Hip pain is a common problem for distance runners. In this article, we’ll take a look at the most common causes of hip pain and injuries. We’ll show you how to prevent serious problems, how to know when it’s time to see a physio, and what you can do to live and run without hip pain.
How do I strengthen my hips for running?
All runners require strong hip musculature in order to enjoy injury-free and faster running. A lot of force goes through the hip muscles during running, and the hip muscles are some of the hardest working muscles in your body. Up to 3 x of your body weight is absorbed by your gluteus medius according to a study that looked at the loads on various muscles when running, so all runners require strong musculature around their hips to ensure they can run pain and injury-free.
There are several movements the hip joint does, which means there are multiple muscles we need to target when developing hip strength.
The gluteus maximus is a powerful hip muscle at the back of the hip. Its primary role is to extend the hip (when the runner’s leg is taken behind the body and propels the body forward). It also has the role of externally rotating the hip, and preventing the stance (landing) leg from collapsing inward when landing on that leg.
On the front of the hip, you have your hip flexors, including your psoas major and iliacus (combining together to make the iliopsoas muscle) and your rectus femoris, also known as the quadriceps (thigh) muscle. These muscles are important to be strong as they help you flex your hip, or move your hip up. Additionally, your rectus femoris helps extend/straighten your knee.
On the outside of your hip, there are many muscles that help stabilise the hip and control abduction and external rotation movements of the hip. The primary muscles which do this are the gluteus medius and minimus. These are also important muscles to be strong, as they help stabilise our pelvis and prevent our hips (and knees) from dropping inwards when on one leg.
You also have some groin muscles at the front of your hip/inside of your leg which also help stabilise the hip and pelvis. Injuries to these adductor muscles often present with groin path rather than hip pain so will be talked about in another blog, but can play an important role in preventing hip pain.
To strengthen the hip, you need to work the hip through all these movements to ensure all muscles are being used and strengthened. A combination of compound movements is best for this, such deadlifts and squats, as they target all these muscles in different ranges. Running is essentially made up of a series of hops, therefore single-leg exercises are just as important. Single leg exercises help with controlling and strengthening the hip and pelvis while in different positions.
There are many exercises to choose from, but our favourites are the single-leg raise, single leg bridge, lunges, Bulgarian split squats and single-leg deadlifts. Additionally, exercises such as the crab walk and fire hydrant exercises can help target and strengthen external rotators/hip abductors.
What are the signs and symptoms of a Hip Strain?
An irritated hip or hip strain can present in a variety of ways. You may experience pain at the front of the hip (a hip flexor strain), on the outside of the hip (hip abductors), or at the back of the hip (hip extensors). Hip pain can also refer to the groin, or down your leg. Strains usually occur after an acute onset or moment in time, they are not as common in the hip for runners but they can occur. If you experience pain after a moment in time, such as during a sprint or jump, and are unable to continue the activity, you may have experienced a hip strain.
If you are experiencing a hip strain, you may feel that you fatigue faster than usual and feel like you can’t run as fast or far. Typically if you have strained your hip flexor you may experience sharp pain with hip contraction (lifting your hip) or when your hip flexor is on stretch (extending your hip), as well as weakness and fatigue in the front of your hip.
It generally isn’t recommended that you perform hip flexor stretches in the first 72 hours after a hip flexor strain. This may interfere with the healing process as scar tissue is forming.
To help avoid running injuries, check out our previous post. Read on if you want to find more about specific hip injuries.
Runners hip pain diagnosis
Tendinopathy
If you experience pain at the start of the run, but it goes away after the first few minutes, meters or even kilometres and feels better as you run, and it’s worse the morning after your run, you may be experiencing tendinopathy in your hip. Tendinopathies are quite common in the hip, the most common being gluteal tendinopathy when you experience pain on the outside of your hip. However, you can also experience pain at the back of the hip (proximal hamstring tendinopathy), at the front of the hip (iliopsoas tendinopathy) and pain in both hips as well.
Bursitis
Bursitis is rarely the root cause of pain in your hip. Bursa’s are fluid-filled sacks that function as a gliding surface and help reduce friction between tissues in the body. Sometimes these bursal sacks can become irritated and inflamed, and the term ‘bursitis’ is often given by medical professionals. Trochanteric bursitis is the most common type of bursitis in the hip.
As the bursa lies in close proximity to other structures, such as muscles and tendons, it is often these structures that are the cause of the pain, rather than the bursa itself. Often by treating the surrounding muscles and tendons with a progressive strength program, we can get significant relief from your pain.
Femoroacetabular Impingement Syndrome (FAI)
Some people can experience a sharp, pinching, or deep aching pain in their hip. This pain is often referred to as ‘impingement’, or femoroacetabular impingement syndrome, which is a term used to describe an irritated hip joint. This sharp pain can be felt in the groin or front of the hip, outside of the hip, or feel like it is really deep in the hip joint. This can feel like a sharp pain during your run, at the start of your run, or after your run after you have cooled down. It can be aggravated by certain positions, such as crossing your legs, flexing your hip, squatting or bending down.
These symptoms are rarely serious and can improve quickly with load modification, targeted strengthening exercises and physiotherapy treatment. It was previously thought that bony differences in your hip bones, called a CAM or PINCER morphology, contributed to these symptoms. However, a recent study found that 47% of the UK population had a CAM morphology but did not have any symptoms!
Labral Tear
The labrum is the cartilage that surrounds your hip joint. It is not uncommon for you to get a tear in your labrum, and non-surgical management is the preferred treatment method majority of the time. In the active athletic population, a study showed that up to 54% of people have a labral tear without showing any symptoms.
If you are experiencing a symptomatic labral tear, you may get a sharp pain deep within your hip point, some clicking, locking or feeling of instability in your hip. You may have reduced range of motion, and experience a deep dull ache when resting. This pain will often present deep within your hip, on the outside of your hip or deep within your buttock, however, it can also refer to the groin.
Referral from the low back
Hip pain can also stem from your low back. Sometimes, the nerves in your back can get irritated and sensitive, which can refer pain down to your hip, groin and leg. If you have pain in your back, as well as your hip or leg, then it is possible that the pain is coming from your lower back. Pain can even travel down to your lateral knee, and mimic knee issues such as IT band syndrome or patellofemoral joint pain. This can be quite common and is usually not serious. The aggravating movements when pain is coming from your low back can vary from person to person, however, sustained sitting, standing for long periods, bending forwards or backwards can increase your hip or back pain. To learn more about how training your hip muscles can help your low back and vice-versa, check out this article.
Stress Fractures
There are a few injuries that are rare but we need to look out for with runners as they can be quite serious. One of these is a stress fracture in your hip, in your femur or pelvic bone. A stress fracture is a complete or incomplete fracture of the bone from repetitive mechanical stress. Unlike normal fractures, stress fractures develop over time due to an accumulation of repetitive load. Typically they will begin as a stress response, then gradually progress into a stress fracture if not treated with sufficient rest for the bone to adapt and heal. They usually present after a recent increase in training load or intensity, will begin with an insidious onset and get worse with activity. Stress fractures will need a period of rest from running to help the bone heal.
For information about Osteoarthritis of the hip joint, read this article here.
Causes of Hip Pain While Running
All of the aforementioned hip issues can cause pain while running. Stress fractures tend to worsen as the run continues, whilst tendinopathies have what is called a ‘warm up’ pattern, where they can improve as the run continues.
Causes of Hip Pain after Running
Pain that continues for hours after a run is completed, indicates that there is more of an inflammatory process occurring in your body, e.g. bursitis. If the pain stops straight after you stop running, that indicates a more mechanical source of pain, e.g. referral from your lower back.
Hip Pain Running Treatment
Depending on the issue, there are numerous ways to treat these conditions. Firstly it is important to reduce pain and improve movement, then move on to strength and conditioning once things have settled.
Some small changes in your running style can assist in reducing symptoms and injury, such as increasing your cadence while running, reducing your stride length or looking at other factors with your running gait which may be contributing to your pain.
Load Management
Often running injuries are caused when there has been a ‘training error’. This is a broad term used to describe mistakes and errors that a runner may make when training. Some common training errors are when a runner increases their running, either distance or speed, too suddenly, which increases their training load. Another mistake some runners make is doing too much in general and not having enough rest for their body to recover in between sessions, resulting in too much volume.
In terms of managing your load, we need to find a load that is tolerable for you without worsening your symptoms. Sometimes a period of total rest from running is required to help settle symptoms, however, usually, you can continue training at some level without worsening your injury. This varies depending on the injury, severity and irritability of your injury. As a general rule, if you experience less than 4-5/10 pain with exercise, your pain is tolerable to you and is settling back to baseline within 24hrs, you can continue training.
It’s not uncommon for runners to report that both their knees and hips hurt after running, if they’re doing too much too soon.
Strength training
Running is demanding on the body – the gluteal muscles are exposed to loads of up to 3 x bodyweight, the quadriceps 6 x bodyweight, and calves 8 x bodyweight according to this study. There is a strong body of evidence to support strength training for runners. Not only can strength training help with current injuries, but strength training can also reduce injury risk by up to 50%, improve running speed and efficiency, improve VO2 max, and improve time to fatigue according to these studies here and here.
Systematic reviews have illustrated that a well planned structured program incorporating resistance and plyometric exercises performed 2-3 times per week is enough to improve running efficiency in runners, whilst reducing your risk of developing an injury by half.
Rest, Sleep and Recovery
It is underestimated how important rest and recovery is when training. Training produces a stress effect on the body’s structures, which essentially places microdamage on our tissues. Periods of rest are used to repair and regenerate these tissues, which leads to building the resilience and strength of these tissues. If training and rest become unbalanced, and your tissues are not given enough time to recover, performance deficits and injuries occur.
A study that looked at the link between the number of rest days and injury risk found that those who had less than 2 rest days per week had a 2.5x risk of overuse injuries, and people training more than 13.5 hours per week had a 2.1x risk factor of developing an injury compared to others.
Prioritising rest days, adequate nutrition, hydration and sleep will all assist with recovery and prevent injury!
For more tips on how to improve your running performance and reduce your injury risk, see this article here.
Hip Pain Exercises
Exercises that target the hip muscles are vital for recovering from the majority of running-related and sports injury hip issues. Check out some of our go-to hip exercises demonstrated below:
For an expert opinion on the next steps for you, or to chat to an expert running physiotherapist, don’t hesitate to reach out by calling the clinic on 8490 0777 or send us an email at admin@thrivephysioplus.com.au
If you’re ready to get started on the right path, you can book online here.
Frequently Asked Questions
Is it OK to run with hip pain?
If your pain is tolerable during your run (i.e. less than a 4-5/10 intensity) and your symptoms return back to baseline within 24 hours after your run, it is generally speaking ok to continue running at that amount.
How do I know if my hip pain is serious?
Your hip pain may be serious if you’re experiencing constant, unrelenting pain and doesn’t settle within a day or two.
Where is hip flexor pain felt?
Hip flexor pain is felt where the hip flexors are located at the front of the hip.
Written by our running physio Heyson Hinge
