression. For some patients, this can be as effective as other modalities when soft-tissue tension is the main driver.

Targeted exercise plays a central role once acute pain is controlled. A graded strengthening program, often starting gently and progressing to heavier slow resistance improves hip control and reduces recurrence. At The Injury Hub, our strength and conditioning coach works alongside clinicians to design tailored loading plans, particularly if gluteal tendinopathy co-exists.

Shockwave therapy has been shown to reduce pain and stimulate healing in chronic lateral hip pain, particularly when symptoms have been present for several months (Rompe et al., 2009).

Ultrasound-guided steroid injection can be very effective for short-term relief when the bursa is the dominant pain generator, such as in night pain from side-lying. While it does not address degenerative tendon changes, it can calm the inflamed bursa and allow rehabilitation to progress (Brinks et al., 2011).

When symptoms persist despite standard management, a reassessment is performed to identify co-existing gluteal tendon tears, lumbar contributions, leg-length discrepancies, or biomechanical issues that may be driving the problem.

At The Injury Hub, we treat trochanteric bursitis and gluteal tendinopathy together when they co-exist, because addressing tendon load and bursal irritation simultaneously gives the best results. By combining precise diagnosis (with onsite ultrasound), hands-on release, a sensible graded strengthening program with our in-house strength and conditioning coach, and adjunct therapies such as shockwave or ultrasound-guided injections, we achieve long-lasting outcomes for our patients.

References

• Brinks, A. et al. (2011) ‘Corticosteroid injections for greater trochanteric pain syndrome: a randomized controlled trial in primary care’, Annals of Family Medicine, 9(3), pp. 226–234.

• Fearon, A.M. et al. (2013) ‘Greater trochanteric pain syndrome: defining the clinical syndrome’, British Journal of Sports Medicine, 47(10), pp. 649–653.

• Ganderton, C. et al. (2017) ‘Gluteal loading versus sham exercises to improve pain and dysfunction in women with greater trochanteric pain syndrome: a randomized controlled trial’, BMJ Open, 7(5), e014419.

• Grimaldi, A. and Fearon, A. (2015) ‘Gluteal tendinopathy: integrating pathomechanics and clinical features in its management’, Journal of Orthopaedic & Sports Physical Therapy, 45(11), pp. 910–922.

• Rompe, J.D. et al. (2009) ‘Home training, local corticosteroid injection, or radial shock wave therapy for greater trochanteric pain syndrome’, American Journal of Sports Medicine, 37(10), pp. 1981–1990.

Hip Osteoarthritis (OA)

Osteoarthritis (OA) of the hip is a degenerative joint condition in which the smooth cartilage that cushions the ball-and-socket joint gradually wears away. As this cartilage thins, the bones of the joint, the femur and the pelvis, start to rub directly against each other. This leads to pain, stiffness, and reduced mobility. Over time, the joint may also develop bony overgrowths (osteophytes), joint space narrowing, and varying degrees of inflammation (Hunter and Bierma-Zeinstra, 2019).

Hip OA often develops gradually, and symptoms can be deceptive. While many patients feel pain deep in the groin, it is just as common for discomfort to be felt along the inside of the thigh or even radiating towards the knee. Stiffness is often worse first thing in the morning or after periods of sitting, and walking longer distances may become increasingly difficult (Litwic et al., 2013).

Diagnosis is usually made through a combination of clinical assessment and imaging. X-rays remain the standard for demonstrating joint space narrowing, osteophytes, and bone changes, while ultrasound can provide valuable real-time information on inflammation in the surrounding soft tissues and guide precise injection therapy if needed. In some cases, MRI may be used to assess cartilage, bone marrow lesions, or associated labral pathology (Roemer et al., 2011).

Management

Treatment depends on the severity of the condition and the patient’s functional needs. In the early stages, hands-on mobilisation and joint-specific exercises can help preserve range of motion and maintain function. Strengthening of supporting muscles, particularly the gluteals, is important for joint stability and reducing load across the hip (French et al., 2013). Education and activity modification, such as pacing long walks, avoiding deep squatting, or managing high-impact activity, are also essential.

In more advanced cases, ultrasound-guided injections can provide effective symptom relief. Hyaluronic acid injections improve joint lubrication and cushioning, while corticosteroids may be appropriate during periods of acute inflammatory flare. A recent meta-analysis supports the use of intra-articular corticosteroids for short-term pain relief in hip OA, though their benefits may diminish over time (McCabe et al., 2016). Conversely, hyaluronic acid has shown promising results in improving longer-term function and reducing pain progression compared with steroid alone (Bannuru et al., 2015).

Where pain and functional loss are severe, referral to an orthopaedic surgeon for consideration of hip replacement is appropriate. Total hip arthroplasty remains one of the most successful surgical procedures, with excellent outcomes for pain and function when conservative measures are no longer sufficient (Learmonth et al., 2007). With the right treatment pathway and tailored activity approach, many people with hip osteoarthritis can continue an active lifestyle for years before surgery becomes necessary.

References

• Bannuru, R.R. et al. (2015) ‘Comparative effectiveness of pharmacologic interventions for knee osteoarthritis: a systematic review and network meta-analysis’, Annals of Internal Medicine, 162(1), pp. 46–54. (includes hip OA data)

• French, H.P. et al. (2013) ‘Exercise for osteoarthritis of the hip’, Cochrane Database of Systematic Reviews, CD007912.

• Hunter, D.J. and Bierma-Zeinstra, S. (2019) ‘Osteoarthritis’, Lancet, 393(10182), pp. 1745–1759.

• Learmonth, I.D., Young, C. and Rorabeck, C. (2007) ‘The operation of the century: total hip replacement’, Lancet, 370(9597), pp. 1508–1519.

• Litwic, A. et al. (2013) ‘Epidemiology and burden of osteoarthritis’, British Medical Bulletin, 105, pp. 185–199.

• McCabe, P.S. et al. (2016) ‘Intra-articular corticosteroid for osteoarthritis of the hip: a randomized controlled trial’, Arthritis & Rheumatology, 68(3), pp. 691–699.

• Roemer, F.W. et al. (2011) ‘Imaging in osteoarthritis’, Osteoarthritis and Cartilage, 19(10), pp. 1175–1189.