Where Is Your Hip Pain Coming From? | Professor Daevyd Rodda

Professor Rodda explains what "hip" actually means, and why the location of your pain matters more than the word itself.

Professor Rodda on where hip pain actually comes from

"Hip" means two different things

The regions of the pelvis and hip where pain is felt, and what each usually points to

When patients talk about hip pain, they often mean any pain from the upper thigh, the outer side, the buttock, or even the lower back. When surgeons say hip, they mean the ball-and-socket joint itself. Pain in these different areas usually comes from different problems, and often more than one is present at the same time.

Pain from the hip joint itself, as in hip arthritis, is usually felt in the groin and down the front of the thigh. Occasionally it is felt all the way down to the knee, and sometimes only in the knee. This is called referred pain, and it causes a great deal of confusion.

Pain on the outer side of the hip, over the bony point, used to be called hip bursitis. That term is no longer used because inflammation of the bursa is only a small part of the problem, and the label often leads to inappropriate treatment such as steroid injections into the bursa, which usually have little or no benefit. The main problem is degeneration and small tears in the gluteal tendons that attach to the trochanter. This is called greater trochanteric pain syndrome.

Pain in the buttock may come from the lumbar spine or the sacroiliac joint. Pain from the lumbar spine can radiate down the back of the thigh, sometimes all the way to the foot, and may result from nerve impingement. These problems are degenerative in nature and much more common in people in their fifties, sixties and seventies.

Often these conditions co-exist, with pain coming from multiple sites at once, which can make diagnosis challenging. So the first question at a consultation is not how bad is your hip but which part of this region is the pain actually coming from. There are four common answers.

Groin pain, usually the hip joint

Pain from the joint itself is felt in the groin. It often radiates down the front of the thigh, and sometimes as far as the knee. Some people present with knee pain and no hip symptoms at all, which is common enough that unexplained knee pain should always prompt an examination of the hip.

Typical features:

Worse with walking, and with weight through the leg
Stiffness after sitting, easing after a few minutes of moving
Difficulty with socks, shoes and toenails
Difficulty getting in and out of a car
A gradually shortening walking distance
In more advanced cases, pain that interrupts sleep

Side-by-side medical illustration of a healthy hip joint and an arthritic hip joint — A healthy hip joint (left) compared with an arthritic one (right). In arthritis the smooth cartilage covering the ball is destroyed, the joint space narrows, and bone spurs form around the margins, the changes that produce the groin pain, stiffness and shortening walking distance listed alongside.

Some people describe a deep ache rather than sharp pain, and some find it hard to point to at all. Both are typical.

Pain on the outer hip, hip bursitis (trochanteric pain syndrome)

This is the one most often confused with hip arthritis, and it is very common.

This condition used to be called hip bursitis. We no longer use this term, as it doesn't describe the actual cause of the pain and can often lead to inappropriate treatment, such as ultrasound-guided steroid injections into the bursa.

The greater trochanter is the bony point you can feel on the side of your hip. The gluteal tendons attach there, with a bursa beneath them. Pain from this region is:

Felt on the outer point of the hip, not the groin
Tender to press on
Worse lying on that side, and often the reason sleep is disturbed
Worse on stairs, or standing on one leg
Sometimes spreading down the outer thigh, but rarely below the knee

It is often called trochanteric bursitis. Current understanding is that it usually involves the gluteal tendons rather than the bursa, which matters, because the treatment differs. Tendon problems respond to progressive loading and physiotherapy. Repeated corticosteroid injections may help in the short term but do not address the underlying problem, and used repeatedly may make the tendon worse.

The gluteus medius muscle, IT-band and inflamed bursa on the outer hip — The gluteus medius, IT-band and inflamed bursa on the outer hip. Pain here is often called bursitis, though it usually involves the tendon rather than the bursa, which is why treatment focuses on loading the tendon rather than repeated injections.

Lower back and buttock pain, often the lumbar spine

Pain in the buttock, particularly if it travels down the back of the thigh or below the knee, more often comes from the lumbar spine.

Features pointing to the back:

Pain that changes with the position of your back rather than your hip
Pain travelling below the knee
Pins and needles, numbness or weakness in the leg or foot
Worse with prolonged standing or walking, eased by sitting or leaning forward
Little relationship to how far the hip is moved

Posterior view of the lumbar spine showing vertebrae, intervertebral discs, facet joints, spinal nerves and the sacrum — The lumbar spine, shown from behind. The spinal nerves exit through small openings (neural foramina) between the vertebrae. When a disc bulges or a foramen narrows, the nerve is compressed, producing pain that radiates from the lower back into the buttock and down the back of the thigh, sometimes below the knee.

Spinal stenosis in particular produces leg pain on walking that is easily mistaken for hip arthritis, because both shorten walking distance. The distinguishing feature is usually that stenosis eases on sitting or leaning forward, and hip pain does not.

Deep pain over the dimple, the sacroiliac joint

The sacroiliac joints connect the sacrum to the pelvis on each side. Pain from these joints is felt deep over the dimple of the buttock, sometimes spreading into the groin or the back of the thigh.

