True hip pain is felt in the groin. Pain on the outside of the hip is usually something else entirely.
What is the most common reason for hip pain?
Hip joint pathology refers to the groin and the front of the thigh, sometimes to the knee.
Pain on the outer hip is far more often trochanteric bursitis or gluteal tendinopathy.
Pain in the buttock is frequently the sacroiliac joint or referred from the lumbar spine.
How it usually presents
- Groin pain and stiffness, worse with rotation — true hip joint.
- Outer hip tenderness, worse lying on that side — bursal or tendon.
- Buttock pain radiating down the leg — spine or sacroiliac.
- Difficulty with socks, shoes and getting in and out of a car.
How we treat it
- Working out which of the three it actually is, because they are treated differently.
- Bursa injection or image-guided joint injection.
- Physical therapy for gluteal tendinopathy, which responds well to loading and badly to rest.
To be assessed, call us or request an appointment. If this began with a crash or a fall, see accident and injury care.
What usually gets missed
Location is the diagnostic key and it is routinely ignored. True hip joint pain is felt in the groin. Pain on the outside of the hip is almost always gluteal tendinopathy or trochanteric bursitis. Pain in the buttock is usually the spine or the sacroiliac joint.
Patients referred for hip pain frequently have three different problems distributed across those three locations, and an injection into the joint does nothing for the outer hip.
What to expect over time
Gluteal tendinopathy responds to progressive loading and responds badly to rest — the opposite of most people’s instinct and of most advice given.
Trochanteric bursitis usually settles with a guided injection plus the loading work that addresses why it became inflamed. Without the second part it recurs reliably.
How can I tell if my hip pain is serious?
Inability to bear weight after a fall, particularly in an older adult, warrants imaging to exclude a fracture even where the X-ray initially looks normal. A hot painful hip with fever needs emergency assessment. Groin pain with night pain in someone with a cancer history requires prompt investigation.
Why it happens
True hip joint pain is usually felt in the groin and referred to the front of the thigh or the knee, and it is worse on weight-bearing and rotation. Pain over the outer hip is more often from the greater trochanteric structures — gluteal tendon and bursa — and pain in the buttock frequently arises from the lumbar spine or sacroiliac joint rather than the hip at all.
What can be mistaken for hip pain?
That distinction accounts for most of the misdiagnosis in this region. Patients are treated for hip arthritis when the source is the lumbar spine, and treated for back pain when the source is the hip. Where both are degenerate, a diagnostic injection into the joint establishes how much of the pain the hip is actually generating.
What the imaging can and cannot tell us
Imaging excludes serious pathology well and identifies pain sources poorly. Degenerative findings are close to universal past middle age and appear in large numbers of people with no symptoms at all, so a report listing several abnormalities rarely settles which one hurts. Where a scan will not change the plan, we will say so rather than ordering it.
Common questions
Why is my ‘hip pain’ being treated as a back problem?
Because pain in the buttock and outer hip most often originates in the spine or sacroiliac joint. The examination decides.
Sacroiliac Joint Pain explains what that looks like.
My pain is in my buttock. Is that my hip?
Often not. Buttock pain more commonly arises from the lumbar spine or the sacroiliac joint. True hip pain is usually felt in the groin.
The detail is in Piriformis Syndrome and Deep Gluteal Pain.
Why does my knee hurt if the problem is my hip?
The hip joint refers pain to the thigh and knee, and knee pain with a normal knee examination is a recognized presentation of hip pathology.
See Knee Pain.
What is the best way to relieve hip pain?
Start by finding out which of three problems you have, because each one is treated differently. Pain in the groin is the hip joint itself and may call for an image-guided joint injection. Pain on the outer hip is usually bursitis or gluteal tendinopathy, treated with a bursa injection and physical therapy built on loading. Pain in the buttock is often the spine or the sacroiliac joint.
Should I rest pain on the outside of my hip?
No. Gluteal tendinopathy, a common cause of outer hip pain, responds to progressive loading and responds badly to rest. That is the opposite of most people’s instinct and of most advice given. Trochanteric bursitis usually settles with a guided injection plus the same loading work. Skip the loading and the bursitis reliably comes back.
Will a hip joint injection help pain on the outside of my hip?
Usually not. An injection into the hip joint treats the joint, and joint pain is felt in the groin and the front of the thigh. Outer hip pain usually comes from the gluteal tendon or the bursa, which need their own treatment. Many people referred for hip pain have more than one of these problems at once, so each location is checked.
Do I need an MRI for hip pain?
Not always. Imaging is good at ruling out serious problems and poor at showing which structure is causing the pain. Wear-and-tear findings are close to universal past middle age and show up in many people with no pain at all. After a fall, when you cannot bear weight, imaging is needed to rule out a fracture. If a scan will not change the plan, we tell you so.
Sources
- Hall M et al. How does hip osteoarthritis differ from knee osteoarthritis?. Osteoarthritis and cartilage, 2022. PubMed 34600121
- Lespasio MJ et al. Hip Osteoarthritis: A Primer. The Permanente journal, 2018. PubMed 29309269
- Pianka MA et al. Greater trochanteric pain syndrome: Evaluation and management of a wide spectrum of pathology. SAGE open medicine, 2021. PubMed 34158938
- Murphy NJ et al. Hip Osteoarthritis: Etiopathogenesis and Implications for Management. Advances in therapy, 2016. PubMed 27671326
Hurt in an accident? Start here.
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