Three places hip pain can start — and why it matters

Hip pain is one of the more confusing symptoms to live with, not because it is rare, but because it can start in at least three entirely different places — and each of those places behaves differently, responds to different treatment, and needs a different plan.

The three origins are:

• The ball-and-socket joint itself — where the top of the thigh bone meets the pelvis. Arthritis, cartilage damage, and impingement all begin here.
• The tendons and bursae around the outer hip — particularly the tendons that attach to the bony prominence on the side of the thigh, and the groin tendons that control leg movement.
• Pain referred from the lower spine — where a compressed nerve root sends signals down into the hip and buttock region, even though the joint itself is fine.

The reason this matters is straightforward: treating a tendon problem as if it were a joint problem, or missing a spinal cause entirely, delays recovery and may make symptoms worse. The patterns do overlap, and self-diagnosis is genuinely unreliable — that is not a reason for concern, it is simply how this part of the body is wired.

What follows is a practical sorting framework — not a verdict — designed to help patients arrive at a consultation with a clearer picture of what they are experiencing and the right questions to ask.

Groin pain and the hip joint

Sitting at the front of the hip, the ball-and-socket joint — where the rounded femoral head fits inside the acetabulum of the pelvis — is lined with smooth cartilage and sealed by a ring of fibrocartilage called the labrum. When something goes wrong here, the pain it produces is characteristically deep and groin-centred: felt in the inguinal crease, the front of the thigh, or sometimes described as an ache that seems to sit right inside the joint rather than on its surface.

The three main intra-articular conditions form more of a spectrum than three separate diseases. In osteoarthritis, the cartilage lining gradually wears, reducing the joint's ability to absorb load and producing stiffness and pain on weight-bearing. In femoroacetabular impingement (FAI), an abnormal bone shape — a cam lesion on the femoral head, a pincer lesion on the acetabular rim, or both — creates mechanical friction inside the joint each time the hip flexes. Sustained impingement commonly damages the labrum, so labral tears frequently coexist with FAI rather than arising independently; they can also follow an acute twisting injury.

On examination, loss of internal rotation is a consistent sign of intra-articular pathology. Clinicians also use the FADIR test — passively moving the hip into flexion, adduction, and internal rotation — which, when it reproduces familiar groin pain, is particularly associated with FAI and labral tears. X-ray is the appropriate first-line image for assessing bone shape and joint-space narrowing; MRI provides the detail needed to evaluate the labrum and remaining cartilage, and informs decisions about whether preservation surgery is realistic.

Outer hip pain and tendon sources

For many patients, the first clue is a specific nightly frustration: rolling onto the affected side in bed is simply impossible. The outer hip — the bony prominence felt through the skin on the side of the thigh, known as the greater trochanter — becomes exquisitely tender, and climbing stairs or standing briefly on one leg reproduces the same ache.

This pattern is the hallmark of greater trochanteric pain syndrome (GTPS), an umbrella term covering gluteal tendinopathy and trochanteric bursitis. Gluteal tendinopathy, where the tendons attaching the gluteal muscles to the greater trochanter become irritated or partially torn, is the most common underlying driver. What sets GTPS apart from joint-originating pain is the location — outer rather than groin — and, critically, the fact that hip rotation remains largely intact. A clinician rotating the hip inwards and outwards can usually do so freely, a finding that points away from the ball-and-socket joint and towards the periarticular soft tissues.

Two anterior-groin variants are worth knowing about because they can superficially resemble intra-articular pain. Psoas tendinopathy causes deep groin pain accompanied by a snapping or clicking sensation at the front of the hip, typically aggravated by repetitive hip flexion — running, dancing, or simply rising from a chair. Adductor tendinopathy sits more medially, producing inner groin discomfort that flares with sudden directional changes; it can overlap clinically with osteitis pubis, making the primary pain generator hard to identify without specialist input.

Conditions in this group also co-exist: psoas tendinopathy alongside early joint disease is not unusual. Where the picture is ambiguous, an ultrasound-guided diagnostic injection — targeting a specific tendon or bursa — is a tool specialists use to confirm which structure is generating the pain.

Buttock pain and when the back is the culprit

The third pattern doesn't sit in the groin or the outer hip — it settles in the buttock, sometimes spreading down the back of the thigh or into the leg. When pain behaves this way, the lumbar spine becomes a serious candidate even when the patient has been thinking 'hip' all along.

