7 Correctable Hip Pain Diagnosis & Treatments for Injured Runners

It sucks to have hip pain. While all of your friends are out running you are stuck at home… well, the sleeping in isn’t too bad, but it’s going to get old fast.

I have had hip pain that’s kept me from training with my team as well.

My injury kept me out for three months. After I recovered, I learned that I could have easily cut that time down by four weeks.

How?

Rehabbing it easy and often… and I’m not talking about rest and ice.

Through my own hip injury, I began to learn more about how to treat and rehab them.

This article is my opportunity to give back to the running community. Read through as I have included information on the more common reasons for hip pain we can get as runners. Here’s the top 7 Hip Pain diagnosis:

I’m Dr. Sebastian Gonzales and I spent 38 hours of my life writing this guide so you can learn how to improve your hip pain so you can run again.

Sebastian Gonzales DC

Chapter 1: Hip Flexor Tendonitis

Chronically tight hip flexor creating hip pain? This is a must read section.

Chapter 2: Hip Impingement or Labral Tear

Click, Pop or Lock of the hip? Pinching in the front? Read this section.

Chapter 3: Adductor Strain

Felt a pop in the high groin area? Read this section first.

Chapter 4: High Hamstring Strain

Can’t sit down without pain on your “sit bone?” Read this chapter first.

Chapter 5: Glute Medius Strain

Ache in the side of the buttocks? Rolling out your hip daily? Read this.

Chapter 6: Trochanteric Bursitis

Doc told you to rest to recover from bursitis? False. Read this chapter

Chapter 7: Piriformis Syndrome

Tired of stretching the back of your hip to minimal results? Read this chapter.

CHAPTER 1: HIP FLEXOR TENDONITIS

  • Pain in the front of your hip when lifting up your knee?
  • Hurts when you step into the car?
  • Gets worse after doing core exercises with your legs?

Hip Flexor Tendonitis is a very common condition that can plague runners, mainly those of the distance variety.

If you run ½ marathons or further, you are at high risk of Hip Flexor Tendonitis.

You don’t have to run in pain any more.

Rehab for Hip Flexor Tendonitis is highly successful when done correctly. I, personally, have not had this injury, but I have managed many cases of it over the years.

Funny, one of my most popular videos still to this day is on “Stretching the Psoas.”

I have learned a lot more since making that video back in 2009.

I’ll share the updated comprehensive video below… It’s 30 mins long but there’s a good reason for it. Consider it like an episode of Married with Children and watch for 30 mins.

What is Hip Flexor Tendonitis?

Tendonitis is irritation to a tendon. This can be chronic (long term) or acute (new injury).

The main hip flexor is the iliopsoas.

The what, you say?

The iliopsoas… you have probably heard of it called the psoas, but it is really two muscles and one tendon. The tendon is what you could be having an issue with.

Hip Flexor Tightness

What causes Hip Flexor Tendonitis?

Hip Flexor Tendonitis is caused when the hip flexors become dominant in the running gait.

You’re probably thinking how can this happen, right?

Do some floor core exercises, and you’ll probably find your hip flexor can get super tight super fast.

Muscles have what is called a normal “length/tension relationship.” They want to be a certain length so they can work well. If your core is not holding your pelvis in an optimal position, then your hip flexor length will change.

Think about being at work…

I’m sure you have optimal working conditions.

– Not too cold but not too hot.
– Not too many emails.
– Not too much background noise.

Muscles need their optimal environment in order to not breakdown. Having proper core strength and the ability to hold the pelvis in the correct position when running will decrease the probability of having downtime from this injury.

Hip Flexor Tightness

How can you rehab Hip Flexor Tendonitis?

As you can guess, in order to rehab Hip Flexor Tendonitis properly, we need to create the optimal environment.

This is not hard to design, but it is a lot of work on your part.

Rehab exercise progression usually includes one that goes from easy to challenging.

Before making things more challenging on the muscles, we always teach proper pelvis and trunk position. This is often a mental game that is frustrating to runners, but it is one that’s very teachable.

Here’s a theory of progression that we often use in cases of Hip Flexor Tendonitis:

  1. Open chain exercise to closed chain exercise
  2. Lightweight to heavy weight
  3. Complete rest to incomplete rest

What does rest have to do with it?

