Hip Pain Explained

Hip Pain Explained will teach you about the anatomy of the hips and pelvic area and how many different types of body tissues interact.  Each of these tissues is discussed in the tabs listed below: joint, soft tissue, bone, back referred, peripheral nerve and other.  It is the interaction of these structures with the central nervous system and brain that result in the feeling of pain.

What is Pain?

Pain is an experience that the brain creates for the purposes of stimulating you to change your behaviour or seek help for a perceived problem with your body. Irritating or potentially damaging stimuli in your body (like high levels of pressure, tension or extremes of temperature) activate sense receptors (danger sensors) in the area. Signals from danger sensors in the body travel through the nervous system to the brain. Here the information is processed and the brain sometimes (but not always) produces a pain experience.

These danger sensors send warning signals to your brain, and your brain then decides whether the signals are dangerous to your health. Your brain uses lots of other stored and real-time information to make this decision, for example:

  • whether you have had an injury to this area before
  • whether you know someone who has had problematic pain or injury in this area
  • whether an injury in this area is likely to impact substantially on your life (ability to work, play sport, stay healthy, interact with family and friends)
  • what you have read or watched about the problem
  • what others have said about the problem (friends, relatives, health professionals)
  • if you are unwell with a cold or flu
  • if you haven’t slept well
  • if you are having a good or bad day
  • if it’s raining or sunny, you are surrounded by harsh noise or calming music, pungent or pleasant smells...

After much scientific study, we now know that pain is not as simple as we once thought. It has been clearly demonstrated many times that:

degree of pain ≠ degree of damage.

Pain is rather a reflection of how dangerous the brain perceives the situation to be and how important it thinks it is for you to do something about it, based on subconscious considerations. The brain truly is amazing!

Persistent or cumulative signals from the danger sensors in your body, will usually trigger a pain experience, but at varying levels for each individual. Danger signals may come from many different structures around the hip and pelvis. The guide below serves as an introduction to these structures.

Pain experienced in the hip, groin and pelvic region may be related to:

  • the joints of the hip & pelvis – hip joint, sacro-iliac joints, pubic symphysis
  • the soft tissues – muscles, tendons, bursae & fascia
  • bones – the femur (thigh bone) or bones of the pelvis
  • local nerves running through and around the hip & pelvis
  • musculoskeletal problems elsewhere in the body, such as the lower back (referred pain)
  • problems with organs, other body systems or health issues masquerading as hip pain
Joint Related

Joint-Related Pain


A joint is formed where two bones are joined together, with varying amounts of movement occurring between them. Pain may be related to the structures involved in the function and support of a joint. The hip joint is the joint most commonly related to pain at the front of the hip (Figure 1.1).

  • The hip joint is the largest ball and socket joint in the body. The ‘ball’ is the head of the femur (thigh bone). The socket in the pelvis, is called the acetabulum (Figure 1.2).
  • Both the ball and socket are lined with smooth cartilage which allows the bones to slide against each other easily (Figure 1.2).
  • The smooth cartilage lining the socket merges into a fringe of more fibrous cartilage that joins around the edge of the bony socket. This is called the labrum (acetabular labrum) (Figure 1.2). It has a variety of functions, assisting in joint stability and health. The labrum makes the joint deeper and hugs firmly around the head of the femur, providing a suction effect. Both of these features contribute to joint stability. The labrum is also involved in the flow of nutrient-rich joint fluid and trapping fluid between the bones when you land on your foot in walking and running. This provides a cushioning effect for your cartilage and helps maintain joint health.
  • The ball and socket joint is surrounded by a fibrous capsule, reinforced by a number of ligaments that run between the pelvis and femur (Figure 1.3). These strong ligaments provide stability for the joint but are also flexible, allowing your hip to move in large ranges of motion. There is a large normal variation in how flexible these ligaments are in different people. 

