Why Does My Hip Hurt? A Guide to Common Causes of Hip Pain

The hip is a deep ball-and-socket joint that connects the upper body, spine, and pelvis to the lower limb. Its primary function is locomotion; it must withstand and transmit enormous forces with every step, relying on surrounding muscles that generate some of the highest loads in the body. Because of its depth and the complexity of its nerve supply, the location of hip pain provides important clues to the offending structure: groin and anterior thigh pain typically points toward the joint itself, outer hip pain toward the tendons and bursa, and intrapelvic or spinal causes should always be considered in the differential diagnosis.

The Most Common Causes of Hip Pain in Adults

Several distinct conditions cause pain originating within the hip joint. Understanding which is present shapes both the expected trajectory of the condition and the most appropriate management approach.

Hip Osteoarthritis

The most prevalent cause of hip joint pain in adults over 50, hip osteoarthritis, involves the progressive deterioration of articular cartilage within the joint. As the cartilage thins, the bony surfaces of the femoral head and acetabulum come into increasing contact, the synovial lining becomes chronically inflamed, and the joint gradually loses its normal range of movement.

Groin pain is the hallmark symptom. In the early stages, it is typically provoked by activity and eases with rest; at more advanced stages, it can become persistent and disturb sleep. Morning stiffness lasting 20–30 minutes before the joint loosens is common. 

Reduced internal rotation is usually the first objective movement loss, manifesting as difficulty rotating the leg when getting in or out of a car, crossing the legs, or putting on shoes and socks, tasks that patients often begin to modify without consciously identifying the hip as the problem.

Femoroacetabular Impingement (FAI)

Impingement in orthopaedic terms involves the contact of two structures, leading to the squeezing of the normal soft tissues that lie between them. In this case, the impingement is between the neck of the femur (the thigh bone) and the rim of the acetabulum (the socket of the hip joint).

FAI occurs when there is an abnormal shape to the femoral head, the acetabular rim, or both. A cam morphology, in which the femoral head-neck junction is not sufficiently concave, causes the femoral neck to impinge against the rim of the socket during hip flexion and internal rotation. A pincer morphology involves excessive bony coverage of the femoral head by the acetabulum, producing impingement through a different mechanism. 

FAI is increasingly recognised in younger active adults and is frequently identified in people who notice groin pain during squatting, deep hip flexion, prolonged sitting, or repetitive rotational activities. It is strongly associated with labral tears, and the two conditions commonly coexist.

Labral Tears

The acetabular labrum is a ring of fibrocartilage that deepens the hip socket, distributes joint loading across a wider surface area, and contributes to the stability of the femoral head. Labral tears produce groin pain and, characteristically, a clicking, catching, or locking sensation at the front of the hip with certain movements. 

Pain is typically reproduced at the end range of hip flexion. Labral tears are most commonly seen alongside FAI or as a consequence of repetitive hip loading demands in athletic populations.

Avascular Necrosis (AVN)

AVN occurs when the blood supply to the femoral head is disrupted, leading to the death of bone tissue within the femoral head. Without adequate circulation, the structural integrity of the femoral head deteriorates and may eventually collapse, leading to a rapid onset of secondary arthritis and pain. Risk factors include prolonged or high-dose corticosteroid use, excessive alcohol intake, prior significant hip trauma, and certain haematological and systemic conditions.

AVN can be insidious in its early stages, presenting with progressive groin and anterior thigh pain that may seem disproportionate to early imaging findings. Early identification is important: if identified before femoral head collapse occurs, interventions aimed at preserving the femoral head rather than replacing it are possible.

Referred Pain from the Lumbar Spine

Compression or irritation of the L2, L3, or L4 nerve roots, from disc disease, facet joint degeneration, or spinal canal narrowing, can refer pain into the groin and anterior thigh in a pattern that closely resembles true hip joint pathology. Features that suggest a spinal origin include associated lower back symptoms, pain that changes with lumbar spine positioning, and neurological symptoms such as pins and needles, burning pain or weakness. Because both hip joint disease and lumbar spine degeneration are common in the same age demographic, a coexisting presentation is regularly encountered and should always be considered.

