Pain in the front of the hip may also be related to soft tissues (Figure 2.1). Soft tissues are non-bony structures that connect, support, or surround other structures and include:

• the muscles, which allow you to move
• the tendons, which connect your muscles to the bone
• the bursae – small, flat pockets of fluid that help all these things slide and glide against one another, reducing friction. There are bursae are all around the body in places where different structures may rub against one another, for example where a tendon runs around a bone.
• the fascia – stretchy, thin, white fibrous tissue. All our muscles are enveloped in fascia, like stretchy stockings that help transfer energy from muscle and movement. Fascia also forms sheaths or tunnels for safe passage of blood vessels and nerves and wraps and supports all our bodily organs.

There are many muscles located in this region that support and move the hip. The muscles that sit at the front of the hip are called the hip flexors (Figure 2.2) and act to lift your knee towards your chest (flexion). The main hip flexor, the iliopsoas muscle is made up of two parts – the psoas muscle that starts at the lumbar spine, and the iliacus that starts from the inside of the pelvis. They come together in the pelvis and run forwards over the front of the pelvis, deep across the front of the hip and join onto the upper thigh bone (femur). The iliopsoas muscle provides important support for the front of the hip joint, the sacroiliac joint of the pelvis and the lower back (lumbar spine). It is also a powerhouse for moving your legs forward in walking, running and stairclimbing.

A number of other longer, more superficial (closer to the surface) hip flexor muscles run from the pelvis and down into the thigh and connect below the knee – the Sartorius, Rectus Femoris and Tensor Fascia Lata (TFL) muscles (Figure 2.3). These muscles help the iliopsoas muscle with lifting the thigh, but their effect also extends across the knee.

Hip Flexor or Iliopsoas Related Pain

Tears or strains may occur within the hip flexor muscles; where the muscles and tendons join (musculotendinous junction); or within the tendons. Traumatic injury resulting in rapid onset of pain is usually associated with sporting actions such as:

• kicking
• sprinting, particularly rapid acceleration
• changing direction at speed.

Changes in tendon health often evolve more slowly, related to your body’s natural make-up (e.g. bony shape, hypermobility) or postural, movement or athletic training habits.

The iliopsoas tendon that joins the iliopsoas muscle to the femur (thigh bone) sits deep at the front of the hip and is separated from the hip joint by a large bursa (iliopectineal or iliopsoas bursa). This bursa reduces friction and helps the tendon slide freely across the front of the hip. The tendon and/or the bursa may become involved and you may receive a diagnosis of:

• iliopsoas tendinopathy – a painful iliopsoas tendon
• anterior snapping hip – snapping of the iliopsoas tendon which can sometimes become painful
• iliopsoas bursitis – inflammation or thickening of the iliopsoas bursa
• iliopsoas impingement – impingement or compression of the iliopsoas tendon against the underlying bone

The hip flexors muscles, and particularly the iliopsoas muscle, have become incorrectly demonised in the popular media for being the source of many problems. These are generally thought to be related to the muscles becoming overly active and tight. There is unfortunately much misinformation on the internet regarding the hip flexors and poor advice regarding management of true hip flexor issues.

Many people are stretching the hip flexors and placing high loads on the front of the hip unnecessarily, often worsening their problem.

Your Hip Pain Professional can:

• assess the hip flexors and decide whether stretching will help or aggravate the problem
• provide important advice about sporting activities, for example:
  • advice re how much is too much
  • allowing adequate recovery between sessions
  • temporary reduction in activity levels may be required
  • rest from particular actions that place highest load across the hip flexors and pelvis
• provide or send you for rehabilitation to optimise function of these muscles

Although relatively more rare than soft tissue or joint problems, bony problems such as a fracture, stress fracture or very rarely, infection or tumour within the bone may cause hip and pelvic pain. In growing children or adolescents, pain may be related to disorders of the growth plates of the femurs or pelvis.

Bone Related Pain in the Front of the Hip

The most likely bone-related issues associated with pain in the anterior hip region, are fractures or stress fractures of the femur or pelvis (pubic ramus), or apophysitis or avulsion fracture of the growth plates at the front of the pelvis (ASIS & AIIS) (Figure 3).  

Bone related pain may be due to:

• Fracture
• Stress fracture
• Avulsion fracture
• Apophysitis

A fracture:

• is the medical term for a broken bone
• usually occurs from a traumatic event like a fall, car accident or more severe sporting injury
• is more likely to occur in a weakened bone e.g. osteoporosis or genetic diseases like osteogenesis imperfecta

The most common fractures associated with anterior hip pain include a fracture of the neck of the femur (common in older women with osteoporosis) or fractures through the pelvis or the main shaft of the femur related to large trauma.