Nerve roots emerging from the lower back — particularly at the L3/L4 and L4/L5 levels — can refer pain into the buttock, outer thigh, and groin in a way that is genuinely difficult to separate from hip joint disease without examination. Three patient-recognisable clues help sort this out:

• Hip rotation remains largely free. Moving the leg inwards and outwards causes little discomfort — which would be unusual if the joint itself were the source.
• Bending the back, coughing, or sneezing provokes the familiar pain rather than weight-bearing through the hip.
• Symptoms extend below the knee, sometimes reaching the foot. Hip joint pain rarely travels this far.

Many patients — particularly those over 60 with both hip osteoarthritis and lumbar degeneration — have pain from both structures at once. Clinicians call this hip-spine syndrome. Treating only one region can produce only partial relief, which is why pinpointing the dominant source requires expert clinical assessment rather than imaging alone; a scan of the hip can look convincing while the spine is quietly doing most of the work.

One symptom cluster always warrants same-day review regardless of suspected origin: numbness in the saddle area, any change in bladder or bowel control, or sudden weakness in both legs. These features need prompt attention.

What a hip assessment actually involves

A specialist hip consultation follows a logical sequence, and knowing what each step involves makes the process considerably less daunting.

History first. The clinician begins by mapping the pain in detail: precisely where it sits, which movements provoke it, whether it disturbs sleep, and how it has changed over weeks or months. Targeted questions — does rotating the leg reproduce the ache, or is it rising from a chair that triggers it? — often point toward a source before any physical test is performed. This part of the assessment is frequently the most informative.

Examination. Gait is observed for asymmetry, and hip range of motion is tested systematically in each direction. Structured provocation tests are then applied — pressing the hip into specific combined positions — to separate joint-originating pain from tendon or referred sources. These manoeuvres build on the location clues gathered in the history rather than replacing them.

Imaging. X-ray is the natural starting point: it reveals joint space, bone morphology, and any structural deformity associated with impingement. MRI adds resolution where soft-tissue detail matters — the labrum, gluteal tendon integrity, and bone marrow changes that plain radiograph cannot show. One principle runs through both modalities: an imaging finding is not a diagnosis in isolation. Mild degenerative changes are common in adults without symptoms, and a scan result only carries clinical weight when it corresponds directly to the patient's pain pattern and examination findings.

When the picture is still unclear. If history, examination, and imaging have not settled the question, an ultrasound-guided injection into a targeted structure — the joint, a bursa, or a tendon — can confirm which is generating the pain, as noted in the section on outer-hip and tendon sources.

The consultation concludes with a written management plan: what the findings mean, which stage the patient is at, and what a sensible next step looks like.

When to stop guessing and get assessed

Some symptoms need urgent attention rather than a routine appointment:

• Severe pain after a fall with inability to bear weight — possible fracture.
• Sudden swelling with heat, redness, or fever — possible joint infection (septic arthritis).
• Severe pain with no preceding injury — possible avascular necrosis.

These are not situations for home management — attend A&E or call 999.

Beyond those red flags, specialist review is appropriate when hip pain has persisted beyond six to eight weeks despite basic self-care, is clearly worsening, or is limiting daily activities. Diagnostic uncertainty — not knowing whether the joint, a tendon, or the lumbar spine is responsible — is equally valid grounds for seeking expert input. Trying treatments sequentially for the wrong structure is how months are lost without meaningful progress.

That, ultimately, is the clearest argument for structured assessment: hip pain managed without a working diagnosis rarely settles as well as hip pain with one.

Lincolnshire Hip, part of the MSK Doctors group, accepts patients without a GP referral for a structured hip assessment at Sleaford and Grantham, covering clinical examination, imaging review, and a written management plan.

1. [1] Hip pain - Wikipedia. https://en.wikipedia.org/?curid=49230666 https://en.wikipedia.org/?curid=49230666
2. [2] Hip pain in adults - NHS. https://www.nhs.uk/conditions/hip-pain/ https://www.nhs.uk/conditions/hip-pain/
3. [3] Greater trochanteric pain syndrome - Wikipedia. https://en.wikipedia.org/?curid=7976648 https://en.wikipedia.org/?curid=7976648