Running form, lifting form, posture, you name it… it all breaks down as you become out of breath. So we need to teach you how to have control of it.

The Lewit Exercise is a great starting point for a core program. We always teach breathing and bracing before we start any core program. This is extremely challenging to most people.

What kinds of treatments can be done for Hip Flexor Tendonitis?

Here are some other treatments that can assist you in recovering from Hip Flexor Tendonitis:

  • Active Release Technique
  • Deep tissue massage
  • Anti-inflammatory injections
  • Regenerative Cell Therapies
  • Chiropractic adjustments or mobilizations
  • Strength training/rehab
  • PRICE therapy
  • Running gait training
  • Eccentric Exercise
  • Postural Endurance
  • Dynamic Mobility
  • General Strength
  • Plyometrics
  • Movement Pattern Correction
  • Co-contraction
Hip Flexor Syndrome

CHAPTER 2: HIP IMPINGEMENT OR LABRAL TEAR

Pinching in the front of the hip?
Deep ache?
Worse with sitting or squatting?

Hip Impingement is one of the hottest topics in hip pain today. Just like majority of other hip injuries from running, it often begins from a degrade in for which starts with lack of core endurance one the course of your workout. I wrote an article on this one topic… after you’re finished with this section come back and READ THIS ARTICLE.

For your convenience, I created some page jumps since Hip Impingement & Labral Injury is a big section.

What is Hip Impingement?

Hip Impingement is a pinch point in your hip. Seems like too simple an answer, and I know you want a little more information, but first, it is important to understand what a pinch point is.

A pinch point is not a muscle or tendon injury.

Hip Impingement is located in the exact same region of the hip flexor syndrome, so how can you tell if it is one or the other?

The easiest way is by describing how it feels.

If you bring your knee to your chest (via your arms) when lying on your back and there is a pinch, then I would suspect hip impingement. This simple test takes the hip flexor out the of the mix because it is not being used.

Your arms pulled your leg up, right?

A pinch point is like slamming your hand in a car door over and over. No matter how many times you attempt to open and close the door, it does nothing to move your hand from the path of the door.

Damage to your hand will inevitably increase, correct?

The same thing happens in Hip Impingement. What is caught in the “door” gets damaged every time you stretch it.

Hip Impingement

What causes Hip Impingement?

Hip Impingement occurs as pelvic and hip mechanics change.

Let’s go back to that car door analogy:

Slowly, your hand inches closer and closer to the door… and finally, it’s close enough to be smashed.

Strength and motion coordination of the core and pelvic muscles are normally what will “move” your hand closer to the door or keep it from being smashed.

Note: the door didn’t move… it stayed where it always was.

It is believed that the hip operates in the same way.

Obviously, there are issues that can occur in the hip just as with the door. The hinges could be falling off. The door jam could be falling off. For cases like these, we need to rehab the hip joint properly as well.

Hip Impingement

How can you rehab Hip Impingement?

Starting with the core and pelvis is the best practice. As much as runners want to believe they have strong cores, they often do not.

Elite runners normally have strong trunks, but they often have core training and weight lifting programmed into the their weekly routine.

My ex-roommate was a college mid-distance and cross county coach. He was the type of coach who was not afraid to push the kids, and as a result, they set PRs and school records.

I was always amazed by the amount of core training they did (four plus days a week for 30 minutes or more).

They also weightlifted at least two days a week. Deadlifts, clean pulls, squats, RDLs, etc. Great stuff!

Out in the post college world, most runners spend 90% of their time on mileage.

Do you see an issue?

Core rehab is the starting point.

I would suggest a detailed program for this condition. I’ll have one coming soon but till then here are some great rehab exercise to centralize the hip joint. To be clear we do need proximal stabilization (core) before we do this. Look back at the rehab suggestions for hip flexor tightness.

What kinds of treatments can be done for Hip Impingement?

