Pain around the hip and pelvis 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 that support and move the hip and pelvis.

Soft Tissues of the Lateral Hip Region (Side):

The muscles that sit around the side of the hip are called the hip abductor muscles (Figures 2.2 and 2.3). Their main functions are to move your leg out away from the midline of your body (abduction) and to anchor your pelvis to your femur when standing on one leg. This allows you to keep your pelvis fairly level and maintain your balance.

There are 3 main layers of hip abductor muscles:

1. Deepest layer–gluteus minimus (smallest muscle), which joins into the hip joint capsule and is thought to have an important role in supporting this joint. It runs from the outer side of the pelvis to its anchor-point on the femur (greater trochanter) (Figure2.2).
2. Middle layer–gluteus medius (middle sized muscle), which also joins the pelvis to the top of the femur (greater trochanter) and is one of the main muscles that helps control pelvic position (Figure2.2).
3. Superficial layer–the upper part of the gluteus maximus (largest gluteal muscle) and the tensor fascia lata (TFL) muscle.These muscles create their effect at the lateral hip through their connections to a long fibrous band that runs down the outside of the hip, thigh and knee, called the iliotibial band (ITB)(Figure2.3).

With all these muscles and their tendons moving over each other and the underlying bones, a number of small flat, fluid-filled cushions (bursae) are present, to help everything slide freely (Figure2.2). The main bursae are the trochanteric bursa, the subgluteus medius bursa and the subgluteus minimus bursa.

Lateral Hip Pain

Acute muscle tears or strains occur most frequently in the gluteus maximus and medius muscles and occasionally in the tensor fascia lata muscle (Figure 2.2 and 2.3). This is more likely to occur during rapid sidestepping or change of direction when running. Tears in these muscles are however relatively rare compared to thigh and groin strains.

Pain over the side of the hip that develops more gradually is most commonly related to the health of the soft tissues at the anchor-point for the gluteus medius and minus on the femur (the greater trochanter) (Figure2.2). You may receive a diagnosis of:

• Gluteal tendinopathy, tendinitis or tear-tendon pain, inflammation or a tear of one or more of the gluteal tendons
• Gluteus medius or minimus tendinopathy, tendinitis or tear-tendon pain, inflammation or a tear of the gluteus medius of minimus tendons
• Trochanteric bursitis, hip bursitis or even just bursitis–an irritated bursa
• Greater Trochanteric Pain Syndrome (GTPS)–a combination of some of the above.

You might like to read further about terms used for lateral hip pain in our blog.

Pain in this area is often attributed to tightness of the ITB and therefore you may read much advice to stretch the ITB as a self-help strategy.

There is however NO evidence to support stretching the ITB as a self-help strategy. In fact, expert Hip Pain Professionals agree that people with gluteal tendon or bursal problems are much more likely to be longer than average, rather than short in the ITB. Stretching may actually provoke the pain,rather than settle it (Figure 2.4).

Read more here on the high-quality scientific evidence that is now available on successful management of this condition (with NO ITB stretching!).

Seek the assistance of a Hip Pain Professional to:

• test if your hip abductors are short & tight or actually too long–many people who have poor control of their hip, especially in single leg weight bearing activities, actually drop their hip out too far, their muscles feeling tight as they work over time to try to provide support. Stretching will not help and may make things worse.
• work out if your hip abductors have any part to play in your problem and provide a plan for recovery

Your Hip Pain Professional can:

• test if your ITB or hip abductors are tight shortened) or not, and provide guidance as to whether stretching will help or aggravate the problem
• provide simple advice for controlling aggravating positions and actions that can immediately help you to start getting your pain under control
• provide or direct you towards a high-quality rehabilitation program that has been shown to be successful under rigorous scientific conditions
• Provide advice regarding the use of steroids or other injections in cases of severe pain or pain unresponsive to evidence-based rehabilitation

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 thigh (femur) or pelvis.

Bone Related Pain at the Lateral Hip

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

Bone Related Pain

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 around the hip and pelvis include a fracture of the neck of the femur (common in older women with osteoporosis), or fractures through the pelvis related to large traumas or where stress fractures have not been attended to early enough.

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

Stress fractures may occur in a number of sites around the hip and pelvis (Figure 3), most commonly the top of the thighbone (neck of the femur). This may result in pain in the lateral hip region.

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, for example, at the front of the pelvis

a) where the sartorius muscle joins to the ASIS (anterior superior iliac spine) or
b) where the rectus femoris muscle joins to the AIIS (anterior inferior iliac spine)

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 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 bio mechanical issues that may be contributing to bone-related pain, for example, running style may have an impact.

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 lumbar (lower back) 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).

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 lower thoracic (T11 & 12) and the upper lumbar vertebrae (L1-3) could, for some people, result in painful sensations across the side of the hip and pelvis region (Figure 4.2). The pain can also at times be felt into the leg and foot.

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 lateral 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.

It is also important to be aware that pain in some regions, particularly lateral hip and buttock pain, is often assumed to be back-related pain when the pain may be all or partly due to a problem of the hip. Again, you may spend valuable time and money getting unnecessary or incomplete treatment.

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

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 Lateral Hip Region (Side):

Nerves that supply the outer side of the hip and thigh (Figure 5.2) include:

• the ilioinguinal nerve
• the posterior branch of the iliohypogastric nerve
• the lateral femoral cutaneous nerve
• the gluteal nerves. The gluteal nerves don’t have a skin supply but can give a deep cramping feel in the buttock. They supply the gluteal muscles ability to function.

Nerve Related Pain/Neuralgia in the Lateral Hip Region

Irritation or damage to the ilioinguinal nerve may occur as it travels 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 nerve 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 this nerve. The symptoms are usually pain, with or without tingling or numbness in the area of nerve supply (Figure5.3). This and another nerve (the iliohypogastric) and the 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 lateral femoral cutaneous nerve may be compressed between the hip flexor muscles as it exits the pelvis just inside the bony point at the front of the hip (anterior superior iliac spine or ASIS). It may also be compressed by tight belt/jeans/trousers or a large abdomen sitting down over the front of the hip(which is also more likely during pregnancy).This nerve may also be stretched or damaged during an anterior approach Total Hip Replacement (where the scar is at the front of the hip). Symptoms developing after hip replacement surgery usually diminish or disappear over time. Symptoms present in the outer thigh region that the nerve supplies (Figure5.3) and are only sensory, with no impact on muscle function.

The gluteal nerves do not have a sensory supply to the skin, but gluteal neuralgia may be felt as a deep buttock pain, sometimes like a cramping feeling. These nerves provide important motor supply to the gluteal(buttock)muscles and the tensor fascia lata (TFL) muscle at the side of the hip. Damage to these nerves may alter your ability to stand on one leg, walk without a limp, climb stairs, and lift the leg out to the side or behind you. The nerves may be irritated or compressed as they pass out into the back of the pelvis and run through the soft tissues of the buttock. Very occasionally, these nerves may also be damaged by surgery, such as a posterior approach Total Hip Replacement (where the scar is at the back of the hip).

For Pain Related to Nerves/Neuralgia throughout the Hip, Pelvis, Buttock and Groin:

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 positions 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 maybe 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 diagrams provided in this section only provide an approximate guide of nerve supply in each 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, Oncologistor Vascular Specialist.

Lower abdominal and pelvic 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.