ANTERIOR HIP PAIN IN RUNNERS

Pain in the front of the hip or the groin is a frequent issue faced by runners, often disrupting training and performance. This is especially the case with increases in long-run distance or overall training volume. Studies suggest that up to 10-15% of all running-related injuries involve the hip or pelvis, with a significant portion affecting the anterior hip region (Taunton et al., 2002). The prevalence is higher in populations with risk factors such as high training volumes, poor biomechanics, or previous injuries.

When experiencing pain, the most intuitive reaction is to stop what you’re doing until the pain goes away. This reaction may resolve the present pain, but upon returning to running the hip pain likely returns as well. Understanding the potential sources of anterior hip pain, risk factors, and the underlying causes can help runners manage symptoms effectively, enabling them to continue their training. 

Sources of Pain

The front of the hip contains several anatomical structures that can become pain-generators. Hip flexor muscles including the iliacus, psoas major, rectus femoris, and tensor fascia lata (TFL) cross the anterior hip joint and are critical for flexing the hip — driving the lower limb forward while running. Strain or tightness in these structures can manifest as pain in the front of the hip. Beneath the muscles, there lives a bursa, a fluid-filled sac that enables tendons to glide smoothly as the muscles contract and relax throughout the gait cycle. Inflammation of the iliopsoas bursa can occur with repetitive hip flexion and may be a source of anterior hip pain. This is often exacerbated by repetitive stress, especially in runners engaging in a lot of uphill running. Deep in this region lies the hip joint itself, which is susceptible to injury and can be a source of pain. Running repetitively loads the hip joint, and while running does not directly cause femoroacetabular impingement (FAI), labral tears, or osteoarthritis it can become painful if a runner already has one of these conditions. Osteoarthritis of the hip involves degeneration of cartilage and can lead to pain and stiffness, especially in older runners or those with a history of hip injuries (Culvenor et al., 2017).

Causes of pain

Every runner and human being contains these aforementioned anatomical structures. So why do some experience pain while others do not? Several risk factors exist which may increase the likelihood of anterior hip pain with running. Perhaps the most common cause of hip pain with running is training error. A sudden increase in running intensity, frequency, or duration can load the hip joint or the muscles surrounding the hip excessively. Aside from training load, the greatest risk factor is a history of previous injury, as any pre-existing labral tear or FAI will raise one’s likelihood of pain with running. FAI involves abnormal contact between the ball and socket of the hip joint and can limit the range of motion. It is more common in runners who engage in high volumes of hip flexion (Reiman et al., 2015), which is required for high-velocity running or sprinting. 

The art of running requires great skill, and adequate stability in the abdominal region to stabilize the trunk while the lower limb swings freely beneath. Muscle imbalances, weakness, or inhibition in the hip abductors and extensors (glutes) or in the abdominals, can lead to compensatory overuse of the hip flexors and excessive load on the hip joint, contributing to pain (Fredericson et al., 2000). If imbalances cause overuse of the hip flexors (iliopsoas, rectus femoris, or TFL), the hip flexors can be strained. Counter to glute and abdominal weakness, if a runner lacks flexibility or strength in the hip flexor muscles they can become strained (Neumann, 2010). This is especially the case in runners who suddenly increase training load without building tissue capacity gradually. 

While altering loading patterns, these muscle imbalances can also influence poor biomechanics and improper running form. Commonly, overstriding or excessive internal rotation of the hip can alter loading patterns at the hip joint and influence pain (Willson et al., 2015).

Management of Hip Pain 

Pain in the front of the hip can feel nagging and uncomfortable. But in most cases, complete rest from running is not advised. Load management is an essential piece of the puzzle and should involve a reduction in running volume and intensity by at least 50% for the first 1-2 weeks. Supplementing a training program with cross-training and lower-impact activities (aqua jogging, cycling, swimming, rowing) during this period can prevent further injury, allowing tissue to heal while maintaining aerobic fitness.  After managing acute symptoms, a gradual return to running volume and intensity is essential. This involves slowly increasing mileage and intensity while monitoring for any recurrence of symptoms.

