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.