Pain in the hip flexor or front of the hip/leg can be associated with several possible causes. When you experience pain in the front of the hip, and it doesn’t have an obvious mechanism of injury (such as tripping in a hole when running), then it’s almost always a repetitive motion injury or related to poor posture and/or biomechanics.
The location of pain in the hip flexor region can range from mid-thigh to the groin area to the lower stomach (from the belly button to the PSIS, which is the posterior superior iliac spine) or the front of the pelvic bone just up and lateral to the groin area where the primary hip flexor (psoas) originates.
Hip Flexor Pain and Pain in the Front of the Hip
Common potential reasons for pain in the front of the hip include:
- Femoral Stress Fracture
- Femoral Acetabular Impingement (FAI)
- Groin Muscle Strain
- Low Back Pain (LBP)
- Hip Flexor Strain
I will cover each one of these in more detail.
There are many common reasons to develop pain in or around the hip flexors. Often the cause for the pain is nearly identical (overuse). It’s important to get the proper diagnosis to insure that you’re treating the right structures.
Femoral Stress Fractures
The femur is the largest and longest bone in the body. However, that doesn’t mean that it can’t develop a stress fracture. Stress fractures are a unique type of bone fracture as they rarely occur due to a specific trauma. Stress fractures typically occur due to a silique of events that leads to the bone not being able to handle the stress of your activity (such as running) which results in a crack in the bone.
Initially, you might barely even notice the pain associated with a stress fracture, but the pain tends to worsen with time. The tenderness usually originates from a specific spot and decreases during rest. As the injury worsens, the pain tends to spread out and become more diffused with a focal area of tenderness. You might have swelling around the painful area. In cases of femoral stress fractures, pain will often be diffuse and spread up and down the femur or thigh.
When the load and/or volume of activity are too much for the bone, a stress fracture will occur. In most cases, a reduction or complete elimination of training will initially be necessary. It will be necessary to take close look at the events that caused the fracture including a thorough examination of your running plan and nutrition levels.
Pain caused by a hernia (particularly, in the inguinal region) can mimic hip flexor or groin pain.
- A small bulge on either side of the pelvic bone. The size can change depending on activity and especially, with coughing and straining.
- There may be a burning or achy sensation in the groin area or near the bugling.
There is increased pain after activity including running and weightlifting. Coughing can make it worse.
- There could be the sensation of heaviness or weakness in the groin area.
If you suspect that you might have a hernia, then it’s important to have it evaluated by a medical professional.
Femoral Acetabular Impingement (FAI)
Femoral Acetabular impingement (FAI), also known as hip impingement, is the major cause of hip osteoarthritis in people under the age of 50. FAI is due to bone spurs (bone overgrowth) along the bones that form the hip joint. The bone overgrowth causes the bones to have an irregular shape and no longer fit together as a perfect ball and socket joint. The bones start to rub and pinch the tissue inside the hip. This will often affect the labrum, which is part of the socket.
- Pain (typically in the groin area and/or toward the outside of the hip).
- Sharp pain with turning, twisting, and/or squatting in a weight bearing position.
- Stiffness and a sense of a dull ache within the hip joint when at rest.
- When FAI symptoms are mild, running may typically only cause the sensation of stiffness and achiness with an occasional stabbing pain. As the bones and cartilage wear, the symptoms will worsen.
The pain tends to vary depending on activity levels. It can wax and wane with long periods of time without much issue. The more active you are, the more likely you will develop worsening symptoms.
Typical Treatment for Femoral Acetabular Impingement (FAI):
- Activity Modification.
- Anti-Inflammatory Medications.
- Physical Therapy. It can be helpful to generally work on improving your range of motion (ROM) and to strengthen the muscles of your hips and pelvis that support the hip joint. This can generally relieve some of the stress on the injured labrum and cartilage.
Groin Muscle Strain
A groin strain is most common in individuals involved in running sports that require frequent cutting and changing of direction. The quick motion and large amount of force can cause a strain or pull in the inner thigh and groin musculature. This can also happen to runners while trail running. You may need to quickly change direction on the trail or jump over and around an obstacle in the path.
- Pain and tenderness in the inner thigh and groin region.
- There is usually a popping sensation during the injury with moderate to severe pain.
- Pain that tends to feel a little better when mildly active in straight planned meaning forwards or backwards (sagittal) motion, but it can become very sharp and stabbing with any quick movements or as the intensity increases.
- Pain tends to be deep and throbbing in the groin area after activity.
- Pain when you bring your legs together (hip adduction) or resist this motion.
- Pain when you raise your knee and flex your hip.
The initial treatment for a groin strain/pull is PRICE (Protection, Rest, Ice, Compression, and Elevation).
Potential Treatments for a Groin Muscle Strain:
- Soft Tissue Mobilization. Slow, direct, and mild pressure over the painful areas can be helpful to elevate tightness and pain. Massage therapy or using a foam roller (or other mobilization tool) around the surrounding areas may also be helpful.
- Exercise. Once you can begin to stretch and exercise the area, it is important to concentrate on are regaining full hip and pelvic mobility without pain and generally working on core stabilization as well as inner thigh and hip strengthening exercises. Progressing more slowly is almost always advised with these injuries.
Low Back Pain (LBP)
One might initially wonder why low back pain (LBP) is listed as a potential reason for pain in the front of the hip or hip flexor. However, pain in the hip flexors and front of the hip can often be associated with LBP.