Considering the association between muscle imbalances and the onset of anterior hip pain, it is essential to address these with strengthening and flexibility exercises. For strengthening, the target muscle groups should be the hip abductors and extensors (glutes) and the abdominal stabilizers. Incorporating single-leg glute bridges, side planks with clamshells, Bulgarian split squats and plank variations can help improve strength and stability in the core and hips. Flexibility exercises including hip flexor stretches and reverse nordics can help lengthen the front of the hip as well. 

A running-specific strengthening and flexibility program can help improve running form and mechanics. Gait analysis with a skilled coach or physical therapist can help assess and address biomechanical factors influencing excessive load on the structures at the front of the hip.  Analyzing running form through video gait analysis can identify biomechanical issues contributing to hip pain. Correcting these issues through gait retraining can reduce stress on the hip joint (Willson et al., 2015). Common running form deviations include overstriding and limited hip extension, which can be corrected and improved with proper cues and drills. 

If pain persists despite individual efforts, it is recommended to seek care from your local health care provider or physical therapist, preferably one who specializes in treating runners. Evidence supports the use of manual therapy, therapeutic exercise, and therapeutic modalities such as dry needling to address symptoms and limitations associated with hip pain (Bedi et al., 2013). 

Anterior hip pain in runners can result from a variety of sources, including muscle strain, joint impingement, labral tears, bursitis, and osteoarthritis. Understanding the anatomical structures involved, risk factors and potential causes is crucial for effective management. By incorporating relative rest, load management, strengthening, flexibility training, and gait retraining, runners can manage symptoms and continue training effectively.

References:

Bedi, A., Kelly, B. T., & Khanduja, V. (2013). "Arthroscopic hip preservation surgery: current concepts and perspective." Bone & Joint Research, 2(4), 46-51.

Culvenor, A. G., Øiestad, B. E., Hart, H. F., Stefanik, J. J., Guermazi, A., & Crossley, K. M. (2017). "Hip osteoarthritis and the role of sports in the development of hip osteoarthritis." Journal of Orthopaedic & Sports Physical Therapy, 47(6), 391-402.

Fredericson, M., Cookingham, C. L., Chaudhari, A. M., Dowdell, B. C., Oestreicher, N., & Sahrmann, S. A. (2000). "Hip abductor weakness in distance runners with iliotibial band syndrome." Clinical Journal of Sport Medicine, 10(3), 169-175.

Lewis, C. L., & Sahrmann, S. A. (2006). "Acetabular labral tears." Physical Therapy, 86(1), 110-121.

Neumann, D. A. (2010). "Kinesiology of the hip: a focus on muscular actions." Journal of Orthopaedic & Sports Physical Therapy, 40(2), 82-94.

Reiman, M. P., Goode, A. P., Cook, C. E., Hölmich, P., Thorborg, K., & Martin, H. D. (2015). "Diagnostic accuracy of clinical tests for the diagnosis of hip femoroacetabular impingement/labral tear: a systematic review with meta-analysis." British Journal of Sports Medicine, 49(12), 811-822.

Taunton, J. E., Ryan, M. B., Clement, D. B., McKenzie, D. C., Lloyd-Smith, D. R., & Zumbo, B. D. (2002). "A retrospective case-control analysis of 2002 running injuries." British Journal of Sports Medicine, 36(2), 95-101.

Verdonk, R., Pernin, J., Patteeuw, A., Hemsell, D. L., & Lustig, S. (2006). "Inflammatory pseudotumor following metal-on-metal hip resurfacing." The Journal of Bone & Joint Surgery, 88(3), 736-741.

Warden, S. J. (2009). "Prophylactic use of NSAIDs by athletes: a risk/benefit assessment." Physiotherapy Theory and Practice, 25(4), 232-249.

Willson, J. D., Ireland, M. L., & Davis, I. (2015). "Core strength and lower extremity alignment during single leg squats." Medicine & Science in Sports & Exercise, 38(5), 945-952.