Hip Flexor Pain When Running or Hiking: Causes and Solutions

You're listening to the Restoring Human Movement podcast. Thanks for joining the movement, movement. I'm Sebastian Gonzales, show curator and head clinician at Performance Play Sports Care in Southern California. This show's for active people, those who refuse to let pain and injury get in the way of their life and how they want to live it. Trails and trips, fields and courts, whatever moves you. Each episode features rotating host, expert guest, and real clinical conversations that help you move better and trust your body again. Here we go. Today, we're going to be covering the topic of hip flexor pain.

That's pain in the front part of the hip. There are a few different diagnoses that will coincide with this based upon changes of the person's presentation and who they talk to. There's a little bit of overlap, but some people say there's hip flexor tendinopathy. Others will say hip flexor tendinosis. The other ones will say hip flexor syndrome, a pulled hip flexor, restrained hip flexor, et cetera. So I'm going to talk about all these in a little bit more generality because I think actually a lot of them are pretty much the same just in some regard. And I'll tell you why in a little bit here and then we'll cover some common questions that a lot of our runners ask.

What it feels like is sharp and pulling pain in the front part of the hip during the push-off phase of running. A lot of the people that we see with this problem, they demonstrate this almost in slow motion to show where they start to feel it. Almost like they start to pull the leg or push the leg off the ground. It's a deep ache in the front of the hip. A lot of people report in the groin or the hip region after long runs or hikes that lingers sometimes in the next day. It tends to be more bothersome with sitting, even deep squatting. Sometimes they report a clicking or snapping sensation at the front part of the hip, which may or may not be painful.

Sometimes people call it snapping hip syndrome too, which we've done podcasts on as well, a full length one just on that, more in regards to dancers. Keep in mind that if there is a painful click and pop, a lot of times it's more of a labral cartilaginous pathology. So history does give us some insight of what it is too. Some people report that there's tightness or heaviness into the front of the hip that never really fully goes away despite how much stretching that they do. A lot of people do that hip flexor stretch where they're kneeling and so on. Not a bad one, but it doesn't work for everybody.

There's also pain that gets worse with going uphill and steep climbs where the hip flexion has more demand. So I can personally testament to this. I was going on a hike and we did a bunch of uphill, we did a bunch of downhill, but on the way down, there was some rolling uphills. Like there was no more elevation decrease at that moment. It was just slightly up and then kind of rolling, if you will. And on the uphills, that was more painful than downhills. It was hard to get my leg to pull itself up. It was like I was dragging it almost. Some feel pain when they're lifting the knee towards their chest, especially in a resistance.

So like standing single leg balance, bringing your knee up toward your chest, like you're working your hip flexor. Sometimes it's painful and that's a common test that we see people do in person and even some of our telehealth. And then the aching that builds over mileage typically. And then it also stiffens the first thing in the morning, oftentimes in the front part of the hip crease that tends to move around periodically. Now, I have a lot of people who mentioned this feels like it goes down into the inner part of the knee. That is probably something else. Some people say they feel it in the lower back.

I can vouch for that. There's when your hip isn't working super well, your back compensates. And so there is a relationship with the hip and the low back in this scenario too. Sprinting and acceleration tends to bother people. Usually doing dead bugs or leg lift exercises bothers them. Sometimes doing a lunge or a step back lunge, that's one of the tests that we use. We have them step back lunge with a narrow or long stance. People feel it differently. A lot of times they feel it in the back part of the back leg, not necessarily the working leg. Usually deadlifting is fine. I know some people have problems with it, but generally deadlifting is pretty fine.

It just feels hard and heavy if you're doing it well. And then some people who are doing squatting, again, back squats tend to bother it probably more so than anything else as you're in the deep portion of it. Now, let me explain this just from a pathological standpoint and like what generally happens here. The hip flexor, I'd say, I think I've only, I've been in practice for about 15 years now and I don't think I've seen more than one person where their image was said to be really abnormal with the hip flexor. Like we're allowed to have tendinopathies or like showing of tendon use, that's okay to have, but like nobody has like a big tear there.

