Conditions · Carrollwood · Tampa Bay
Hip Pain
Groin, outer hip, or buttock: three different problems in one small area. What the words on your report mean, and how an examination tells them apart.
Say hip, and the person across from you is picturing a different place than you are. Groin, outer hip, buttock: three addresses in one small area, and the report that comes back is written in words nobody translates for you. This page is the translator. Hip and low back also trade symptoms constantly, and Dr. Bobby Koser, DC, chiropractic physician, completed post-doctoral training in spinal MRI interpretation and clinical correlation, so the spine side of your paperwork is read as closely as the hip side. Bring whatever you have.
Hip Pain Overview
Where you point when you say hip
Three people can say hip and mean three different places. Which one is yours narrows the field, and it lines up with what the examination tests. It does not identify the structure by itself, because a painful hip joint can be felt in the groin, the outer hip, or the buttock.
- The groin and the front crease sit over the ball-and-socket joint itself, where the top of the thigh bone meets the pelvis.
- The outer hip sits over the greater trochanter, the bony knob on the side of your leg where the gluteal tendons anchor onto bone.
- The buttock sits over the gluteal muscles, with the sacroiliac joint underneath, where the base of your spine meets the back of your pelvis.
Narrowing the field is not settling it: where you point tells the examination where to start.
What the words on your report mean
Radiologists, orthopedists and therapists describe the same hip in different vocabularies, which is how one hip collects four names in a week.
Greater trochanteric pain syndrome, and hip bursitis
The gluteal tendons anchor onto the greater trochanter, the bony knob on the outside of your hip, and a bursa, a small fluid-filled cushion, sits between tendon and bone. Reports say bursitis for the cushion and tendinopathy for the tendon, and GTPS is the umbrella term for that outer-hip area.
Also written as: trochanteric bursitis, gluteal tendinopathy, gluteus medius or minimus tendinopathy, hip abductor tendon tear, iliotibial band syndrome, lateral hip pain.
Labral tear, and the words that travel with it
The labrum is a rim of cartilage running around the edge of the hip socket, like a gasket around a lid. A tear or fraying means the scan describes a defect in that rim, and a paralabral cyst is a pocket of fluid beside it.
Also written as: acetabular labral tear, hip labrum tear, labral fraying, labral degeneration. A chondral or cartilage defect names the lining on the ball or socket rather than the rim.
Arthritis words on a hip X-ray or MRI
These describe how the ball and socket look on the image. Joint space narrowing means the gap between them measures thinner, osteophytes or bone spurs are extra bone along the rim, and subchondral sclerosis and cysts name the bone under the cartilage.
Also written as: hip osteoarthritis, hip arthritis, coxarthrosis, degenerative joint disease of the hip, DJD of the hip, bone spurs in the hip.
Femoroacetabular impingement: cam, pincer, alpha angle
These words describe the shape of the ball and socket as it was measured on the image. Cam refers to extra bone where the ball meets the neck of the thigh bone, pincer to a socket rim covering more of the ball than the measured average, and impingement to those shapes meeting at the end of a movement. Dysplasia describes a socket covering less of the ball than average. Whether the shape has anything to do with your symptoms is an examination question.
Also written as: FAI, hip impingement, cam or pincer morphology, cam lesion, acetabular dysplasia, hip dysplasia, lateral center-edge angle, alpha angle.
A finding is not a diagnosis
A research review pooled 29 studies of hip imaging. Most carried a moderate to high risk of bias, with only five judged low risk, and the scans were MRI, MR arthrography, which is an MRI with contrast placed into the joint, or CT, so none of it maps onto a plain X-ray.
In that review a labral tear was seen in 62% of the people who had hip or groin pain, a figure the reviewers graded as limited evidence, with a range of statistical uncertainty from 47% to 75%. It was seen in 54% of the people who had no pain, graded as moderate evidence, range 41% to 66%. Their own conclusion was that these rates are highly variable from study to study in both groups.1
Read that in both directions, because both are true at once. Put the other way, close to 4 in 10 of the people who had pain showed no labral tear at all, and more than half of those with no pain showed one. A labral tear on your report is not by itself the source of what you feel, and your pain is not less real because the same words appear on reports belonging to people who feel fine. In that review the finding was reported more often in people who had pain than in people who did not.
1. Heerey JJ, Kemp JL, Mosler AB, Jones DM, Pizzari T, Souza RB, Crossley KM. What is the prevalence of imaging-defined intra-articular hip pathologies in people with and without pain? A systematic review and meta-analysis. Br J Sports Med. 2018;52(9):581-593. PubMed
Hip pain and low back pain, in the same conversation
A hip complaint often arrives with a back complaint attached, which is why sacroiliitis, SI joint dysfunction, lumbar radiculopathy and piriformis syndrome turn up on hip paperwork. A nerve root leaving the low back can be felt in the buttock, the outer hip, or down the thigh, the pattern known as sciatica or a pinched nerve.