A stress fracture:

• is the medical term used for a fracture that occurs due to a build-up of repetitive stress
• is usually related to overuse -an accumulation of repeated small traumas e.g. long-distance running
• is more likely to occur with rapid increases in athletic training volume and/or inadequate recovery time
• starts as localised swelling in the area of bone exposed to highest stress (you won’t see this at skin level as it is just within the bone)–this may be called a stress reaction or bony stress response
• may progress to full fracture if you don’t rest

An avulsion fracture:

• is where a small piece of bone is pulled away from the main part of the bone 
• may occur in adults where a large force across a ligament (joins bone – bone) or tendon (joins muscle to bone), causes a small piece of bone to come away with the ligament or tendon 
• may occur in children at the bony growth plates (read more in the next section) 

Apophysitis: 

• usually referred to as ‘growing pains’
• occurs in adolescents
• is due to long bones such as the femur growing more quickly than the muscles, which then tug on the growth zones in the immature pelvis
• most commonly occurs at sites where some of the large muscles attach at the front of the pelvis (Figure 3):
  • where the sartorius muscle joins to the ASIS (anterior superior iliac  spine).
  • where the rectus femoris muscle joins to the AIIS (anterior inferior iliac spine).

You can visit the “Soft Tissue Related Pain” tab to view these muscles.

The pain of apophysitis is related to an inflammation of the bony growth centres where these muscles attach.  Pain is generally experienced locally at the area of muscle attachment but can radiate around the area as well.

Other growth-related bony issues:

• Perthes disease or Legg-Calvé-Perthes Disease – is misshaping of the femoral head related to issues with blood flow to the bone. Most common during ages 4-10 years.
• Slipped Capital Femoral Epiphysis or Slipped Upper Femoral Epiphysis-usually a small shift in the growth plate in the neck of the femur that can change the shape of the head and neck of the femur. Most common during ages 8-15 years.

Pain related to the bones could also be felt anywhere around the hip or pelvis region depending on the bone affected and the cause of the bone pain. Click on our Pain Locator Map to review the areas you feel pain and learn more about the bones that may be related to pain in each area.

Your Hip Pain Professional can:

• perform a thorough assessment and let you know if a bone issue may be suspected. In these cases, you may be advised to undertake further imaging or referral to a medical specialist for further advice
• provide or refer you for rehabilitation at an appropriate time following bony injury
• provide important information about managing sporting activity and recovery in those with bony stress injuries or adolescents with bony ‘growing pains’
• address muscular or biomechanical issues that may be contributing to bone-related pain, for example, running style may have an impact.

Pain experienced around the anterior hip (front) 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 lumbar (lower back) discs or joints, 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 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. Referred nerve pain in the front of the hip is usually from higher levels (T12 & L1-3) – within the dashed box on the body chart.   

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 the front of 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 problem and if you have more than one area contributing to the problem
• develop a comprehensive plan to help the problem – If your pain is lumbar-referred or radicular, you may need treatment on your back and not your hip or if you have two problem areas, both will need to be addressed within a comprehensive management plan
• recommend further tests or refer you to another specialist if the problem does not appear to be in 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

In viewing the individual nerves that may be contributing to your anterior hip pain, be aware that some nerves may cross through and supply more than one region.  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 Anterior Hip and Groin Regions:

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

• the iliohypogastric nerve
• the ilioinguinal nerve
• the genitofemoral nerve
• the obturator nerve
• the femoral nerve: the anterior femoral cutaneous nerve

Nerve Related Pain/Neuralgia in the Anterior Hip & Groin Regions

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.

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.

For Pain Related to Nerves/Neuralgia of the Anterior Hip:

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 have been performing that may be contributing to the irritation 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 if required.   
• In some cases, 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. 

There are other processes that may produce pain around the hip and pelvis.

These include:

• Systemic/Rheumatological conditions: eg Rheumatoid Arthritis, Polymyalgia, Polyarthralgia
• Infective processes: Septic arthritis, Osteomyelitis, Viral Arthritis
• Neoplastic processes (cancer)
• Vascular issues: Avascular Necrosis, External Iliac Artery Entrapment, varicotic gluteal vessels compressing the sciatic nerve

These conditions are relatively rare compared to musculoskeletal pain, but when present you will need to see a medical practitioner and usually a specialist for that system or problem, for example, a Rheumatologist, Orthopaedic Specialist, Oncologist, Vascular Specialist.  

Anterior Hip pain can also be associated with organ problems (ovaries, uterus, bowel, bladder, prostate). One of the most common causes of organ-related pain in females is endometriosis. This occurs when tissue that is similar to the lining of the uterus (womb) grows outside the uterus attaching to other structures such as the pelvic ligaments or the bladder and bowel. This can lead to debilitating pain that may be cyclic, relating to the menstrual cycle. Diagnosis and management of organ related problems will usually require the assistance of a specialist, for example a gynaecologist (female reproductive organs), urologist (bladder and prostate) or gastroenterologist (gut/bowel). 

A skilled assessment by a Hip Pain Professional will help clarify if the problem requires further medical attention and whether it is likely to be related to a musculoskeletal problem or not. 

Your Hip Pain Professional can:

• provide a detailed assessment
• assist in determining if the problem is musculoskeletal or not
• develop a plan to help if the problem is musculoskeletal
• recommend further tests or send you to another specialist if the problem does not appear to be in the musculoskeletal system.