Nobody has a fray of it really. They say that it can flip over sections of the hip as it goes through range. I can't really vouch for that. There is a clicking popping that happens again, but it's not like you're gonna really rub the tendon or the musculature way. The tendon that most people are interested in mostly is usually the iliopsoas or they'll say the psoas because the ilium and the psoas muscle come together forming the iliopsoas and they have a common tendon. By the way, this podcast is not medical information. It's educational purposes only. Now, I have a colleague who I think they do a really good job of helping the person that they see or the people that they see really understand where this hip flexor tension tends to come from because if there's really no positive MRIs and x-rays of anything, how can we really lean into the idea that there's anything really pathologically wrong with it?

Let's just say just a tangent. If we saw something like a tendinopathy there, generally with tendinopathies, the treatment is loading the tissue. You can do it isometrically first and then you eventually go into movement and that's going to be general strength conditioning and you can start with easy things like isometric leg holds, etc. But it's not usually very necessary. I usually don't have people do flutter kicks and dead bugs and things of that nature to solve this problem. It usually doesn't have to go that far. But my colleague, what she says is because people are really, when they come in, they're really married to this idea that there's something wrong with their hip flexor, especially it seems like a lot of runners and endurance athletes are.

They say, well, I can feel it there. I know it's there. I've read this stuff online. I know it, I've heard this podcast. They described exactly my symptoms and somebody said the hip flexor could be too tight. So now they also say that it's too weak because it's too tight and I need to strengthen it. So I know it's hip flexor. And she says, well, what do you think makes it tight? And they say, well, I don't know. Maybe it's overuse. Well, but you only have this on one side. So you did the same amount of mileage on both sides. Is there a different side to side? And as we start to unravel the history a little bit more, it seems to be a commonality that the person has a past history of hip stiffness on a side or they have a past history of lower back pain that's now subsided and their back is generally stiff at times, but it's not really like a big concern to them.

Some people have an old history of a knee injury like an ACL or meniscus. And you look down at their quad and their quad is actually visibly smaller on one side because they've spent so much time off of that leg, you know, 20 years ago. Other people have never done really any legitimate core work or hip strengthening work. And now their hip flexors are working extra to compensate for a poor core or a weak hip. Even though the hip works range of motion wise, it works perfectly fine under passive range of motion testing. And also they've never had a past history of back issues, but also they never had a past history of really doing good solid core training.

Usually doing basic things like planks, side planks, bird dogs are a good starting point. Chops and lifts are good starting points too. I always tell a lot of our runners who are dealing with hip and low back and knee stuff how important challenging the frontal plane is and that's side plank. And then so I give them an out a little bit with some testing, but I say, hey, do you know what you should be at generally within time frame? Like how long you can hold the side plank from your feet, not your knees, hands or elbows is fine. You know how long you should generally be able to do this at any point in time, like not warming up, not working up to it.

Like how long should it be on both sides equally? And they say, I don't know. And I said, at least 60 seconds. Most of the nature I think says 90, but I give them an out, you know, but I also tell them about the 90 second too. 90 seconds is actually very hard, but funny when it's with you. Like once I say that, people say, oh, I can do it. You know, and they try and it's very hard. And they're struggling to get to like 30 or 45 seconds because they'd never really done it well. I've met people who can't do it for five seconds. And I say, look, this isn't like, this doesn't make you a bad person.

It just makes it so there's an opportunity here. Like how can we really say that your hip flexor is able to do less work if you're not, if you don't do the basic steps to get some good core stability and strengthen the hip. I've done podcasts in the recent past where I talked about general benchmarks for certain lifts or certain like movements with exercises that have a dominant hip, dominant joint that we're using. So example, hip dominant exercise. Like most people, it's a recreational athletes. I'm not even gonna give a really an age range, but I've gotten some lash back on people into their 60s and 70s.