One study puts numbers on how often the two turn up together. It was cross-sectional, meaning everyone was assessed at one point in time, so it shows what appears alongside what, not which came first.
In that study, greater trochanteric pain syndrome was counted as tenderness when the bony point on the outer hip is pressed, in people who reported hip pain and who had no signs of hip osteoarthritis and no generalized myofascial tenderness. Among those 3,026 community-dwelling adults aged 50 to 79, it was found on one side in 15.0% of women and 6.6% of men, and on both sides in 8.5% of women and 1.9% of men. Put the other way, in that study roughly 3 in 4 women and more than 9 in 10 men in that age band had no such finding on either side. In that same study, after accounting for age, sex, body mass index, knee arthritis and other factors, the odds of that outer-hip finding were higher in people who also reported low back pain (odds ratio 2.79, range of uncertainty 2.22 to 3.50, a comparison between groups rather than a number about one person).2
Two things turning up together in that study does not tell us that either one brought on the other. It does say that outer-hip pain and low back pain keep company often enough that looking at one and stopping there leaves questions open.
2. Segal NA, Felson DT, Torner JC, Zhu Y, Curtis JR, Niu J, Nevitt MC; Multicenter Osteoarthritis Study Group. Greater trochanteric pain syndrome: epidemiology and associated factors. Arch Phys Med Rehabil. 2007;88(8):988-992. PubMed
Symptoms, and the warning signs we screen for
Hips announce themselves through ordinary tasks: socks and shoes, stairs, getting out of a car. Some notice a walking distance that keeps shortening. Others notice it only in bed, lying on that side. Pain that wakes you is information rather than a mattress problem.
Common, and examined here
- Pain in the groin or the crease at the front of the hip
- Pain over the bony point on the outside, or lying on that side
- Deep buttock pain, with or without pain down the thigh
- Clicking, popping, or a hip that catches
- A hip report nobody has explained to you
Emergency, not an appointment
- Hip or groin pain after a fall or crash when you cannot put weight through that leg, the leg looks shorter or turned outward, or it is stuck in one position
- A hip that is hot and swollen with fever or chills, especially after an infection, a joint injection, or hip surgery
- New loss of bowel or bladder control, new numbness in the groin or inner thighs, or leg weakness getting worse quickly
- New swelling, warmth and redness through the thigh or calf, especially with new shortness of breath or chest pain
- Hip pain after a fall in an older adult, even if walking is still possible
Go to the emergency department now. Bowel or bladder changes with groin numbness can signal cauda equina syndrome, compression of the nerve roots at the base of the spinal canal, a surgical emergency. A fall in an older adult needs same-day evaluation and imaging.
How we approach hip pain
The examination comes first: your history, the hip taken through its range, the muscles and tendons around it tested, the low back and sacroiliac joint checked in the same visit, and any report you carry read with you rather than at you. Dr. Koser’s post-doctoral training in spinal MRI interpretation and clinical correlation covers the spine side of that question. That visit is the Pain Source Exam.
When a muscle or tendon target sits deeper than the fingers can confirm, a live ultrasound look may be added at the table. That is an ultrasound screening look at muscle and soft tissue inside the examination, not a stand-in for an X-ray or MRI.
Care is then built from the examination rather than the report: whichever of Dr. Koser’s adjusting techniques it points to and whether adjusting belongs in the plan at all, dry needling for the muscles guarding the area, hands-on soft-tissue work, and a loading plan you can follow, measured again at the next visit.
When the examination points somewhere else, we say so and send your records with you.
- A hip that locks, catches hard, or gives way: orthopedic opinion and imaging before any trial of care.
- Load-related groin pain that worsens with hopping or standing on one leg: urgent imaging, with weight kept off that leg until it is cleared.
- Groin pain with unremarkable X-rays after high-dose steroid treatment or with sickle cell disease: MRI and referral rather than a course of care, to rule out osteonecrosis, loss of blood supply to the bone in the ball of the hip.
- A child or adolescent with a limp and hip, thigh, or knee pain: pediatric orthopedics the same day, because a hip problem at that age is often felt at the knee.
Surgery decisions belong with surgeons, and being in the right room is part of the job here. More than one joint? Our joint pain page has that version and the prices. Hurt in a car accident? Florida’s PIP law requires care to begin within 14 days: start at our auto accident page.
What the research shows
Below are two kinds of evidence: a randomized trial, a study where chance decided which treatment each person received so the comparison is fair, and a national guideline, where a panel of specialists and patients reviewed the research and graded its advice.
