Understanding Hip Pain —
Finding the Source

This is the most important diagnostic question in hip pain assessment — and the answer is not always obvious. True hip joint pain (intra-articular) almost always includes groin pain. It is worsened by weight-bearing activities, restricted hip internal rotation, and specifically reproduced by clinical tests that load the hip joint (FABER, FADIR). Lumbar referred pain tends to accompany back symptoms, may spread into the anterior thigh or knee, and is reproduced by lumbar movement or neural tension tests rather than hip provocation tests.

The single most reliable indicator of true hip joint pathology is restricted and painful internal rotation of the hip in a flexed position — a finding that is rarely produced by lumbar spine pathology. Conversely, pain that disappears when the spine is assessed in extension or that follows a dermatomal pattern into the thigh strongly suggests a lumbar origin. ROOT METHOD's assessment applies both sets of tests systematically to ensure the correct source is identified, not assumed.

Femoroacetabular impingement (FAI) is a morphological condition in which abnormal contact occurs between the femoral head and the acetabular rim during hip movement — typically at end-range flexion and internal rotation. There are two types: cam impingement, where an abnormal bony prominence on the femoral head catches on the acetabular rim during flexion; and pincer impingement, where over-coverage of the femoral head by the acetabulum causes repeated compression of the labrum. Both types can coexist and both can damage the labrum and cartilage over time.

FAI is the most common cause of hip pain in young to middle-aged active adults and athletes. It produces deep groin pain, typically with prolonged sitting, hip flexion activities, and twisting movements. Early identification is important because labral damage secondary to untreated FAI accelerates the development of hip osteoarthritis. Conservative management — activity modification, movement retraining, hip muscle strengthening — can be highly effective in the early stages. Arthroscopic surgery is considered when conservative measures fail.

Greater trochanteric pain syndrome (GTPS) — previously called trochanteric bursitis — is a tendinopathy of the gluteus medius and gluteus minimus tendons at their insertion on the greater trochanter of the femur, often accompanied by associated bursal inflammation. Despite historical focus on the bursa, the primary pathology is degenerative change within the gluteal tendons rather than bursitis. This distinction matters clinically because treatment directed at the tendon (load management, progressive strengthening) is more effective than anti-inflammatory treatment alone.

GTPS is most common in women over 40 and in those with a wider pelvis or leg length discrepancy. The hallmark symptom is lateral hip pain — over and around the greater trochanter — that is significantly worsened by lying on the affected side, crossing the legs, sitting with legs crossed, and prolonged walking. The single-leg stance test (Trendelenburg) typically reproduces symptoms. Compressive loading of the gluteal tendons — adduction postures — drives the pathology and should be avoided during rehabilitation.

No — the majority of hip pain conditions are managed successfully without surgery. Even hip osteoarthritis, which is progressive, can be managed conservatively for extended periods through a combination of targeted exercise, load management, weight optimisation, and activity modification. Studies consistently show that structured exercise programmes reduce pain and improve function in hip OA comparably to analgesic medication, often with more durable results.

Joint replacement is considered when conservative management has been optimised and fails to provide adequate pain relief, when quality of life is significantly impaired, and when there is evidence of severe structural joint destruction. Total hip replacement is one of the most successful surgical interventions in medicine — but it is not the inevitable destination for everyone with hip pain. ROOT METHOD's approach is to determine whether conservative management has been correctly directed, before surgical options are considered.

Yes — hip dysfunction can produce knee pain through two mechanisms. First, the lumbar spine refers pain into the anterior thigh and knee through the L3 and L4 nerve roots; this is sometimes experienced as knee pain without any primary knee pathology. Second, altered hip mechanics — reduced hip abductor strength, increased hip adduction, and impaired hip control during walking — increase the valgus loading on the medial knee, producing patellofemoral or medial knee pain over time.

Patients with unexplained knee pain — particularly medial or anterior — who have had negative knee investigations should have their hip and lumbar spine systematically examined. A significant proportion of patellofemoral pain syndrome presentations are driven by hip abductor weakness and impaired hip control rather than primary knee pathology. Treating the knee without addressing the hip creates a clinical cycle of partial improvement and recurrence.

The appropriate activity modifications depend on the structural source of pain. For FAI and labral pathology, deep hip flexion activities — deep squatting, seated positions with the hips flexed beyond 90°, cycling with a low seat — should be reduced during symptomatic periods. For greater trochanteric pain syndrome, compressive loading of the gluteal tendons is the primary driver — crossing the legs, sleeping on the affected side, and sitting with legs crossed should be specifically avoided, as these positions compress the tendons against the greater trochanter.

For hip osteoarthritis, impact activity should be balanced against the known benefits of regular low-impact exercise. Swimming, cycling (with appropriate seat height), and walking on level surfaces are generally well tolerated. Heavy asymmetric loading, prolonged single-leg activities, and extreme ranges of motion should be avoided during symptomatic flares. ROOT METHOD provides specific activity guidance as part of the treatment protocol — generic modification advice without a structural diagnosis is rarely effective.