Pain Related to the Hip Joint

Changes in joint health:

  • may occur in association with some conditions such as:
    • hip osteoarthritis
    • femoroacetabular impingement syndrome (FAIS)
    • acetabular dysplasia
    • hip instability
    • childhood developmental issues of the hip (Congenital dislocation of the hip, Perthes Disease, Slipped Upper Capital Femoral Epiphysis)
  • DO NOT ALWAYS RESULT IN PAIN (Some level of wear or injury to tissues within the joint is so common in adults, it is thought to be ‘normal’. Identification of changes in joint health on XRays or scans is therefore not considered meaningful unless related to pain or other symptoms) 
  • are poorly correlated with level of pain
  • most often become painful with one or more of the following factors:
    • too much or too little activity
    • rapid changes in activity levels
    • activities that put large forces across the hip joint (e.g. stretching too far or landing heavily)
    • certain sustained or repetitive postures or movement habits that create small changes that add up over time
    • high body weight
    • other general health factors

Pain related to the hip joint is most commonly experienced at the front of the hip (anterior hip), but may also be felt in the groin, side of the hip (lateral hip) or deep in the buttock. Other things may also cause pain in these areas, so visit our Pain Locator Map to read about different things that may be related to pain in each of these regions. 


After a thorough assessment, your Hip Pain Professional will be able to:

  • tell you whether the hip joint and changes on any XRays or scans, are likely to be related to your pain.
  • assess for factors that could be contributing to the problem
  • set a plan to help you:
    • reduce your pain
    • improve your ability to do everyday activities involved with work and the household
    • return to sport or modified activity
    • look after your hip joints for the long term, such as through targeted exercise and education around positions, stretches, exercises or activities that may not be ideal for your joint
    • refer you for further investigation if required
    • provide or refer you for further medical intervention, if appropriate (injections, surgical opinion)

The Pubic Symphysis

The pubic symphysis (Figure 1.5) is the joint where each half of the pelvis joins at the front of the body. The word ͚symphysis simply means – a place where two bones are closely joined. This joint is a flat or plane joint, that includes:

  • a fibrous disc that sits between the pubic bones, working as a shock absorber
  • four strong ligaments that support the joint

Only very small movements occur at this joint. For example, some rotation occurs during walking, as one side of the pelvis moves slightly forward and the other slightly back, following the movement of the legs.

Pain Related to the Pubic Symphysis

Pubic Symphysis pain is most commonly associated with injury or excess strain due to:

  • a major trauma, such as a fall into the splits or a direct impact to the pubic region
  • increased stretchiness of the joint ligaments during pregnancy – this is a normal response to hormone changes in preparation for childbirth
  • trauma during childbirth – breech delivery, forceps/vacuum delivery
  • a gradual build-up of joint stress, such as repetitive movements where the legs move far apart, as may occur in certain sports
  • large repetitive forces created by the surrounding muscles, particularly the inner thigh muscles. This is most common in field or court sports that involve changing direction at high speed or kicking.

Pain related to the pubic symphysis is most commonly experienced in the groin region and/or directly over the joint. Groin pain that occurs over the pubic symphysis is referred to as Pubic Related Groin Pain. Other problems may also cause pain in the groin region, so visit our Pain Locator Map to read about different things that may be related to pain here.

Your Hip Pain Professional will assess your pubic pain and examine all the contributing factors. Advice and management approach will be determined by each individuals contributing factors – for example, previous trauma, pregnancy, level of conditioning and athletic involvement.

After a thorough assessment, a Hip Pain Professional  will be able to tell you whether changes on your XRays or scans are likely to be related to your pain and what factors could be contributing to the problem. They will also set a plan to help you:

  • reduce your pain
  • improve your ability to do everyday activities involved with work and the household
  • return to sport or modified activity
  • look after your hip joints for the long term.


The Sacroiliac Joints

The sacroiliac joints (sometimes abbreviated to SIJs or SI joints) are the joints formed between the two bony wings of the pelvis and the tailbone (sacrum) (Figure 1.6).

  • These joints are designed for stability with extremely little movement capacity. They are flat or plane joints though the surfaces of the joint are not completely flat. They are irregular or bumpy to allow some interlocking of the bones for the stability they need.
  • They are also surrounded by some of the strongest ligaments in the body. This stable joint structure allows transfer of large forces between the body and the legs during walking, running and jumping.
  • Some movement occurs in these joints during walking and running, where one leg is moving forward and the other backward, resulting in a small amount of joint rotation.
  • Movement at the sacroiliac joints will also occur during extremes of hip or back motion, although most scientists agree that the amount of movement that occurs at the sacroiliac joints is very small.

