5 causes of hip pain in runners and how to fix them

hip pain running
5 causes of hip pain and how to fix themGetty Images

Hip pain when running or just after is a common complaint among runners of all ages, but getting to the bottom of the issue isn’t always clear-cut.

While the hip itself is the ball and socket joint where the femur (thigh bone) attaches to the pelvis, the area commonly described as the hip runs from the top of the pelvis down to the base of your bottom. It's where the powerhouses of running (your legs) connect to the body’s stablising core, and is a spaghetti junction of muscles, tendons, nerves and bones, which means that there is a whole range of potential underlying causes for that pain in your side.

What’s more, the problem isn’t always a localised one – in fact, hip pain could be signalling an issue or injury elsewhere in your body.

'Instead of thinking locally, I also think globally and make sure that all of the dysfunctions have been addressed, explains consultant physiotherapist for the Institute of Sport Exercise and Health Dr Bruce Paton. 'I’d see how the leg’s rotating and how the leg’s moving as a whole when running, and look at things like joint stiffness, joint instability, muscle flexibility and making sure that the muscles are strong.'

What does hip pain feel like when running?

Due to the makeup of the area, there is a range of pain you can experience in the hip area when running, and it doesn’t just occur in a single, isolated spot. The intensity of the pain can also vary – from a sharp ache that gets worse with any activity (potential signs of a stress fracture) to a dull ache on the boney side of your hip (burisitis).

Any pain is worth investigating and not ignoring though – a minor injury can soon turn into a major one if left, meaning more time away from running.

Here, Paton talks through the five most common causes of hip pain in runners and how to treat and prevent them.

1.Muscle strain and tendinopathy

What is it and how is it caused?

The hip is home to 17 different muscles that are divided into four groups – the gluteal, lateral rotator, adductor and iliopsoas. And, you guessed it, it’s possible to strain them all.

Muscle strain and tendinopathy is often a symptom of muscle overuse, but that doesn’t necessarily mean it’s solely caused by a sudden increase in mileage. 'We sometimes find that there are quite a few contributing factors,' explains Paton. 'One is the flexibility in the muscle – so whether the hamstrings are flexible, for example. We also find strength is a factor – so if muscles are weaker than we would expect or sometimes the hamstring [is working more] because other muscles are weak.'

He adds that everyday activities outside of running can also cause an overload on a tendon, resulting in pain in the hips – for example, sitting. 'Patients will go for a run, work the tendon – tendons like tension and pulling – and then go sit for six or eight hours at work. The sitting actually gives a whole lot of compression to that tendon.'

What are the symptoms?

'The location of the pain can vary from around the sit bone because it’s the part of the pelvis that the hamstring is attached onto,' says Paton, 'through to an ache on the outside of the hip that can relate to tendinopathy of the gluteus medius or the gluteal tendons.'

How should I treat it?

Resting is the best form of treatment, but Paton concedes that it doesn’t always solve the problem, as the tendon can sometimes 'stay a little bit disordered'. If this is the case, he recommends seeing a physiotherapist, who can determine the root cause of the problem.

How can I prevent it?

He encourages runners to watch their postures outside of their running and how much sitting they do because the tendons don't always like compression.

2. Iliotibial Band Syndrome

What is it and how is it caused?

Speak to most runners and they’ll either personally have had a brush with iliotibial band (ITB) syndrome or will know someone who has. The ITB is a long, inch-wide strip of tissue that runs from the iliac crest (top of the pelvis) down into the knee, but its inflammation can be the cause of run-ending pain. 'The ITB is like a tendon,' explains says Paton. It likes tension, but typically it gets compression (aka sitting). That compression and repeated cycling with repeated elastic energy (aka running) seems to be what initiates the tendinopathy, so it's load that brings it on, but it's not necessarily an inflammatory thing.

'On the front of the pelvis, you've got the TFL [tennsor fasciae latae] muscle and on the back of the pelvic brim, you've got the gluteus medius. If the gluteus medius is weak, it allows the pelvis to tilt forward. What happens in long runs is that gradually the gluteus medius fatigues, and then the brain has only got one hip abductor to use. It uses that muscle – the TFL [tennsor fasciae latae] muscle – on the end of the ITB. The shortening of the TFL then pulls on the ITB, causing it to become too tight and therefore painful.'

He says that it’s common with runners who haven’t followed a long-distance training plan before, such as a marathon training plan, who increase their mileage too quickly.

What are the symptoms?

Paton explains that while it’s more common around the knee, it can also cause pain at the trochanter – the part that slightly protrudes at the top of the thigh bone.

How should I treat it?

It is possible to stretch out the ITB a number of ways. Paton recommends bending your leg at the knee while standing on the other leg, like a standard quad stretch. The ankle of the bent leg should be held by the opposite side’s hand. 'Squeeze the glutes so that you tilt to get a better stretch in the quads and the ITB.'

