Why Do My Hips Hurt? The Physical Therapy Approach to Chronic Hip Pain

That nagging hip ache, the one that makes standing up a little harder, turns a casual walk into something you have to think about, or keeps you from squatting, bending, or moving the way you used to, can take more out of you than you realize. It’s not just annoying. It’s limiting. It can make you feel older than you are and disconnected from the active, comfortable life you want back.

As a Doctor of Physical Therapy, I see patients every day who are struggling with chronic hip pain and restricted movement. They are looking for answers and a clear path forward. In this article we will explain the why behind your pain and the how of effective, evidence-based treatment.

What Causes Chronic Hip Pain?

Diagnosing the true source of chronic hip pain is a complex process. The hip is a major load-bearing joint surrounded by a dense network of muscles, ligaments, and nerves. Pain can originate from the joint itself, the surrounding soft tissues, or even be referred from other areas. Research highlights that chronic hip pain is multifactorial, meaning it often has more than one contributing cause (Ahuja et al., 2020). Furthermore, a study in the Journal of Korean Medical Science found that many cases of chronic hip pain in young adults are initially misdiagnosed by primary physicians, underscoring the need for a specialized evaluation to pinpoint the correct issue (Lee et al., 2018).

What Could Be Causing My Hip Pain?

Several common structural and inflammatory conditions are frequent culprits behind hip pain and stiffness.

Femoroacetabular Impingement (FAI):

This occurs when the bones of the hip joint (the ball and socket) are abnormally shaped, causing them to rub or “impinge” on each other during movement. This can damage the cartilage and labrum over time.

Labral Tears:

The labrum is a ring of cartilage that lines the rim of your hip socket, acting like a gasket to provide stability and seal the joint. A tear in this structure, often caused by trauma, FAI, or repetitive movements, can lead to sharp, catching pain, clicking, and a sense of instability. The labrum is crucial for normal hip function, and its injury can be a significant source of chronic symptoms (Groh & Herrera, 2009).

Hip Osteoarthritis (OA):

This is a degenerative “wear-and-tear” condition where the protective cartilage covering the ends of the bones gradually breaks down. This leads to pain, stiffness, and loss of mobility as bone-on-bone friction increases.

Bursitis and Tendinopathies:

The hip is surrounded by fluid-filled sacs called bursae that cushion the joint, and powerful tendons that attach muscle to bone. When these soft tissues become inflamed from overuse or mechanical stress—a condition known as bursitis or tendinopathy—it can cause significant pain, typically on the outside of the hip. The principles of rehabilitating these soft tissue injuries involve managing load, reducing inflammation, and correcting underlying biomechanical faults (Hammond et al., 2021).

Pelvic Floor

Referred pain can also come from the pelvic floor. This is typically due to a muscle imbalance. Muscle guarding from the pelvic floor can make SIJ signs and symptoms radiate to the hip. Pelvic floor tension can refer to the hip. Some of the anatomy of the pelvic floor is adjacent and shares connective tissue with hip rotators.

Hip Pain from Muscle Imbalances and Movement Dysfunction

Often, hip pain isn’t caused by a structural problem within the joint itself, but by how the muscles controlling it are functioning. A hip muscle imbalance—where some muscles become tight and overactive while others become weak and inhibited—disrupts normal biomechanics and creates dysfunctional movement patterns. For example, chronically tight hip flexors paired with weak gluteal (buttock) muscles can alter the position of the pelvis and femur, leading to strain on the joint capsule, tendons, or even the lower back. A key part of the solution is targeted muscle re-education, a process of retraining the nervous system and muscles to work together correctly (Reiman & Matheson, 2013).

How Posture, Sitting, and Lifestyle Habits Impact Hip Mechanics

Many patients believe their pain is an inevitable part of “just getting old”. However, our daily habits often play a significant and modifiable role. Prolonged sitting is a primary offender, contributing to a pattern of shortened, tight hip flexors and “deactivated” or weak gluteal muscles. This combination forces other muscles to overcompensate and can place the hip joint in a chronically stressed position. Similarly, poor standing posture, such as habitually leaning onto one leg, creates asymmetrical loading forces that can lead to overuse injuries and pain on one side of the body.

Referred Hip Pain from the Low Back or SI Joint

One of the most confusing aspects of hip pain is that it may not be coming from the hip at all. The nerves that provide sensation to the hip, groin, and buttock region originate in the lumbar spine (low back). If a nerve root is irritated or compressed by a condition like a herniated disc or spinal stenosis (lumbar radiculopathy), it can send pain signals that are felt in the hip. This is known as referred pain. Similarly, dysfunction in the sacroiliac (SI) joints, which connect your spine to your pelvis, can also refer pain to the buttock and hip area.