Here are some other treatments that can assist you in recovering from Hip Impingement:

  • Active Release Technique
  • Deep tissue massage
  • Anti-inflammatory injections
  • Regenerative Cell Therapies
  • Chiropractic adjustments or mobilizations
  • Strength training/rehab
  • PRICE therapy
  • Running gait training
  • Eccentric Exercise
  • Postural Endurance
  • Dynamic Mobility
  • General Strength
  • Plyometrics
  • Movement Pattern Correction
  • Co-contraction
Hip Impingement FAI

CHAPTER 3: ADDUCTOR STRAIN

  • Groin pain?
  • Did you feel a pop when it happened?
  • Can’t raise your leg?

The adductor group of muscles is complex. Dare I say it… the adductor group is the most important category of muscles of the hip for an athlete.

They do it all!

They flex the hip, they extend the hip, and they can even rotate it!

They are a sexy group of muscles; able to do all of these functions, and that is why when you injure one of them, it is an absolute must to rehab it.

Read this article and learn more about how we rehab and treat adductor injuries.

What is an Adductor Strain?

An Adductor Strain is a strain to the adductor muscle or tendon.

Too simple?

Ok. The adductor is only one muscle from a collection of muscles from the hip. Most commonly, as a runner, you will have a strain of the adductor longus or adductor magnus.

What is a strain?

A strain is actually a low-grade muscle tear.

A Grade I tear to be exact.

It should be treated as a tear. If you do not know how to treat a tear, we have a one of the best articles on the rehab timeline of muscle tears on the web. You can access it here after you are done with this section.

What causes an Adductor Strain?

An Adductor Strain can be caused by overuse or over demand.

Overuse is making a muscle do more than it physically can if it is in normal health and biomechanics are perfect.

Over demand is making a muscle do more than it physically can when it is in poor health or biomechanics are not perfect.

An analogy for over demand is this:

Remember the old martial arts movies?

Usually, someone was expected to punch through a plank of wood, right?

There was nothing wrong with this wood (if used as wood normally is), but in this case, it was subjected to a punch.

Note: they never punched the wood from the top down. That’s because the wood plank is stronger that way.

In over demand cases, the muscle is not being allowed to be in its strongest state and it breaks as a result.

I did a podcast on the current classifications of muscle injuries as of 2012. It will shed some light on pain with a negative MRI you have. Enjoy.

How can you rehab an Adductor Strain?

Rehab of an Adductor Strain is a little different than that of other hip injuries. Since it is low-grade tear, it needs more TLC in the form of deep tissue work before exercise rehab.

Weeks 1-3 are a great time for deep tissue work to help keep the scar tissue at the proper length.

Week 2 and onward are a great time to incorporate some adductor specific rehab.

Training the core and pelvic muscles is important from week 0 until you are feeling better.

Here is a self-help muscle work treatment that has worked well for our clients.

It is lacrosse ball rolling on the adductor. This is for the high adductor on the backside, so if you have a different region of pain than what is indicated on the video, then you may need to get something more for your condition.

What kinds of treatments can be done for an Adductor Strain?

Here are some other treatments that can assist you in recovering from an Adductor Strain:

  • Active Release Technique
  • Deep tissue massage
  • Anti-inflammatory injections
  • Regenerative Cell Therapies
  • Chiropractic adjustments or mobilizations
  • Strength training/rehab
  • PRICE therapy
  • Running gait training
  • Eccentric Exercise
  • Postural Endurance
  • Dynamic Mobility
  • General Strength
  • Plyometrics
  • Movement Pattern Correction
  • Co-contraction

CHAPTER 4: HIGH HAMSTRING STRAIN

  • Painful to sit down?
  • Does it hurt on the “sit bone?”
  • Painful to run, but often loosens up after 15 minutes?

These are signs of a possible high hamstring injury.

Hamstring injuries will limit the distance and speed you are able to run for months if you do not take the proper rehab approach.

The great news is rehab on this type of injury has been studied extensively and is very well understood. Now, the only thing standing between you and your running happiness is you.

Read on to get the facts about high hamstring rehab.

What is a High Hamstring Strain?

If you read about the Adductor Strain, you will understand a High Hamstring Strain better.

It is the same thing, but in a different muscle and tendon.

Let’s recap.

The hamstrings are on the backside of the thigh and start at the gluteal crease. This insertion onto the “sit bone” is an extremely common site of injury with runners.

Also known as High Hamstring Tendonopathy, this type of hamstring injury can take months to heal and can be extremely frustrating for all type of athletes.