The largest muscle group that flexes the hip is the psoas major and minor. These two muscles originate on the front part of the spine deep inside the abdominal area from the thoracic twelfth vertebrae and lumbar vertebrae L5-L1. This means that any issue affecting the spine can also cause pain for these two hip flexor muscles. In addition, pain in the spine tends to refer pain to other areas of the pelvis and lower leg depending on where the pain actually originates. The pain may or may not be directly over the injury site.
Hip Flexor Strain
There are many common reasons to develop pain in the front of the thigh. Pain in the hip flexors themselves can also be a complicated manner. There are several muscles that actually flex the hip including: the psoas major and minor; iliacus; sartorius; and the rectus femoris (one of the quadriceps muscles). Often with a true hip flexor strain, it’s not uncommon to have multiple muscle groups injured or affected.
The two most common reasons to have hip flexor pain is a traumatic strain or an overuse injury (typically due to faulty biomechanics and/or postural dysfunction).
- A sudden and sharp pain/pulling in the front of the hip at time of injury. Depending on the severity, you may or may not be able to complete your activity.
As pain worsens, there is usually a sensation of deep achiness. Associated muscle spasms and weakness are present.
- In more severe cases, a person will limp and have a notably shorter stride length.
- Pain when lifting the knee/flexing the hip is worse with resistance.
- Stretching will initially help reduce the pain, but it will quickly return as a person continues with upright activity.
- Notable pain and stiffness (particularly first thing in the morning or after prolonged sitting and rest).
In the case of an overuse injury, pain in the hip flexors will worsen as activity level and intensity increases and will increase generally over time. Pain that is initially experienced at the beginning of a run can partially resolve midway during the run. Then the pain will slowly increase and escalate as the run progresses. It gets worse the longer and further you go. Stretching the hip flexor will have a mild positive effect, but it’s typically short lived. This is more common with chronic issues such as tendinitis.
Treatment for Hip Flexor Pain
- Rest. Initially it is typically best to rest including stopping all running activity for a period of time and tapering down from your regular exercise activity and any activity that worsens your symptoms. You should not return to running until you can be pain-free throughout the day.
- Anti-inflammatories. Consider speaking with your medical professional about a short course of anti-inflammatory medication to help speed up your recovery. You may also consider more natural anti-inflammatories that could be used.
- Improve your mobility. Mobility issues and myofascial restrictions are highly correlated with hip flexor pain. Often there is tightness in the quadriceps (the rectus femoris is a hip flexor), the thigh (inner and outer) and/or hamstrings, and the back extensors. These areas of tightness are associated with hip flexor pain. Utilize self-mobilization techniques to work on the areas above, below, and around the painful area.
- Strengthen your core muscles. Focus on the strength of your back extensors and core muscles.
- Strengthen your hip muscles. Weakness in the hip external rotators and the hip abductors (like the gluteus medius) can be associated with hip flexor pain as weakness in these areas typically leads to altered running mechanics. Strengthening of these muscle groups can help you to avoid future hip issues as well as reduce your risk of developing other knee related issues including: Hip Bursitis; IT Band pain; and Patellar Femoral Pain Syndrome (PFPS).
- Have your gait analyzed while running. Gait or running abnormalities can increase your risk of developing hip flexor pain. An anterior pelvic tilt is just one of many issues that can affect running biomechanics and can lead to hip flexor pain. Check with your local running store or a physical therapy clinic that may offer a monthly gait analysis clinic. If you’re unable to obtain a gait analysis, ask your spouse or a friend to video record you (from behind) while you’re running. Then watch the recording to see if there are issues with your running posture and/or biomechanics.
The best way to rehabilitate hip flexor pain is to avoid it in the first place! Always work on lower leg mobility as part of your recovery protocol. Implement a strength training routine that targets the hip musculature as part of your ongoing cross training as well as a core strengthening routine. If your race includes many hills or is a trail race, then be sure to adequately train for both the uphill and downhill portion and the uneven terrain so that your body is ready for the stress.
If you start to develop hip flexor pain, then start your rehabilitation by resting while tapering down intensity and training volume. You may or may not have to stop running for a portion of time. It’s symptom dependent and determined by the severity of the strain. Try to use exercise, such as aquatic exercise, to maintain cardiovascular fitness. Always perform an adequate warm up and cool down.
More specific strategies to help you determine the cause of your hip flexor pain along with more thorough treatment and prevention strategies for those suffering from hip flexor pain are covered in the Resilient Runner Program, which is designed to help YOU meet YOUR training goals by insuring you have the tools to avoid injury, recover quickly, and train at a peak level.
What’s Inside the Resilient Runner Program:
Guidance on preventing and self-treating Hip Flexor Pain as well as many other common running related injuries, including Runner’s Knee, IT Band Syndrome, Piriformis Syndrome, and more!
Specific guidelines on when and how to return to running after experiencing an injury.
Rehabilitation guides with step-by-step photos demonstrating recommended exercises.
Step-by-step instructions on how to apply Kinesiological tape.
Downloadable podcasts, videos, and more!
If you’re tired of ongoing aches, pains, and injuries, learn how to become a resilient runner so that you can continue to train and compete in order to meet your goals!
Read more about the Resilient Runner here: