You finish a long run and feel a nagging ache near your hip. But exactly where that pain lives is one of the most important clues to figuring out what’s wrong. When people tell us they have pain in their hip, we first ask whether the pain is on the outside of their hip, deep in their groin, or somewhere in between.
Many runners describe any pain in the hip region as simply “hip pain,” but the anatomy here is complex. Getting the location right helps you (and your PT) quickly narrow down the likely culprits, avoid making things worse, and get back to running smarter.
Location Matters
Think of your hip as having two distinct problem zones. They sit near each other anatomically but are served by different structures, muscles, and tendons. Each area tends to develop different types of injuries.
Lateral/Posterior Hip Pain
- Pain on the outer side of the hip or more posterior in the buttocks
- Often tender to direct touch
- Often hurts lying on that side at night
- Sometimes feels worse going up stairs or hills
- Sometimes radiates down the outer thigh
Anterior Hip Pain/Groin Pain
- Pain in the front crease of the hip
- Deep ache, sometimes hard to pinpoint
- Hurts with flexing the hip (lifting your knee)
- May feel like a catch or click inside the joint
- Can refer to the inner thigh or buttock
These distinctions aren’t absolute, but they’re a reliable starting point. Let’s go through each zone.
Lateral Hip Pain
The lateral hip is home to some of the most commonly misunderstood running injuries. For years, conditions in this area were broadly labeled “bursitis,” but we now know the tendons themselves are usually the primary culprit.
Gluteal tendinopathy (greater trochanteric pain syndrome)
This is the most common cause of lateral hip pain in runners and active adults, especially women over 40. The gluteal tendons, which attach the glute muscles to the bony bump on the outside of your hip called the greater trochanter, become irritated and degenerate under repeated compressive load. It produces a deep, aching pain directly over the outer hip that is classically worse first thing in the morning, after sitting with legs crossed, and when walking uphill. Many people are told they have “bursitis,” and while the bursa (a small fluid-filled sac nearby) can also be inflamed, the tendon is usually where the problem starts. This is important to know because tendons are treated very differently from other injuries. They respond best to load (strength), rather than rest.
IT band syndrome
The iliotibial (IT) band is a thick strip of connective tissue running from the outside of your hip all the way down to your knee. When it becomes irritated, it can cause a sharp or burning pain on the outer side of the knee, but it frequently presents with discomfort along the outer thigh and into the lateral hip as well. If your lateral pain tends to come on at a predictable point in your run and improve when you stop, IT band syndrome is worth considering. IT band syndrome is often the result of a sudden increase in mileage, running on cambered roads, or biomechanical factors such as hip weakness. Treating the inflammation can help, but IT band syndrome responds best to treating the root cause to avoid irritation of the fascial-like tissue.
Piriformis syndrome and deep gluteal pain
I mention this as a separate injury from gluteal tendinopathy only because it is a well-known muscle among runners. I would argue it’s not often the problem people think it is, with gluteal tendinopathy being more common and presenting with similar symptoms. The piriformis is a small but important muscle deep in the buttocks that can become tight or irritated in runners, particularly those with poor hip stability or who sit for long hours. It produces a deep, aching pain in the buttocks and outer hip area. What makes this one tricky is that the sciatic nerve runs near (and occasionally through) the piriformis, so some people experience radiating pain or tingling down the back of the thigh — a pattern that can mimic a disc problem in the lower back. If there is tingling or radiating pain, it is important to distinguish between a low back, posterior hip, or hamstring issue.
Ischiofemoral Impingement
Ischiofemoral impingement (IFI) is a less commonly recognized but increasingly diagnosed source of posterior hip and groin pain that occurs when the space between the ischium (the lowest bony part of your pelvis) and the lesser trochanter (a small bony projection on the inner femur) becomes narrowed, pinching the quadratus femoris muscle that runs between them. Runners often describe it as a deep, diffuse ache in the buttock or posterior hip crease — sometimes extending into the inner thigh — that is hard to pinpoint and easy to mistake for a hamstring issue, hip flexor problem, or even sciatica. It tends to flare with activities that bring the hip into extension and adduction simultaneously, such as the push-off phase of running, walking with a long stride, or crossing one leg over the other. Women are diagnosed more frequently than men, likely due to differences in pelvic geometry that naturally narrow the ischiofemoral space. Because IFI sits at an anatomical crossroads between the posterior hip, inner thigh, and groin, it is frequently overlooked on a standard evaluation — a high index of suspicion, combined with MRI findings showing edema or atrophy of the quadratus femoris, is typically needed to confirm it.
Anterior Hip Pain/Groin Pain
Hip flexor strain or tendinopathy
The hip flexors, primarily the iliopsoas muscle group, are among the hardest-working muscles in a runner’s body. They lift the thigh with each stride and are frequently overloaded, especially with speed work, hill running, or when core stability is lacking. A hip flexor strain causes pain in the front of the hip and groin that is sharp during activity and tender to the touch. Chronic overuse can lead to tendinopathy, a more stubborn condition where the tendon tissue itself degenerates. Some people also experience a painless or occasionally painful “snapping” sensation in the groin when the hip flexor tendon slides over a bony ridge — this is called snapping hip or coxa saltans, and when it hurts, it’s called snapping hip syndrome. Be wary of simply stretching a painful hip flexor. Hip flexor tendinopathy responds well to loading (strengthening), but it is also beneficial to learn how to properly recruit the diaphragm, pelvic floor, and other core muscles to avoid overuse of the hip flexor.
