Common Causes of Hip and Pelvic Pain in Runners
Hip or pelvic pain is a common complaint for runners and can range from severe problems, such as stress fractures or arthritis, to mild problems, such as muscle strains or bursitis.
By Andrew Gregory, M.D.
Hip or pelvic pain is a common complaint for runners and can range from severe problems, such as stress fractures or arthritis, to mild problems, such as muscle strains or bursitis. Common causes I see in runners are IT band bursitis, stress fractures, and piriformis syndrome. Any pain that limits your ability to run should be evaluated by a sports medicine trained physician. Evaluation consists of obtaining a history of the problem; a physical exam of the hip, pelvis, back and lower leg; and imaging, which can include x-rays, MRI, or CT scan.
Sources of Hip Pain
Hip pain can come from multiple sources including bone, joint, muscle, tendon, and bursa (fluid-filled sacs that decrease friction at boney prominences). There are three separate joints: two sacroiliac joints, the pubic symphysis, and two hip joints. The bones of the pelvis include the sacrum (tailbone), ilium (pelvic wings), ischium, superior and inferior pubic ramii, and femur (thigh bone).
There are many muscles that attach to the pelvis and hip and are important in running. The powerful hip flexors (iliopsoas, rectus femoris, and sartorius) attach in the front and flex or bend the hip. The abductor group of muscles includes the tensor fascia lata and gluteus medius and minimus, which abduct or pull the leg away from midline. The hip extensors include the gluteal maximus and the four hamstrings. The hip adductors pull the leg across the midline and include the gracilis, pectinius, and adductor longus, brevis, and magnus.
Anterior Hip Pain
The location of the hip pain can be very helpful to the doctor in finding where the pain originates. Anterior hip, groin, or thigh pain usually comes from the hip joint or one of the hip flexors. The hip joint is a ball and socket joint that connects the femur to the pelvis. Problems of the hip joint can include arthritis (commonly develops in the third or fourth decade of life), labral tears (cartilage rim of the socket), and avascular necrosis (loss of blood supply to the ball).
Lateral Hip Pain
Lateral hip pain most commonly comes from bursitis of the iliotibial band at the greater trochanter, or tendonopathy at the iliac crest. Popping can occur as the IT band passes over the greater trochanter as the hip goes from flexion to extension.
IT band bursitis causes lateral hip pain that occurs with running and can be severe enough to preclude running. Sometimes a pop may be felt on the lateral side of the hip that can be confused with the hip coming out of place. Tenderness to pressing over the greater trochanter of the femur is indicative of bursitis. This is frequently associated with hip abductor weakness or IT band tightness. The treatment is hip abductor strengthening, IT band stretching, anti-inflammatory medications, ice, and relative rest. Sometimes injections of corticosteroids can be helpful.
Posterior Hip Pain
Posterior hip pain is commonly from piriformis syndrome (pain and tightness of the piriformis muscle) or bursitis of the ischial tuberosity. Piriformis syndrome can be associated with pain that radiates or shoots down the back of the leg, as the sciatic nerve can pass through the piriformis muscle in some people. However, because the most common cause of this kind of radiating pain is from a pinched nerve in the spine from a disc herniation, the spine should always be evaluated at the same time.
Hip Stress Fractures
Stress fractures of the hip and pelvis are common in runners and are often overlooked because in the beginning they can feel like a muscle pull. Deep pain that worsens with running or hopping and gets worse over time is suspicious for a stress fracture. Tenderness on the bone is indicative; however, oftentimes the bone is difficult to push on because of the overlying muscle.
X-rays may not show a stress fracture for 3-4 weeks, so MRI can be helpful in showing an early injury to the bone. Most stress fractures can be treated with simple rest from running, however, some are more severe and crutches or even surgery may be necessary. These typically occur because of an error in training (doing too much too fast). A good rule of thumb is not to increase duration, frequency, or intensity of training by more than ten percent per week. Women who miss menstrual periods are at increased risk of developing stress fractures.
Piriformis syndrome is a common cause of posterior hip pain in runners. This is deep buttock pain that occurs with running and can be accompanied by pain radiating down the back of the leg. The muscle is tender to deep palpation and stretching (hip flexion adduction and internal rotation). Treatment consists of deep tissue massage of the area, stretching the piriformis muscle, and strengthening the hip abductors/external rotators. This is a problem that usually takes weeks or months to get better with physical therapy.
Medial or groin pain can come from an inguinal hernia (defect or hole in the abdominal muscle), or an adductor tendonopathy at the attachment on the superior pubic ramus or osteitis pubis (inflammation of the pubic symphysis). These problems can be difficult to distinguish from each other even for experienced physicians.
In summary, there are many causes of hip and pelvis pain in the runner. Some of the problems are serious and others are not, so all problems should be evaluated if they are interfering with running. A sports medicine physician in conjunction with a physical therapist is best suited for evaluation and treatment of these conditions.
Andrew Gregory, M.D.
Vanderbilt Sports Medicine, Nashville, TN