The trial enrolled 204 adults aged 35 to 70 who had pain over the outer hip for more than three months from gluteal tendinopathy, an irritated tendon where the gluteal muscles anchor onto the bony knob on the side of the hip, confirmed by both a clinical diagnosis and an MRI. It compared three paths: a physiotherapist-led program of education plus exercise, 14 sessions over eight weeks, a single corticosteroid injection, and a wait-and-see approach. On pain scores at one year, the exercise and injection groups were not different. On the trial’s other measure, people rating their own hip as improved, 51 of 66 in the education-plus-exercise group reported improvement at eight weeks, compared with 38 of 65 after the injection and 20 of 68 who waited, and at that eight-week mark both treatments were associated with better ratings than waiting. At 52 weeks, 51 of 65 in the exercise group reported improvement, compared with 36 of 63 after the injection and 31 of 60 who waited, and at that mark exercise was associated with better ratings than either. Those ratings came from the participants themselves, who knew which treatment they had received.3
The guideline came from the American College of Rheumatology and the Arthritis Foundation in 2019, covering osteoarthritis of the hand, hip, and knee, with each piece of advice graded as either strong or conditional. They made a strong recommendation for exercise, for weight loss in patients with knee and/or hip osteoarthritis who are overweight or obese, and for programs that teach self-management skills, the day-to-day skills of looking after a condition. And the authors write that treatment decisions should be shared between clinician and patient and should account for the patient’s own values, preferences, and other health conditions.4
These are group results and graded recommendations, not a prediction about your hip, and finding out where you stand is what the examination is for.
3. Mellor R, Bennell K, Grimaldi A, Nicolson P, Kasza J, Hodges P, Wajswelner H, Vicenzino B. Education plus exercise versus corticosteroid injection use versus a wait and see approach on global outcome and pain from gluteal tendinopathy: prospective, single blinded, randomised clinical trial. BMJ. 2018;361:k1662. PubMed
4. Kolasinski SL, Neogi T, Hochberg MC, et al. 2019 American College of Rheumatology/Arthritis Foundation Guideline for the Management of Osteoarthritis of the Hand, Hip, and Knee. Arthritis Rheumatol. 2020;72(2):220-233. PubMed
Common questions about hip pain
Why does my hip hurt at night when I lie on that side?
Lying on that side loads the outer hip, where the gluteal tendons anchor onto the bony knob and a bursa sits between tendon and bone, so that area is examined first. The joint itself and the low back can be felt there too. Night pain is a symptom to report, not to work around.
Is this pain actually my hip, or is it coming from my back?
Both are possible, and a page cannot decide it in either direction. The hip, the sacroiliac joint and the lower spine sit inches apart. In one study of adults aged 50 to 79, an outer-hip finding turned up more often in people who also reported low back pain, though that study cannot say which came first.
My pain is in my groin, not on the outside. Does that mean something different?
It narrows the field. The groin and the front crease sit over the ball-and-socket joint itself, the outer hip over the tendons and the bursa on the side, and the buttock over the gluteal muscles with the sacroiliac joint underneath. Where you point is where the examination starts, not where it ends.
My X-ray says arthritis in my hip. Is that why it hurts?
Possibly, and the picture does not answer that by itself. Joint space narrowing, osteophytes and subchondral change describe how the ball and socket look, not what you feel. Your pain is not less real because those words appear on other people’s reports, and whether they explain your symptoms is what the examination works out.
My MRI says I have a labral tear. Do I need surgery?
That decision belongs with a surgeon. In one review of hip scans, labral tears were seen in people who had hip or groin pain and in people who had none, and in that review more often in people who had pain. Your pain is not less real because the same words turn up on other people’s reports, and whether the tear explains what you feel is what the examination works out.
Can a chiropractor help hip pain, or do I need an orthopedist?
Start with an examination and let it decide. Restricted joints in the hip, pelvis and low back, and the muscles and tendons around them, are what a chiropractic physician examines and treats directly. A hip that locks or gives way, or a leg you cannot put weight through, belongs with an orthopedist from the outset.
I hurt my hip in a crash and my report names arthritis or impingement. Does that mean the crash is not why I hurt?
That is a question about cause, and a picture does not answer it alone. An imaging report describes what the hip looked like on the day of the scan, not when anything began. We examine you, document what we find, and record how you function now against what you could do before. Florida’s PIP law puts a clock on it: care must begin within 14 days. Start at our auto accident page.
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This page is general health information and is not medical advice for any individual. The studies summarized describe groups, not any one person’s outcome, and whether any finding on your imaging explains your symptoms can only be determined by examination. Talk to Dr. Bobby Koser, DC, about your own situation, and seek emergency care immediately for the warning signs listed above.
Show us where you point.
A complete examination with Dr. Bobby Koser, DC, the hip and the low back looked at together, and your findings explained the same day.