Early Signs of Hip Joint Degeneration

Hip joint degeneration rarely announces itself with sudden or dramatic symptoms. It tends to emerge gradually, through functional changes that patients frequently attribute to age, fitness, or temporary muscle fatigue. 

The following patterns are worth paying attention to:

• Difficulty putting on shoes and socks: Reduced hip rotation and flexion make this routine noticeably harder. Many patients modify their dress before they consciously identify the hip as a problem area.
• Stiffness getting in or out of a car: The combined flexion and rotation required to enter or exit a standard vehicle is one of the first activities to provoke symptoms in early hip joint disease.
• Morning stiffness: A period of 15–30 minutes of joint stiffness after waking or prolonged sitting, which eases with gentle movement as the joint warms up. This pattern of start-up stiffness is a recognised early feature of hip osteoarthritis.
• A developing limp: Patients often do not notice a change in their gait until someone else points it out. The body unconsciously adjusts to reduce the load on a painful joint, and the resulting antalgic gait can become habitual before it is recognised as a symptom.
• Reduced walking tolerance: Previously comfortable distances gradually become limited. This is commonly rationalised as a fitness or age-related change rather than a joint problem.

These changes are gradual and easily overlooked. Their clinical significance is that they reflect progressive joint limitation, and the earlier that limitation is recognised and addressed, the broader the range of management options available.

If you leave it alone, Hip Pain Gets Worse…

Understanding how hip pain tends to evolve when left unmanaged explains both why symptoms worsen over time and why that trajectory is not inevitable with appropriate intervention.

When hip pain develops, the natural response is to reduce activities that provoke it. Walking distances shorten. Stairs and inclines are avoided. Recreational activities are curtailed. This pain-avoidance behaviour is rational in the short term, but it sets in motion a cycle that becomes progressively harder to reverse without targeted support.

As activity reduces, the muscles surrounding the hip weaken from disuse. The hip abductors, gluteus medius and minimus, are particularly important here. During every stride, the hip abductors on the standing leg contract to stabilise the pelvis and prevent it from dropping toward the swinging leg. 

When these muscles are strong and functioning well, they absorb and distribute the forces that pass through the hip joint with each step. When they weaken, the joint itself must manage those forces with diminishing muscular support. The result is a hip that is simultaneously more inflamed and less protected. Pain worsens with activities that were previously tolerable. The patient reduces activity further. Weakness deepens. The cycle continues.

A secondary consequence is the antalgic limp’s effect on the rest of the body. By shortening the stance phase on the painful side and altering pelvic mechanics, the compensatory gait pattern increases load on the contralateral hip and the ipsilateral knee. Patients are frequently surprised when their other hip or knee begins to produce symptoms; these are direct downstream effects of the movement adaptation adopted to protect the original painful joint.

Getting the Right Diagnosis

Because hip pain can arise from the joint itself, from surrounding soft tissues, or from the lumbar spine, and these conditions frequently coexist, a formal clinical assessment is the starting point for accurate diagnosis and effective management.

Physical examination assesses hip range of motion with particular attention to internal rotation (the movement most reliably lost early in hip OA), the FADIR test (flexion, adduction, and internal rotation, which reproduces impingement and labral symptoms), and the Trendelenburg sign (an indicator of hip abductor muscle weakness that often develops secondary to pain-related inactivity). Gait is assessed to identify antalgic patterns and pelvic mechanics.

Imaging is used to confirm and characterise clinical findings:

• X-ray: The standard first-line investigation for suspected hip OA. Demonstrates joint space narrowing, subchondral bone changes, and osteophyte formation clearly and accessibly. Weight-bearing views provide the most clinically relevant information.
• MRI: Provides a detailed assessment of soft tissue structures, the labrum, hip abductor tendons, and the femoral head (including early avascular changes). An MRI arthrogram, in which contrast is injected into the joint before imaging, is particularly sensitive for labral tears.