It is often worse rolling over in bed, getting out of a car, or standing on one leg to dress. It can follow pregnancy or a fall onto the buttock, or develop without obvious cause.

Sacroiliac pain is under-recognised, and is a common reason a hip is investigated when the joint is not the problem.

Posterior view of the pelvis showing the sacroiliac joint, sacrum, coccyx and ilium, with a detail of the joint cartilage and ligaments — The sacroiliac joint, where the sacrum meets the pelvis. The joint is held together by strong ligaments and has a thin layer of cartilage. Though it moves only a little, it is a common source of pain felt deep over the dimple of the buttock.

They often occur together

This is the part a list of symptoms cannot capture.

Someone in their late sixties may quite reasonably have hip arthritis, degenerative change in the lower back, and trochanteric pain, all at once. All three become more common with age, and having one does not protect you from the others.

So the question is not usually which of these do you have, it is often more than one. The question is which of them is producing the symptoms limiting you now, because that determines what is treated first.

It is also why an X-ray showing arthritis does not settle the matter. It shows arthritis is present. It does not show that the arthritis is what is causing your pain.

How the source is worked out

Three things, in order of usefulness.

What you describe. Where the pain is, what makes it worse, what you can no longer do, and whether it disturbs your sleep. This is more informative than most people expect, and it is worth thinking about beforehand.

The examination. We will watch you walk, move the hip through its range, and press over a few specific points. Loss of rotation, reproduction of pain on particular movements, and tenderness over the trochanter each point in a different direction. This often tells us more than the scan.

Imaging. A weight-bearing X-ray of the pelvis is usually all that is needed to assess the joint. Further imaging is arranged only if the picture is unclear or another condition is suspected.

When the diagnosis is still not clear

Most of the time, those three things settle it.

Occasionally they do not, usually when several structures could plausibly be responsible and the examination does not clearly favour one. In that situation a diagnostic injection can answer the question directly.

Local anaesthetic is injected into the hip joint under CT guidance, at Sunshine Coast Radiology. If the pain substantially improves for a few hours afterwards, the joint is the source. If nothing changes, it is not, and attention turns elsewhere.

This is a test rather than a treatment. The relief is temporary by design, it is the information that matters. Professor Rodda uses it selectively, when the clinical findings, examination and X-ray have not produced a clear answer between them, rather than as a routine step.

Questions to ask

Is my pain coming from the hip joint, or from somewhere else?

If more than one thing is contributing, which is causing most of my symptoms?

Does my X-ray match what I am feeling?

Would a diagnostic injection help clarify things?

What should be treated first?

Common questions

Is the hip joint where I think it is?

When most people say hip they mean the whole region from the upper thigh around to the buttock. The hip joint itself is a single ball-and-socket joint sitting deep and towards the front, roughly behind the groin crease. Pain in the wider region often comes from the lower back, the sacroiliac joint or the tendons on the outer hip rather than from the joint.

Why does my hip pain feel like it is in my groin?

The hip joint sits deep and towards the front of the body, rather than at the bony point on the outer side. Pain from the joint is therefore felt in the groin, often radiating down the front of the thigh and sometimes as far as the knee. Pain on the outer hip usually comes from the tendons instead.

Why does my knee hurt when the problem is my hip?

The hip joint and the front of the thigh and knee share nerve supply from the same spinal levels, so pain from the hip is commonly referred to the knee. Some people present with knee pain and no hip symptoms at all. Assessment of unexplained knee pain routinely includes examining the hip for this reason.

Is pain on the outside of my hip arthritis?

Usually not. Pain over the bony point on the outer hip, tender to touch and worse when lying on that side, typically comes from the gluteal tendons and bursa rather than the joint. This is called greater trochanteric pain syndrome. It can occur alongside hip arthritis, and the two are frequently confused.

Can back problems cause hip pain?

Yes. Pain from the lumbar spine is commonly felt in the buttock and the back of the thigh, and spinal stenosis can limit walking distance in a way that resembles hip arthritis. Features suggesting the back include pain travelling below the knee, pins and needles or numbness, and relief on sitting or leaning forward.

Can I have more than one cause of hip pain at once?

Yes, and it is common. Hip arthritis, degenerative change in the lower back and greater trochanteric pain all become more frequent with age, and any combination can occur together. The task at consultation is identifying which is producing your current symptoms, since that determines what is treated first.

What is a diagnostic injection?

A diagnostic injection places local anaesthetic into the hip joint under CT guidance to establish whether the joint is the source of pain. If symptoms substantially improve for a few hours afterwards, the joint is responsible. It is used selectively, when examination and X-ray have not produced a clear answer, and it is a test rather than a treatment.

What is trochanteric bursitis?

Trochanteric bursitis is the older name for pain over the outer point of the hip. Current understanding is that this usually involves the gluteal tendons rather than the bursa, so it is now more often called greater trochanteric pain syndrome. The distinction matters because tendon problems are treated with progressive loading and physiotherapy rather than repeated injections.

Common questions.