He also suggested kneeling on the ground with your good side and lunging the affected leg backwards. 'Squeeze the glutes and bring your arm on the same side up above the head and away from the back leg. It picks up the hip flexors, the ITB, the rectus femoris on the front of the quads and the TFL. It also stretches that whole sling of connective tissue up through the abdominals.'

How can I prevent it?

Paton says that improved strength can help, either achieved by doing at least one faster running session per week or a hill session, or by doing isolated exercises. He highlights the gluteus medius as being a key muscle to strengthen. His go-to exercise for this is a closed-chain hip abduction. Standing on one leg with the other raised, let the pelvis drop on the side of your raised leg. You then use your glute muscles on the standing side to lift it a level again.

3. Bursitis

What is it and how is it caused?

The body contains more than 100 bursae – small sacs full of fluid that are located between bones and surrounding tissue to help reduce tension and wear and tear at common points of friction. Two of these bursae are located on either side of your hips at the trochanter – the part that slightly protrudes at the top of the thigh bone, where ITB syndrome can flare up.

Pain can occur when the bursa becomes inflamed or irritated through overuse, but Paton adds that there can be non-running causes to consider, too. 'Sometimes if people don't have much fat, they don't have much cushioning, so if they lie on a hard surface (like a hard mattress), their bone is very close to it so the bursa can react a bit.'

What are the symptoms?

Pain on either side of your hips at the trochanter – the part that slightly protrudes at the top of the thigh bone.

How should I treat it?

Treatment for bursitis involves resting and relieving the compression, which could be as simple as sleeping on your other side, if you find it becomes inflamed.

How can I prevent it?

Paton recommends that the best prevention is strength work, particularly focusing on the gluteus medius and gluteus minimus with exercises such as leg presses. 'What I sometimes find is that the runners can't push their bodyweight when using a press machine, and yet their leg is having to take their bodyweight through during an entire half marathon or marathon.'

He recommends strength training twice a week – and using a heavy load but a low number of reps – doing three sets to fatigue. 'With my patients, I tend to find that over about six to 12 weeks, we can double the amount of weight they can push on the leg press.'

4. Stress fractures

What is it and how is it caused?

The hip area is home to a number of bones, meaning that stress fractures can also be a cause of pain.

While direct trauma such as a fall is an obvious, unavoidable cause, Paton adds that there can be other contributing factors that lead to a stress fracture, which shouldn’t be missed.

'Things like calorie restriction and RED-S [relative energy deficiency in sport] can cause common stress fractures in the hip, the neck of the femur and the pubic ramus [the lower part of the pelvis],' he says. 'Things like calcium intake and diet have an effect, but if a runner's doing a lot of mileage and they're not intaking enough calories and they don't have enough break times between runs, energy deficiency is a factor.'

What are the symptoms?

You’re likely to know if you have a stress fracture – the pain makes it uncomfortable to stand and walk and unbearable to run.

How should I treat it?

If you have this pain, Paton says you should stop running to allow the bone to recover. 'Start with a period of maybe of using crutches, trying to offload and rest to let the bone settle, and then a period of really phased weight bearing and then phased-in loading.'

Also, if the stress fracture wasn’t caused by trauma, Paton suggests looking at all possible contributing factors to prevent it from happening again. 'The injury might relate to a runner's biomechanics, muscle flexibility or strength but things like footwear, training load, frequency, intensity and duration, plus the surfaces they run and whether or not they warm up before a run are all factors.'

5. Osteoarthritis

What is it and how is it caused?

Another potential cause of hip pain while running is osteoarthritis – which tends to be reserved for runners coming into their 40s and 50s. This is when the hip itself – the ball and socket joint – causes pain.

'Arthritis relates to a degenerative change in the cartilage, but it ends up being a kind of disease of the whole joints,' explains Paton. 'We see a lot of people with gradual thinning cartilage, especially if they've had an injury at a young age.

'Most people don't have pain but there can be a point where the cartilage is a bit thinner and the bone underneath bruises – there are a lot of nerve fibres in bone and it's a very strong pain generator.'

What are the symptoms?

Pain at the ball and socket hip joint but some people experience no pain at all.

How should I treat it?

Recovery involves giving the bone some downtime and unloading. But a case of osteoarthritis in the hip doesn’t have to spell the end of your running career. 'Sometimes the hip is very stiff – it's a big joint and the ligaments are very strong. When they get stiff, it's very hard to change the range of movement in the joint, but you can change it by stretching and doing mobilisation work, especially after heat like a ho shower. If we can increase the range, we can increase the rotation and then the cartilage gets a much more even loading – you don't get a focused amount of load over one area – so often that helps.'

How can I prevent it?

Paton also recommends swapping out some of your longer or high-intensity runs for non-weight-bearing forms of cardio, like training on a rowing machine or exercise bike. He also recommends strength training as a great preventative exercise.

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