And they say, I can't do that. I'm 16, 70. Well, you could, you know, we're not gonna tell Jack Lane to go and do less just because he's at a certain age. But like generally people who are being physically active within their 30s, 40s, 50s, they should be able to at least lift their own body weight in a deadlift or comparable lift to that at very least. And usually when I state this, most of our runners say, oh, well, I've been doing dumbbells. Well, how big are your dumbbells? 20 pounds. Two of them? So that's 40 pounds. How much do you weigh? I weigh 140. We should be able to do at least 140.

Well, I haven't done that. Right. It doesn't make you a bad person. It's just, I mean, there's a big gap here. So identifying the symptoms is one thing, like whether we have, it's a hip flexor or hip tendinopathy or hip flexor syndrome, et cetera. Like that's kind of irrelevant because you're not really a surgical case. It's, we have to identify the root cause of things. And it comes down to investigating with a good history, figuring out what you have done and figure out where that gap is and then finding a way to fill the gap so you don't have this reoccurring problem that keeps happening. A lot of places and a lot of people when they're really looking at pain, they will look at the area of pain.

They'll treat the area of pain with rest, ice, heat, stretch, tissue work, ultrasounds, et cetera. But they really don't look around to see what the deficiencies are. Like the body does not work independently. All the areas are linked up. The body is one unit. Body one unit. Like you can't separate these things. Even doing pull-ups can help out with hip flexor conditions. And I've seen a lot of people where actually they aggravate their hip flexor by doing pull-ups. So it is part of it. The body's one unit. Now for a quick pause before we keep going. Hey everybody, it's Sebastian. If what we've been describing in the show so far sounds very familiar and you've been dealing with some ache, pain, or stiffness that keeps coming back no matter what you do and no matter what you try, we're offering a free discovery call today where we brainstorm with you what has been working for you what hasn't been working and we also try to unravel what is a critical part of the puzzle that you've actually been missing that's keeping you from full recovery and getting back to full activity.

The link's in the description. It only takes a few minutes to fill out the form. Okay, back to the show. Let me get some questions in here of some of the people have reached out to ask some things. There will be some little bit of repeat but let's see if I can narrow things down. I stretch my hip flexor every single day and it feels tight the next morning. Why is stretching not working for me? I think we've got to go back to that gap here. What is the gap that is not getting you to the place where you want to be? How do I know at least from this question here and we get a lot of questions on our YouTube we get them on our podcast.

They're very legitimate questions but also there's not enough information to really answer this. If this person does not lift a single weight in their entire life I think the biggest gap that we can fill is showing them some good quality resistance training and it doesn't have to be with barbells or dumbbells or free weights. It could just be with simple machines. Like literally anything that they do is going to benefit them and I bet their hip flexor will start to feel better. Now if they've been doing that let's just say take it the other way they've been doing that and they deadlift like three times their body weight they back squat two times their body weight and they go to the gym six days a week.

Maybe they're doing too much. They need a little recovery time. So we need to scale back and then figure out what an adequate benchmark is for them for their lifting because if this is a runner they don't need to do that much. They just need to do enough because their main activity is running. We don't want to make the person feel worse just to get stronger so they can't actually run or hike or do the things that they want to do. But most of the time if stretching is something that you have been doing and it's not working and you've done it diligently that is not the gap. So you don't need to continue with it.

But if I don't stretch and I started stretching and it started to make me feel better that is my gap. So I hope you guys are seeing that this is a different based upon each person. Question two I felt a pop in my hip during a sprint and now I have pain in the front of my hip. Did I tear my hip flexor and how serious is it? Well I think we can start with what are things that would identify that it probably is a tear and to what severity because I've met a lot of people with POPs and they don't really have any imaging finding of hip flexor tears. So usually people who have tears it's in two joint muscles.

So the hamstrings two joint muscle rectus femoris two joint muscle iliopsoas one biceps two joint muscle. So there's there's ones that are cross two joints that have a little bit more risk and I wouldn't necessarily be scared of it but if we were looking at a possible tear and there was like a real POP like people who know who have had a tear know what a POP is like. It's like someone shot you. It's like someone threw a baseball at your leg and you felt the boom right? And then followed by immediate disability. Like within a minute you cannot actually walk anymore. It's not like oh I played the rest of the game and you think it's a tear?