How Physical Therapists Evaluate Hip Pain and Restricted Movement

To solve a problem, you must first understand it. A physical therapy evaluation is a systematic process of investigation designed to uncover the root cause of your hip pain and restricted movement. It goes far beyond just looking at the painful area; it assesses how your entire body moves. This process lays out the groundwork for a truly personalized treatment plan.

Measuring Strength, Mobility, Leg Length, and Pelvic Alignment

The objective examination involves taking precise measurements to get a clear picture of your physical status. A physical therapist will:

• Measure Hip Mobility: We measure your hip’s range of motion in all directions (flexion, extension, rotation, etc.). This tells us which specific movements are restricted.
• Assess Muscle Strength: Through manual muscle testing, we grade the strength of key hip muscles, such as the glutes, hip flexors, and abductors. Weakness in specific muscles provides crucial clues about imbalances.
• Check Pelvic Alignment and Leg Length: We use specific tests and landmarks to assess for pelvic tilts, rotations, or apparent leg length discrepancies, which can significantly alter hip mechanics.
• Perform Special Tests: We may use specific hands-on tests, like the Thomas Test to assess hip flexor length or the FABER test to screen for joint or SI joint pathology.

Assessing strength and flexibility is a vital part of a comprehensive rehabilitation program (Tyler et al., 2014). These objective measures provide a critical baseline from which we can track your progress and ensure your treatment plan is effective.

Functional Movement Testing: Squat, Gait, and Single-Leg Stability

Pain and restriction often become most apparent during movement. That’s why we don’t just assess you while you’re lying on a table. We need to see your body in action.

• Gait Analysis: We watch you walk to observe patterns like a Trendelenburg gait (where the hip drops on one side), which indicates gluteus medius weakness.
• Squat Assessment: Analyzing how you perform a simple bodyweight squat can reveal a wealth of information about hip mobility limitations, muscle imbalances (e.g., knees caving inward), and compensatory strategies.
• Single-Leg Stability: Asking you to stand on one leg or perform a single-leg squat tests the ability of your hip and core muscles to stabilize your pelvis. Poor performance here is directly linked to an increased risk of injury.

This functional testing is crucial because it highlights the relationship between your core, hip, and pelvic floor (Willson et al., 2005). The information gathered helps us create a highly personalized and effective treatment plan that addresses not just your symptoms, but the faulty movement patterns that cause them (14).

Why Hip Mobility Matters for Your Entire Body

Your hip is the central pivot point of your body, connecting your upper and lower halves. Its health has a profound impact on the entire kinetic chain—the interconnected system of joints and muscles that work together to create movement. When the hip loses its ability to move freely, other areas are forced to compensate, often leading to a cascade of problems. Improving hip joint movement can therefore significantly alleviate symptoms in adjacent areas (Haber et al., 2023). This is why understanding how to improve hip mobility is so critical for issues like back pain.

How a Stiff Hip Affects the Back and Knee

One of the most common and problematic restrictions is a loss of hip rotation, particularly internal rotation. Think of your hip as a ball-and-socket joint designed for 360-degree movement. If that ball can’t rotate freely within the socket, your body will find a way to achieve the motion elsewhere. Often, this compensation occurs at the lumbar spine or the knee. To make up for a stiff hip, your lower back may be forced to twist excessively, leading to low back pain and SI joint dysfunction. This link between hip muscle imbalance and low back pain is a common clinical finding (Nadler et al., 2002). Downstream, the knee may be forced to rotate or collapse inward to compensate, placing abnormal stress on its ligaments and cartilage. The analogy is like a rusty door hinge; if the hinge won’t turn, you’re forced to bend and warp the door frame to get it open.

The Connection Between Core Stability and Hip Function

The term “core” refers to much more than just your abdominal muscles. It’s a muscular box comprised of the diaphragm at the top, the pelvic floor at the bottom, the abdominals in the front, and the deep spinal muscles in the back. The primary job of this “box” is to provide core stability. Core stability is the foundation that allows for the production, transfer, and control of force and motion to the lower body (Willson et al., 2005). A stable core creates a solid platform for your powerful hip muscles to pull from. Without it, the pelvis becomes unstable, forcing the hip muscles to work ineffectively and predisposing the area to strain and injury. A key, often overlooked, aspect of core stability is proper diaphragmatic breathing, which helps regulate intra-abdominal pressure and stabilize the spine from within.

The Role of the Glutes in Pelvic Control and Pain Prevention

The gluteal muscles (gluteus maximus, medius, and minimus) are the powerhouse of the hip. They are not just for show; they are absolutely essential for pelvic control and pain prevention.

• Gluteus Maximus: The largest of the three, it is the primary muscle for powerful hip extension (moving your leg behind you), crucial for climbing stairs, running, and getting up from a chair.
• Gluteus Medius and Minimus: Located on the side of the hip, these muscles are critical for stabilizing the pelvis when you are on one leg, such as during walking or running.