What causes a High Hamstring Strain?

High Hamstring Strains are created the same way any other strain of the hip and leg is.

Overuse, trauma or over demand of the tissue.

If you want more on this, scroll back to the Adductor Strain section.

Hamstring injuries do have one thing unique about them though. They are predictable in the fact that they become more probable the faster you run.

Striders are a good example. I have had many runners come in saying their injuries begin after doing striders. I have nothing against striders, but the quick speed and larger range of motion are factors in hamstring injuries.

There are many other possible factors, but these are just a few you should be aware of.

High Hamstring Strain

How can you rehab a High Hamstring Strain?

Hamstring Strain rehab programs are much better than they use to be, BUT it is important to understand the type of injury that a “hammy” strain is.

Hamstring injuries are highly temperamental. They will flare up during rehab and reintroduction to running, so don’t get frustrated.

Frustration and stopping a rehab program is the number one reason I have seen that causes runners to not recover.

We recommend the follow exercise categories for our rehab programs.

  • Multidirectional trunk stabilization
  • Complex motions both unloaded and loaded
  • Local eccentric exercises
  • Hip mobility
  • Change of direction drills
  • Plyometrics
  • Sprinting form instruction

One exercise you could have read about is the Nordic Hamstring Exercise. I have used it in many rehab programs, but I caution everyone about how intense these can be.

If you do it too early, you will hurt yourself. If you do too many reps and sets, you will hurt yourself.

Here’s our video on the Nordic Hamstring Exercise:

We also eventually need to challenge the hamstring in a lengthening hip hinge pattern. First unweighted and then weighted. Lastly, we would increase the speed.

Romanian Deadlifts are a great way to learn hip hinge movements. This video should show you everything you need to know.

What kinds of treatments can be done for a High Hamstring Strain?

Here are some other treatments that can assist you in recovering from a Hamstring Strain:

  • Active Release Technique
  • Deep tissue massage
  • Anti-inflammatory injections
  • Regenerative Cell Therapies
  • Chiropractic adjustments or mobilizations
  • Strength training/rehab
  • PRICE therapy
  • Running gait training
  • Eccentric Exercise
  • Postural Endurance
  • Dynamic Mobility
  • General Strength
  • Plyometrics
  • Movement Pattern Correction
  • Co-contraction

CHAPTER 5: GLUTEUS MEDIUS STRAIN

  • Pain on the side of your hip while sleeping?
  • Better when you roll off of it?
  • Deep ache on the side of the hip?

I would estimate a Gluteus Medius Strain as being in the top five most common injuries of the hip a runner could come down with.

It is a very easy injury to rehab and often times does not need medication or injections.

Read through this section and learn how we treat and rehab a Gluteus Medius Strain

What is a Gluteus Medius Strain?

If you have been blowing through this whole article, you have already read about Adductor and Hamstring Strains. Glute Medius Strains are the same, but in a new area.

The interesting part of about a Glute Medius Strain is that it is commonly misdiagnosed as Trochanteric Bursitis. Sometimes called “Hip Bursitis”, this condition is actually an injury to the glute medius tendon where it inserts on the femur.

Around the femur is a natural fluid-filled sac called a bursa. The bursa can become inflamed, but this is usually because the adjacent glute medius tendon has damage.

The bursa is the not the issue. It is the tendon.

What causes a Gluteus Medius Strain?

A Glute Medius Strain is often primarily caused by poor function of the core and pelvis.

How can this be?

The glute medius is a lateral stabilizer of the hip joint.

What is lateral motion?

Think about when you stand with most of your weight on one leg than you shift it to the other. Your hip juts out to the side, correct? This challenges the glute medius of that loaded hip.

With running, excessive lateral motion can challenge the glute medius over and over again… leading to damage.

To rehab it we need to tighten those motions up.

Hip Pain Runner

How can you rehab a Gluteus Medius Strain?

Just as with the other hip injuries, the core and pelvis are huge components. If you want to know more, scroll up and read the rehab sections prior. The only major difference is we emphasis lateral motion in a closed chain progression of exercises. An example is Lateral Band Walks.

We often work on closed chain hip rotational motions within the program too.

If you’re lost now, that is not my intention. We often have clients who get confused about their rehab in the beginning, but after they start to do it all, they understand completely.

What kinds of treatments can be done for a Glute Medius Strain?

Here are some other treatments that can assist you in recovering from a Glute Medius Strain:

  • Active Release Technique
  • Deep tissue massage
  • Anti-inflammatory injections
  • Regenerative Cell Therapies
  • Chiropractic adjustments or mobilizations
  • Strength training/rehab
  • PRICE therapy
  • Running gait training
  • Eccentric Exercise
  • Postural Endurance
  • Dynamic Mobility
  • General Strength
  • Plyometrics
  • Movement Pattern Correction
  • Co-contraction
Glutues Medius Therapy

CHAPTER 6: TROCHANTERIC BURSITIS

What is Trochanteric Bursitis?

The trochanteric bursa is a normal occurring structure in the lateral (outer) hip. It can become inflamed and painful.

It very commonly is associated with a glute medius tendon injury, and when this is the case, the tendon injury should be addressed.

The bursa can be irritated as a secondary issue.

Because more often than not, Trochanteric Bursitis is from a glute medius tendon injury, I will not write any more about it.

Wonder why I am writing about it in the first place then?

Because many runners believe they have it. I just wanted to get the word out on the current thought process surrounding the bursal irritation.

I don’t want anyone to waste their time learning about this condition. Rehab is focused more on the glute medius tendon injury.

Please see above for a full write up.

CHAPTER 7: PIRIFORMIS SYNDROME

  • Stabbing pain in the glute area?
  • Numbness on and off in the back of the thigh?
  • Sometimes radiates to the foot?
  • No low back pain?

Together, these symptoms could indicate Piriformis Syndrome is your injury. But there is also the possibility that a back injury has created a radiculopathy or even sciatica.

Only a proper exam can tell, so get to your sports doc for this one.

This is one of the few injuries of the hip that will have you chasing pain. Nerve pain can travel a long distance. Treatment on the areas of referred pain will result in very low improvement rates.

What is Piriformis Syndrome?

Piriformis Syndrome is a condition where a muscle (called the piriformis) tightens down on a nerve that passes under or through it (called the sciatic nerve).

Because it is a nerve compression injury, the resulting distribution of the loss of sensation and pain can go all the way down to the foot.

Most of the time people come in saying:

“It really hurts right here (points to the butt cheek), and it shoots down the back of my thigh, behind the knee and to the bottom of the foot.”

It can present in different variations if this pattern below the knee, but above it, the presentation is pretty standard.

piriformis syndrome treatment

What causes Piriformis Syndrome?

Piriformis Syndrome is a direct result of hyper-tonicity (tightness) of the piriformis muscle.

What causes the tightness in the first place is a different story.

Muscles of the hip can become tight from having to do more work than they are intended to do.

Since the piriformis crosses the sacroiliac joint, it does assist in stabilizing it. If the joint is too loose, then the muscle is required to work in excess.

piriformis syndrome treatment

How can you rehab Piriformis Syndrome?

I am going to sound like a broken record when I say this, but it is the truth. The keys are having a working core, pelvis and running gait.

To have it all (and a bag of chips), you need these components:

  • Multidirectional trunk stabilization
  • Complex motions both unloaded and loaded
  • Local stabilization exercises
  • Hip mobility
  • Change of direction drills
  • Plyometrics
  • Gait form instruction

Stop making your muscles work so hard, and they will stop getting pissed.

Here is one exercise we use for local stabilization. This exercise had very high EMG activity of the piriformis muscle in testing.

It is called the Prone Heel Squeeze.

What kinds of treatments can be done for Piriformis Syndrome?

Here are some treatments and therapies that can greatly assist in decreasing the symptoms of piriformis syndrome:

  • Active Release Technique
  • Deep tissue massage
  • Anti-inflammatory injections
  • Regenerative Cell Therapies
  • Chiropractic adjustments or mobilizations
  • Strength training/rehab
  • PRICE therapy
  • Running gait training
  • Eccentric Exercise
  • Postural Endurance
  • Dynamic Mobility
  • General Strength
  • Plyometrics
  • Movement Pattern Correction
  • Co-contraction
piriformis syndrome treatment

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