Pain Related to the Sacroiliac Joint

Pain and functional difficulties related to the sacroiliac joint:

  • most commonly develop during pregnancy or childbirth
  • may occur after a major trauma, such as a hard fall onto the bottom or a large force through one leg, for example being dragged by one leg after a fall from a horse or water-skis.
  • may develop over time, related to certain types of repetitive forces.
  • can develop when there is a problem with the lower back or hip joints, transferring extra load across the sacroiliac joint.

Sacroiliac pain and dysfunction are however, greatly over-diagnosed. While true instability does occur, it is relatively rare and there are many people living unnecessarily in fear, related to a diagnosis of pelvic instability or being told their pelvis keeps moving out of place.

Here are a few facts about the sacroiliac joint that may dispel some of this fear:

  • The structure of the sacroiliac joint makes it a very stable joint
  • Asymmetry in the human body is normal
    • Differences in tightness of the muscles that join on to either side of the pelvis occur naturally, related to leg or arm dominance, sport and occupation. This asymmetry may cause an appearance of asymmetry in the resting position and movement of the pelvis. This is normal and has not been linked to harm.
    • Differences in leg length of up to around 1cm are common and normal. Leg length difference may also produce an appearance of asymmetry in pelvic position in standing.
  • A click occurring in a joint does not mean it has moved ͚in or out of position. All of us click and pop, some just a little more than others. These are usually normal joint or tendon sounds.

There are also causes for sacroiliac joint pain that are related to other general health conditions. Sacroiliitis refers to an inflammation of the sacroiliac joints associated with a systemic inflammatory disease such as Ankylosing Spondylitis. You can read more about non-musculoskeletal causes of hip and pelvic pain here.

Pain related to the sacroiliac joints is most commonly experienced in the upper buttock region, usually right over the joint, in the area of the dimples at the top of the buttocks. As the pelvis is a ring joined at the front by the pubic symphysis, problems with the sacroiliac joints are sometimes associated with pain in the groin region. There are many other causes for groin pain however, so visit our Pain Locator Map to read about different factors that may be related to pain in each of these regions.

Your Hip Pain Professional will be able to assess your sacroiliac joints to determine if they are likely to be the cause of your pain. If you have sacroiliac joint related pain, you may require:

  • advice on modifications to activities or positions – e.g. workplace set-up
  • an exercise program to provide optimal muscle support around the joints
  • advice regarding short term bracing or taping – only appropriate for short term use and usually only for severe pain and during late stage pregnancy or after trauma
  • an injection for short term relief of severe pain, while you work on your rehabilitation

The Sacrococcygeal Joint

  • The sacrococcygeal joint is the joint in the tailbone formed between the sacrum and the coccyx (Figure 1.7).
  • The coccyx is a small triangular shaped bone made up of 3-5 fused segments. Many ligaments attach to the coccyx helping to provide stability and support for the pelvis, its muscles and contents.

Pain related to the Sacrococcygeal Joint – Coccydynia

Pain relating to the coccyx and sacrococcygeal joint is known as coccydynia (pronounced cox-y-dynia). A sudden onset of coccygeal pain is usually associated with trauma, externally such as from a fall backwards onto the bone, or internally such as in childbirth. Onset can also be gradual, commonly related to sustained pressure from sitting or local muscle forces.

Factors associated with an increased risk of developing coccydynia are:

  • being overweight
  • being female – women are 5 times more likely to develop the condition
  • increased flexibility or mobility of the joint (hypermobility)
  • reduced flexibility or stiffness of the joint (hypomobility)
  • variants of coccyx shape
  • pelvic floor muscle weakness or overactivity
  • other general health factors (see other causes section): These must be ruled out.

Your Hip Pain Professional can reduce your pain associated with coccydynia by addressing factors such as:

  • excessive weight bearing on the coccyx due to seating or habitual sitting postures
  • weakness, spasm or altered activity in the muscles that attach to the coccyx including the gluteus maximus (buttock) and pelvic floor muscles (see the soft tissue section)
  • altered stress and strain on the structures that attach to the coccyx which may have occurred after trauma or as a gradual build up over time.
  • providing or referring you for a pain-relieving injection into the area or in very rare cases, to a surgeon.
Soft Tissue Related
Bone Related
Back Related
Peripheral Nerve
Other causes

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