No. Probably not. Like you you're able to still function. When you have a real tear and I don't wish it upon anybody but you know they heal up well. When you have a real tear you know it's not a question anymore. It's not like hey you know maybe I'm too sick to go to work. You think I should maybe go to work today? It's not like that. It's like I am floored. I cannot physically get out of bed because I know it follows up with it within a week there's actually a pretty substantial amount of bruising that happens and the bruising usually happens distal or more down from towards the ground than where the tear happened.

So if there was going to be hip flexor tear actually or rectus femoris muscle tear which is part of the quad it would actually start to present more towards the knee than the actual location where it happened because blood goes down with gravity. And usually what I tell people is they're really concerned about that. I mean I've had a few I've had about like three hamstring tears I think at this point in one strain. I always tell them don't just do the basics like don't you don't need to be stretching in a bunch you don't need to be trying like don't try to do anything really that is going to massage it out or I wouldn't get like I wouldn't do that stuff like it's beyond that at this point and you need to get a little bit of time to recover.

And also too if you start doing a bunch of bruising work or what we call mash work you're going to bruise the area on its own so how do you know if the bruising came from the tissue work or it came from the actual tear if there was a tear but alternative MRI would show it if it really was a big concern x-rays would not it's kind of like a waste of time unless you're looking for a bony issue or a labral tear would show up partially in some forms in an MRI so MRI is not that expensive if people really do want to know I tell them go ahead and do it like I've paid cash for some of my MRI and they're like I think at that time they were 600 bucks or so and you know it's not that bad and for me it helped me with a little bit of peace of mind knowing that I didn't have what I feared that I had and if that's you then talk to your doctor and see if you can just get an MRI and if they won't agree to it because it's not really needed and they say medical necessity because the insurance won't pay this is kind of like pushes onto that whole fear thing where we know that if to make this person a worse runner and to make them feel like they're not succeeding with their physical endeavors and I know a lot of runners run for the mental clarity and stuff like that I like we want to give them wins and we don't want to disable this person and so usually I tell them like be smart like you don't have to baby this thing but I wouldn't be reckless with it either like if you were planning an event and it's like two weeks from now like be okay with missing it but if you're just doing training runs and recreational ones and that's fine if you're hanging out with your group if you're just doing it for cardio and you're doing alone you don't like running you don't need to run you can do other things for cardio there's other ways to get that need to address that gap but usually we have like a two out of ten rule if things bother someone two out of ten when they start running or hiking and it starts to get better usually that's not a bad thing that warms itself up this is what we see a lot of times with some of our tendon issues and stuff like that with a tear like it would be worse right and a lot of times people will with various different types of conditions that create activities green light is it doesn't hurt yellow is cautionary and this is what we do here at performance ways when we work with people we help them identify what's safe to do because it's not easy having an injury physically it's not easy but also people's mind gets really occupied with what they should be doing what's safe they read these things on the internet and I mean I've seen so many people at this point where they are just so confused with conflicting information on the internet with different videos and podcasts and stuff like that and I always told them I said that information that you read is not bad information necessarily but it's within a certain context they write these articles they do these podcasts with a certain person and injury type and even age demographics in mind and so if you want to curate your care to you and not have to worry about do's and don'ts and so on then you need to see someone who actually can give you those answers and then trust them a little bit and if they don't deserve your trust because they've wronged you or they've given bad information that's a whole different thing but you give every give your health provider a chance to give you a good suggestion and don't expect miracles it was a process that got most people here it's it'll process that gets them out too it's not an overnight phenomenon so I hope this was helpful to you and don't worry too much about your hip groin issue it will get better if you find the right care if anything in today's episode resonated with you visit the link in your podcast player there you'll find any free resource that we mentioned in the show any guest links and a link for a free discovery call with us we're licensed to work with our outdoor active people via telehealth across many states in the U.S.

at this point in fact we cover almost half of the population in the U.S. we add more states every year thanks for listening subscribe to the show and we'll see you in the next one