Pain experienced around the hip and pelvis sometimes has nothing to do with problems in this area.

Problems in the lower back can result in back pain and/or pain through the hips and down into the legs. There are two main ways this might occur:

Referred pain

Referred pain is pain felt in a part of the body other than its actual source. For example, if there is a problem in the lower back (lumbar or sacral spine) discs or joints (L3-S1), small nerve endings serving these structures generate ‘danger’ messages that are transmitted along small nerve fibres into the spinal cord.

However, this area of the spinal cord also receives information from structures in the hip and pelvis.The brain is unable to distinguish where the information came from, (the back, the hip or the pelvis) so you might feel pain in any one or a combination of these areas (Figure 4.1).

Referred pain:

• is usually a dull, aching or gnawing pain
• can expand into a wide area that is difficult to localize
• is not related to a problem of the nerve roots in the spine
• is not associated with other nerve-related symptoms such as tingling or numbness

Radicular Pain

Radicular pain is pain associated with irritation of the nerve roots as they exit the spine. Most commonly this is associated with inflammation or compression from the nearby disc. The nerve roots that exit at each level of the spine give rise to sensation indifferent areas of the skin, called dermatomes (Figure 4.2).

The nerve roots that exit at each level of the spine give rise to sensation in different areas of the skin, called dermatomes (Figure 4.2). When a nerve root is irritated at the spine, pain may be felt in the area of skin that the nerve root supplies. For example, compression of the nerve roots that exit between the upper lumbar vertebrae (L1 & 2) could, for some people, result in painful sensations across the groin region (Figure 4.2).

Radicular pain:

• is related to a problem of the nerve roots in the spine
• is usually accompanied by stabbing or shooting pains
• is usually easier to localise than referred pain
• may also be associated with an additional or background, deep, dull ache
• may be accompanied by other nerve related symptoms such as tingling, itching, burning or numbness

If the pain in your hip is due to a problem in the back, you can spend valuable time and money getting unnecessary treatment on the wrong area and this might delay an important diagnosis and your recovery.

Your Hip Pain Professional can:

• provide a skilled assessment
• help figure out the actual source of the symptoms and if you have more than one area contributing to those symptoms
• develop a comprehensive plan–If your pain is lumbar-referred or radicular, you may need treatment on your back and not your hip or if you have two areas contributing to your symptoms, both will need to be addressed within a comprehensive management plan
• recommend further tests or refer you to another specialist if the condition does not appear to be related to the musculoskeletal system.

The nervous system (Figure 5.1) is a complex network of nerves and cells that carry messages between the brain and spinal cord and your body. It is through this system that we feel, move and control our bodily functions.

Nerve roots leave the spinal cord via the intervertebral foramina (holes or spaces between the vertebrae) and join together from various levels of the spine to travel as cord-like structures, called nerves, to their destinations.

It is these nerves that travel outside the spinal cord that are referred to as “peripheral nerves”.

Some peripheral nerves travel only a short distance and others all the way from the lower back to the foot. Along their journey they run between and through muscles and fibrous tunnels.

While radicular pain arises from a problem as the nerve root exits the spine, nerve-related pain may develop due to a problem along the pathway of a peripheral nerve, outside the spine. Pain related to a nerve is called “Neuralgia”.

Neuralgia felt around the hip and pelvis may develop in many ways including excessive compression or stretch of the nerve. This may be caused by a sudden, acute mechanism, for example a fall or blow to the area resulting in compression, or the leg being caught and wrenched, resulting in stretch.

Alternatively, the onset may be subtle, with a gradual onset associated with sustained postures or repetitive movements that cause cumulative nerve irritation.

Nerves will also be influenced by the health of the tissues they run through or alongside. For example, high muscle tension or tendinopathy may over time result in irritation of neighbouring nerves.  Nerve related symptoms are usually experienced differently from pain associated with muscle and joint problems.

Peripheral nerve irritability may result in:

• symptoms in the area served by that peripheral nerve (which is different from dermatomal patterns associated with nerve root irritation -radicular pain)
• burning pain
• odd zings or zaps of pain
• tingly sensations or numbness
• weakness – only for those nerves that supply muscles, like the femoral nerve

Be aware that some nerves may cross through and supply more than one region around the hip and pelvis. Additionally, some areas of skin may have several nerves that serve the area. This sometimes makes accurate diagnosis tricky. Your hip pain professional will help to identify the cause of your pain.

Nerves of the Groin Region:

Nerves that supply the front to inside of the hip, groin and thigh (Figure 5.2) include:

• the iliohypogastric nerve
• the ilioinguinal nerve
• the obturator nerve
• the anterior femoral cutaneous nerve (a branch of the femoral nerve)

Nerve Related Pain/Neuralgia in the Groin Region

Irritation or damage to the ilioinguinal, iliohypogastric and genitofemoral nerves may occur as they travel through the muscles of the back and abdomen. Most commonly, symptoms may arise following some sort of abdominal or groin surgery, such as hernia repair.

The nerves may be damaged at the time of surgery or become entrapped in the scar tissue or mesh used for hernia repair. Endometriosis may also sometimes affect these nerves.

The symptoms are usually pain, with or without tingling or numbness in the area of nerve supply (Figure 5.3). The iliohypogastric and ilioinguinal nerves also provide some motor supply (the ability to make the muscles contract and work) to the abdominal muscles, so there may be some weakness of the abdominals experienced in conjunction with the nerve irritation.

The obturator nerve runs through the pelvic cavity and may be affected by pregnancy or pelvic surgery, as it exits the pelvis through a tunnel called the obturator canal, or as it runs between some of the deep muscles (the obturator externus & pectineus).

People with obturator neuralgia may experience pain, tingling or numbness in its area of skin supply (Figure 5.3) and may experience some weakness of the adductor (inner thigh) muscles it supplies.

The symptoms are often only felt during/after activity when the nerve has been compressed between contracting muscles.

Neuralgia of the femoral nerve is not very common, but may develop following pelvic surgery (gynaecological, prostate, bladder surgery), hip surgery or sometimes associated with problems of the adjacent soft tissue structures (psoas bursa or iliopsoasmuscle and tendon).

Femoral nerve related symptoms may be felt in the front of the thigh (in the region of the anterior femoral nerve branches that serve the skin) (Figure 5.3).

Sometimes symptoms may also be felt over the inner surface of the calf and shin (served by another branch of the femoral nerve called the saphenous nerve).

If the femoral nerve is more severely affected, muscle weakness may occur in the hip flexors (muscles at the front of the hip that lift the thigh) and the quadriceps (muscles at the front of the thigh that straighten the knee).

For Pain Related to the Nerves/Neuralgia of the Groin Region

Your Hip Pain Professional can:

• Perform specific tests in the clinic to see if nerve involvement is likely
• Provide treatments and give you exercises that may improve the health or movement of the nerve
• Help improve health of the muscles and tendons beside the nerve (this may be the source of nerve irritation)
• Review the position you spend time in and activities you perform daily and provide strategies when performing these tasks that might help protect the nerve, thus reducing your symptoms.  This may include changing your sitting or lying posture, or changing stretches or strength exercises that you may have been performing that may be contributing to the irritation of the nerve.
• Provide nerve gliding or mobility exercises that can be useful in some situations.
• Refer you for further tests or to a neurologist, orthopaedic specialist or other pain specialist required.
• In some case, your hip pain professional may refer you to a pelvic floor physio for further assessment should they consider the pelvic floor muscles are involved.

*Please note: Nerve supply can overlap and be quite variable between individuals.  The diagram provided in this section provides an approximate guide only of the nerve supply in this region.