An important clinical principle: imaging findings must always be interpreted alongside the clinical picture. Mild degenerative changes on X-ray do not necessarily account for significant pain; conversely, patients with marked radiographic change sometimes remain highly functional. 

The degree of structural change visible on imaging does not reliably predict symptom severity, and management decisions are shaped by the full clinical assessment rather than imaging alone.

What Can Be Done Before Surgery

For most patients presenting with early-to-moderate hip joint pain, non-surgical management is not a holding strategy; it is the primary treatment. The evidence base for conservative care in hip OA and related conditions is substantial, and the outcomes achievable with a well-structured programme are meaningful.

Targeted physiotherapy

The foundation of conservative management. A programme specifically focused on progressive strengthening of the hip abductor and extensor muscles rebuilds the muscular support that the joint depends on. Generic exercise programmes that do not address these specific muscle groups are less likely to produce durable results. Strengthening should be introduced progressively and at the right point in the management sequence.

Activity modification 

Identifying and temporarily reducing the specific activities that generate the most joint stress while preserving general movement and overall fitness. The goal is modification, not the elimination of activity. Complete rest is rarely beneficial and allows weakness to deepen.

Weight management

Body weight is directly related to hip joint loading. Meaningful weight loss reduces the compressive forces transmitted through the hip joint with each step, reducing pain and slowing the progression of degeneration. Even modest weight loss can produce clinically noticeable improvement in symptoms.

Anti-inflammatory strategies

Oral anti-inflammatory medication during symptomatic flare-ups, and when appropriate, a corticosteroid injection into the hip joint. A joint injection addresses the inflammatory component of the condition and can create a productive window for physiotherapy. Its greatest value lies in being part of a structured rehabilitation programme rather than as a standalone intervention.

A note on injection therapy

A hip joint injection delivers corticosteroid directly into the joint, reducing synovial inflammation and temporarily relieving pain. It is not a cure and its effect is not permanent, but it can meaningfully reduce the inflammatory burden on the joint and allow physiotherapy to begin more effectively. The injection is typically performed under ultrasound or X-ray guidance to ensure accurate placement.

When to Seek a Specialist Assessment

An orthopaedic assessment is appropriate when:

• Groin or anterior thigh pain has persisted beyond 6–8 weeks and has not responded to rest and simple analgesia
• Daily activities, dressing, walking distances, and car travel are being meaningfully limited
• Night pain regularly disrupts sleep
• A progressive limp has developed or is worsening
• Pain is no longer responding to conservative measures that previously provided relief
• There is sudden or rapidly worsening pain in a patient with known risk factors for avascular necrosis

Seeking assessment early does not mean surgery is being considered. It means obtaining a precise diagnosis, understanding the underlying condition and its likely natural history, and establishing a management plan appropriate to the individual’s presentation. For many patients, that plan involves no surgery at all. For those in whom surgery does become relevant at some point, early assessment provides the information needed to make those decisions clearly and at the right time.

Hip pain that presents in the groin, limits daily function, or is gradually changing the way a person moves is worth investigating properly, not because surgery is inevitable, but because early clarity leads to earlier intervention, more options, and better outcomes.

The most common causes of true hip joint pain are identifiable, manageable, and best addressed before significant secondary muscle weakness and compensatory movement patterns become entrenched. The groin pain that many patients dismiss as a pulled muscle or a back problem may be the hip’s earliest signal that it needs attention.

For patients in Sydney’s Eastern or Southern Suburbs experiencing groin pain, hip stiffness, or a progressive change in their gait, an assessment with Dr Dan Cohen provides a precise clinical diagnosis and a structured management plan, surgical or otherwise, tailored to the individual.

Book a consultation at Bondi Junction or Kogarah today.