Weakness in these muscles, particularly the gluteus medius, can lead to the “Trendelenburg” gait pattern mentioned earlier, where the pelvis drops on the opposite side. This creates shearing forces across the low back and abnormal stress on the hip and knee. Targeted activation of these deep hip muscles has been shown to change the loading patterns at the hip joint, underscoring the importance of specific strengthening for both treatment and prevention (Meinders et al., 2022).

The Physical Therapy Approach to Treating Chronic Hip Pain

Once a thorough evaluation has identified the root causes of your pain, we can build your treatment plan for recovery. The physical therapy approach is a multi-faceted strategy focused not just on temporary relief, but on creating lasting change.

Restoring Mobility Through Joint and Soft Tissue Techniques

The first step is often to calm down irritated tissues and restore normal joint mechanics. This is the “hands-on” component of physical therapy, known as manual therapy.

• Joint Mobilizations: If your hip joint capsule is tight and restricting movement, your therapist will use skilled, graded movements of the joint to improve its mobility. This is a gentle technique designed to stretch the deep connective tissues you can’t stretch on your own. The goal is to improve capsule mobility and restore optimal joint movement (Reiman & Matheson, 2013).
• Soft Tissue Mobilization: To address tight and overactive muscles, your therapist may use various techniques like massage, myofascial release, or instrument-assisted soft tissue mobilization to reduce muscle tension, break up adhesions, and improve the flexibility of the muscles and fascia surrounding the hip.

Retraining Movement Patterns for Better Hip Function

Pain relief is only part of the equation. If we don’t address the faulty movement patterns that created the problem, the pain is likely to return. This is the educational and neuromuscular re-education phase of therapy. A huge part of physical therapy is coaching patients on how to adjust their daily movements to reduce strain. This process involves teaching your brain and muscles to work together in a more efficient way (Reiman & Matheson, 2013). 

Strengthening Hip Stabilizers for Long-Term Relief and Load Tolerance

The final and most crucial pillar is building strength. A progressive strengthening program is essential for long-term success in hip rehabilitation (Tyler et al., 2014). The goal is to move beyond pain relief and build a robust, resilient system that can tolerate the loads of daily life, work, and recreation. This involves targeted hip strengthening exercises for the entire hip and core complex. Key exercises often include:

• Glute Bridges: To activate and strengthen the gluteus maximus and hamstrings.
• Clamshells: To target the gluteus medius for pelvic stability.
• Bird-Dog: To enhance core stability while coordinating hip movement.
• Side Planks: To strengthen the core and lateral hip stabilizers.

Your physical therapist will guide you on proper form, sets, reps, and progression to ensure you are building strength safely and effectively.

How Chiropractic Care Complements Physical Therapy for Hip Pain

In our integrative clinic, we recognize that the body works as a unified system. While physical therapy addresses muscle function and movement patterns, chiropractic care provides a powerful complementary approach by focusing on spinal and pelvic alignment. This synergy can be particularly effective when hip pain is driven or influenced by issues in the low back and pelvis.

Restoring Pelvic and Lumbar Alignment to Improve Hip Mechanics

A chiropractor’s primary role in this team is to assess and restore proper alignment of the lumbar spine and sacroiliac (SI) joints. A misaligned pelvis can create a functional leg length discrepancy and alter the mechanics of the hip joint, placing chronic stress on it. By using precise adjustments to correct these misalignments, a chiropractor can address a primary root cause of referred hip pain. Think of it as aligning the car’s frame (the work of the chiropractor) before performing a wheel alignment and strengthening the suspension (the work of the physical therapist).

How Chiropractic Adjustments Reduce Joint Stress and Enhance Mobility

A chiropractic adjustment, or spinal manipulative therapy, is a specific, controlled force applied to a joint to restore its proper motion. When spinal or pelvic joints are restricted, it can lead to protective muscle guarding and increased mechanical stress. An adjustment can help improve the mobility of these segments, which in turn can help “unload” the hip joint and reduce pain signals. This process complements the joint and soft tissue mobilization performed by the physical therapist, working to improve overall system mobility from both a spinal and extremity perspective.

When to See a Physical Therapist or Chiropractor for Hip Pain

While some minor aches resolve on their own, you don’t have to live with persistent pain. 

It’s time to seek professional help if you experience:

• Pain that lasts for more than two or three weeks.
• Pain that is constant or worsens over time.
• Pain that interferes with your sleep or daily activities like walking, climbing stairs, or standing up from a chair.
• A feeling of instability, “giving way,” catching, or locking in the hip.
• Getting a proper diagnosis is critical to avoid wasting time on ineffective treatments and to prevent chronic issues from worsening.

Conclusion

If you’re tired of living with hip pain and are ready to find the root cause, schedule a comprehensive evaluation with our integrative team today. Let us help you build your personalized plan to restore movement and get back to the activities you love.

This article is for informational purposes only and does not constitute medical advice. The content is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition.

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