Below is a list of potential causes of hip pain:

• Arthritis
• Hip impingement syndrome
• Labral tears
• Fractures
• Muscle injury or bursitis
• Referral from the lumbar spine or pelvis
  
  Other Causes of Hip Pain In Children & Adolescents:
• Legg-Calve-Perthes disease: This occurs due to an impaired blood flow to the hip and occurs most commonly in children between 2-15 years of age
• Slipped femoral epiphysis: this is a slippage of the top part of the head of the hip bone. It is common in adolescence and can cause groin or knee pain.

Anatomy of the Hip Joint

The hip is a ball and socket joint similar to the shoulder joint. The head of the thigh bone (femur) sits into the socket of the pelvis. 

In addition the muscles and ligaments that cross the joint from all sides also add to the stability and strength of the joint. Overuse injury usually occurs due to repetitive micro-trauma to the joint and surrounding tissues. 

What Causes Hip Pain?

Pain in the hip region can arise from the soft tissue structures surrounding the joint or from the joint itself.

Joint related Hip pain: Occurs due to degenerative or inflammatory conditions that affect the joint directly like osteoarthritis or rheumatoid arthritis. Other bony injuries that can cause hip pain include impingement syndrome, labral tears, fractures of the femur, posterior dislocation of the hip, femoro-acetabular impingement (FAI), fractures and avascular necrosis.

Most conditions are treated with physiotherapy; however, severe joint conditions may require surgical interventions such as partial or total hip replacement followed by physiotherapy. Surgery for non-arthritic hip patients has increased by nearly 442% over the last decade the the UK and by 1800% in the United States.

9 Main Causes of hip pain

1. Hip Impingement Syndromes:Femoroacetabular impingement (FAI) is a recently suggested potential cause of hip and groin pain. In the past this pathological process was undiagnosed. FAI describes a condition involving abnormal contact between the femoral neck (top of the leg bone – femur) and the labrum of the pelvis.Although impingement is diagnosed on a frequent basis based on MRI scans, much like findings from MRI’s of the spine, the prevalence of deformities on hip joint MRI scans is very high. Research suggests that the prevalence of abnormalities at the head of the thigh bone (femur) was 37%. An even higher prevalence of 54.8% was present amongst athletes. The authors also reported a prevalence of deformity of the hip socket of 67%. 
   I frequently see people who report a history of being diagnosed with a hip impingement and are certain that this is the sole cause of their symptoms. In many, if not most cases, there are other drivers of pain. For this reason, physiotherapy based management is considered the best first line treatment for impingement
   
   The labrum is a ring of cartilage that follows the outside rim of the hip socket.  Pain is normally located in the groin, but can also move down the anterior thigh, lateral hip or gluteal region. The most common movement that brings on pain is end-range flexion and internal rotation. Patients often find it difficult to sit for more than 20-30 minutes.
2. Acetabular Labral TearsLabral tears, like hip impingement syndromes, are being diagnosed with a rapidly increasing frequency. This is partially down to increased sensitivity of MRI scans. Incidence of labral tears has been suggested to be as high as 22-55% in young athletes.
   The labrum is a fibrocartilaginous structure that surrounds the hip joint. The labrum is commonly injured from sports involving repetitive twisting or pivoting motions such as with gas & soccer. It is thought the the labrum takes on a weight-bearing role at the extreme of motion with excessive forces leading to tearing. A Grade I tear is a full thickness tear, a Grade II is a partial thickness tear and a Grade III is a degenerative tear. Patients with labral tears may limp or report pain going up or down the stairs. They may have dull pain that may be present at night
3. Hip OsteoarthritisNormal onset of pain from hip arthritis is over the age of 50. It is characterised by persistent pain in the groin and may also move to the buttock or anterior thigh. It is common to report early morning stiffness  and stiffness with prolonged rest. Weight bearing activities such as walking and squatting can increase the pain.
4. Greater trochanteric bursitis

   Trochanteric bursitis is the most common cause of hip pain in runners. Bursae are fluid filled pouches located between the tendon and the bony surface or between two tendons. Patient complains of pain and tenderness over the outer side of the hip that radiates down the thigh. Pain may also appear while running and climbing stairs. Rest and activity modification play an important role in recovery. 

5. Ischial bursitis

   Ischial bursitis is another common condition that causes pain in the buttocks. This bursa is located between the ischial tuberosity and the hamstring tendon. Prolonged sitting or sprinting can cause injury to the bursa. The patient presents with pain and tenderness over the buttock fold. Stretching the hamstrings may also be painful. Rest, activity modification and gentle stretching exercises help in recovery. 

6. Iliopsoas tendinitis –The Iliopsoas is a major flexor of the hip. Repetitive flexion movement as seen in dancers, gymnasts and runners can cause irritation and inflammation of the tendon. The patient presents with pain in the hip and thigh along with audible snapping of the hip as the inflamed tendon moves during hip flexion and extension. Rest, ice and eccentric strengthening of the muscle help to overcome the condition.
7. Hamstring tendinitis –Commonly seen in runners and bikers, the condition is characterised by deep buttock pain, pain while sitting. It is also known as chronic high hamstring tendinopathy and is caused due to repetitive hip extension. The injury is slow to heal and is managed by hamstring flexibility and an eccentric strengthening program.
8. Iliotibial band Syndrome –Typically seen in runners & cyclists, the condition occurs due to friction of the iliotibial band against the lower end of thigh bone during repetitive hip movements. The pain is present in the hip and outer side of thigh. Knee flexion greater than 30° also tends to bring on symptoms. Deep tissue massage & biomechanical (movement pattern) analysis is a key component in addressing this condition.
9. Groin Strain –Groin strain is also known as adductor muscle strain. This is commonly seen in sports with sudden start and stop movements like soccer and basketball. The player complains of intense pain in the groin and difficulty in bringing the legs closer. Rest and isometric stretching/strengthening help to heal the injured tissue.
10. Hamstring Strain –This debilitating condition is commonly seen in athletes and has a strong tendency to recur if not rehabbed appropriately. The player may complain of severe sharp pain in the buttocks or upper thigh, inability to stand, and pain on sitting. RICE (Rest, Ice, Compression, Elevation) protocol followed by graded stretching and strengthening of the hamstring helps in complete recovery. Rehab should be graduated to reduce the risk of recurrence of injury.
11. Piriformis Syndrome –The piriformis is an important muscle in the buttock and in nearly 30% of the population, the sciatic nerve goes through it. Certain activities can cause the muscle to go into spasm which in turn compresses the nerve. This results in pain in the buttock accompanied by numbness and tingling in the back of the thigh. Walking and stair climbing is difficult. Stretching of the piriformis along with hamstring and hip extensors helps to resolve this pain.
12. Low back Injury –A disc injury in the low back can impact on the nerves that supply the hip and groin region. It is common for individuals with low back or buttock pain to mistake this as hip pain. The hip joint itself lies laterally at the top of the thigh. Patients will often point to the glute region as the location of their hip pain; however, this is a different structure and is often related to the gluteal muscles or may potentially refer from the low back. The sacroiliac joint is also reported as being a potential cause of hip & groin pain.
    
    
13. Stress fracture –The condition is commonly seen in runners and dancers and can result from a sudden increase in training volume or cumulative load over several years. The athlete usually complains of an aching or nagging pain in the groin that does not subside with rest. The athlete may experience a drop in performance, night pains and difficulty weight bearing thorugh the leg. Rest and guided rehabilitation helps the athlete to return to preinjury status. MRI is the investigation of choice for stress fractures since x-rays have very low sensitivity and the fractures may not show up in the initial stages.
14. Avascular Necrosis –Risk factors for avascular necrosis include long term steroid use, drug abuse, sickle cell anaemia and alcoholism.Avascular necrosis can give rise to severe night pain. MRI is the best scan for diagnosing this condition and it can often be missed on x-ray imaging in the first 4-5 months.

Can the cause of hip pain be somewhere else?

Many of the structures surrounding the hip joint can refer to the region and masquerade as hip pain. Low back conditions such as lumbar radiculopathy, disc prolapse and sacroiliac joint dysfunction can refer to the hip. Abdominal muscle strains and genitourinary conditions are also a potential source of referral to the hip. Lower abdominal or gastrointestinal conditions can also refer to this region.

Knee injuries can also alter movement patterns and give rise to hip pain. This is known as referred pain. Careful diagnosis based on detailed patient history, accurate physical examination and administration of specific tests help to differentiate between true hip pain and referred pain.

What we do at Naas Physiotherapy Clinic

We are a patient focused clinic with highly qualified and skilled physiotherapists dedicated to helping those who are suffering from hip pain. Many patients who come to us with hip pain are athletes & we understand the importance a proper rehab protocol and early return to sport. Our focus is on developing individualised treatment plans. Prevention of injury and minimising recurrence is our sole objective.

The following treatment options are available at our clinic:

• Complete Biomechanical Analysis
• Running Assessment
• Correction of muscle strength imbalance
• Analysis of training plan 
• Sports specific drills
• Manipulation & Myofascial release
• Post-operative rehabilitation after partial or total hip replacement

Ref:

Frank JM, Harris JD, Erickson BJ, et al. Prevalence of Femoroacetabular Impingement Imaging Findings in Asymptomatic Volunteers: A Systematic Review. Arthroscopy. 2015;31(6):1199-1204. doi:10.1016/j.arthro.2014.11.042 https://pubmed.ncbi.nlm.nih.gov/25636988/

To find out more contact us at Naas Physio Clinic on:
(045) 874 682

or email us at info@physioclinic.ie