Hip impingement (femoroacetabular impingement, or FAI)
FAI occurs when bony abnormalities on the ball or socket of the hip joint cause abnormal contact and pinching of the joint structures during movement. It’s more common than most people realize and is often discovered in active adults who have had vague groin or anterior hip discomfort for years. The hallmark symptom is a deep groin ache that worsens with activities that require end-range hip flexion. These activities include squatting deeply, sitting for long periods, or accelerating hard out of a stride. Some people feel a sharp pinch when bringing the knee up toward the chest. FAI does not always require surgery; many people do very well with activity modification, targeted physical therapy, strength training, and running form retraining.
Hip labral tear
The labrum is a ring of cartilage that lines the rim of the hip socket, deepening it and helping to stabilize the joint. Labral tears can occur from a single traumatic event, but more commonly develop gradually from hip impingement, repetitive loading, or structural factors. Symptoms include a deep groin ache, a feeling of “catching” or locking in the hip, and sometimes a clicking sensation and sharp pain. Pain is often worse with prolonged sitting, pivoting, and transitions from sitting to standing. There are a lot of people who have labral tears who do not have pain. As with hip impingement, many people do very well with activity modification, targeted physical therapy, strength training, and running form retraining.
Adductor tendinopathy
The adductor muscles (inner thigh) attach to the pubic bone and the inside of the thigh. These tendons can become overloaded in runners, especially with lateral movement, steep uphills, or stride-width changes. The result is pain in the inner groin that is worse at the start of a run and can ease once warmed up, only to return after. It’s often tender to press directly on the pubic bone where the tendons attach. Adductor-related groin pain shares overlap with a condition called athletic pubalgia (sports hernia), which is a separate but related issue worth ruling out. Adductor injuries can be managed with adductor loading (strengthening) and core muscle retraining.
Hip osteoarthritis
Osteoarthritis of the hip typically presents as a deep, achy groin pain in adults over 45, though it can occur earlier. The pain tends to be stiff and dull first thing in the morning, eases with gentle movement, then worsens again after prolonged activity. Range of motion gradually becomes limited, particularly rotation. This is one of the more common diagnoses found in active adults who dismiss persistent groin pain as a “muscle thing.” The good news is that many people with hip OA continue running successfully for years with the right management strategy.
Red flags: femoral stress fractures
Most hip pain in runners is caused by soft tissue problems — tendons, muscles, bursae — that respond well to conservative treatment. But there is one injury that demands immediate attention: a femoral stress fracture.
The femur is the large bone of the thigh. The femoral neck — the narrow section connecting the ball of the hip to the femoral shaft — is under enormous stress in runners. When cumulative bone loading exceeds the bone’s ability to remodel and repair, tiny cracks can form. A complete fracture of the femoral neck is a surgical emergency that can compromise the blood supply to the femoral head and lead to avascular necrosis (bone death). This is rare, but the consequences of missing it are severe enough that every runner should know the warning signs.
Stop running and seek medical evaluation if you experience any of the following:
- Deep groin or anterior thigh pain that worsens progressively over days to weeks, particularly in someone who has recently increased training volume, started running after a break, or has a history of relative energy deficiency, disordered eating, or low bone density
- Pain in the groin or thigh that is hard to pinpoint. Pain that moves around.
- Pain that starts during a run and forces you to stop or significantly limp — stress fracture pain typically does not “warm up” the way soft tissue overuse injuries sometimes do
- Night pain or pain at rest in the groin, hip, or anterior thigh — musculoskeletal soft tissue issues rarely hurt at rest in the absence of movement; bone pain often does
- Pain with a single-leg hop test on the affected side — this is a simple in-office screen for bone stress, but a strongly positive response (severe pain with hopping) is a meaningful clinical warning sign
Risk factors that increase your likelihood of a femoral stress fracture include female sex, low bone density or history of osteoporosis, a history of amenorrhea (missed menstrual periods due to low energy availability), very rapid training increases, insufficient caloric intake for training load, previous stress fractures elsewhere, and a sudden switch to harder running surfaces.
If you have deep groin pain that worsens with each run, is present at rest or at night, or has developed alongside a significant jump in your training, do not try to run through it. Standard X-rays do not rule out stress fractures. If you come to see us with these symptoms, we will likely refer you to a sports medicine or orthopedic physician for an MRI.
What to do next
Hip pain in runners is common, but it is rarely simple. The location of your pain, how it behaves over a run, what positions provoke it, and your training history all factor into making the right diagnosis. Self-diagnosing and self-treating are reasonable for mild, intermittent discomfort, but persistent pain that limits your training or keeps coming back deserves professional attention.
At our physical therapy practice, we work exclusively with runners and active adults, and we take the time to understand not just where you hurt, but how you move, what your training looks like, and what your goals are. Whether you’re dealing with a classic case of gluteal tendinopathy or something that needs more urgent imaging, we can help you figure out what’s going on and get you back to the miles you love.
When in doubt, come get checked out. Your hips do a lot of work for you — they deserve the same care you’d give a worn-down shoe.
