Where the pain sits tells you most of what you need. Pain on the outer hip that hurts lying on that side is usually gluteal tendon pain. Groin pain that stiffens the joint is usually osteoarthritis. Buttock pain that travels is usually referred from the back. Pain in the front crease when lifting the knee is usually a hip flexor. Deep pinching groin pain in a younger person points at impingement.
Where the ache sits squarely in the buttock and you are trying to tell it apart from sciatica, the distinguishing features are set out in PhysioHub’s guide to buttock muscle pain.
Location does most of the diagnostic work in the hip. This table maps the four areas people point at to what usually explains them, and what tends to help.
| Where it hurts | Usual cause | Telltale sign | First things that help |
|---|---|---|---|
| Outer hip, on the bone | Gluteal tendinopathy | Cannot lie on that side at night | Pillow between knees, stop crossing legs, isometric holds |
| Groin and front of hip | Hip osteoarthritis | Stiff first thing, hard to put socks on | Regular walking or cycling, strength work, weight management |
| Buttock, sometimes down the leg | Referred from the lower back or sacroiliac joint | Worse bending, sitting or coughing | Movement, position changes, treating the back |
| Front crease, sharp on lifting the knee | Hip flexor strain | Came on during a sprint, kick or hill | Relative rest, gentle range, graded loading |
| Deep groin, pinching in a squat | Impingement or labral irritation | Younger, active, pinch at end range | Avoiding end-range positions, hip and trunk strength |
Two of these have a clear first-line treatment with trial evidence behind it. The rest are managed on the pattern rather than on a scan.
This is a documentary review of published trial evidence and guidance rather than a diagnosis of your hip. The five causes here are the ones that account for the large majority of hip pain presenting to musculoskeletal services. Others considered and left out because they are less common include hip fractures and stress fractures, avascular necrosis, inflammatory arthritis, hernias, pelvic and abdominal causes, and referred pain from the knee.
The order reflects how often each explains hip pain in adults, weighed against how clearly it can be identified without imaging.
The sources read were the LEAP trial, a randomised trial of 204 people with gluteal tendinopathy published in the BMJ in 2018, and NICE guideline NG226 on osteoarthritis. Evidence checked in August 2026.
What could not be checked: no study has ranked these five by frequency in a UK primary care population, so the order rests on clinical presentation patterns rather than on a count. Hip pain after a fall in anyone over 60, an inability to bear weight, night pain with fever or unexplained weight loss, or a hip that has suddenly lost movement all need urgent assessment rather than self-management.
Point with one finger. Ask yourself where you would press if someone told you to show them the pain. The bony point on the side, the crease at the front, and the middle of the buttock lead to three different answers.
Notice what makes it worse rather than what it feels like. Night pain lying on the side, difficulty with socks and shoes, pain on coughing, and a sharp catch when lifting the knee are each far more informative than whether the pain is sharp or dull.
Check whether the joint itself moves. Sitting down and crossing one ankle over the opposite knee is a rough test of hip rotation. If that is markedly harder on the painful side, the joint is involved. If it is easy, the problem is more likely outside the joint.
Find out where it stops. Pain that stays above the knee behaves differently from pain that runs into the calf or foot, and the second pattern points at the back rather than the hip.
What it is
Irritation of the gluteal tendons where they attach to the bony point on the outside of the hip, often with the small fluid-filled sac over them involved. It is also called greater trochanteric pain syndrome.
Who it affects
Most commonly women in their 40s to 60s, and anyone who has recently increased walking, hill work or standing on one leg. It is the most common cause of outer hip pain by a clear margin.
How it presents
Pain and tenderness directly on the bony point, an inability to lie on that side at night, pain on stairs and on standing up after sitting. Walking often makes it worse rather than better, which distinguishes it from most hip joint problems.
What the evidence supports
The LEAP trial randomised 204 people to load management education plus exercise, a single corticosteroid injection, or wait-and-see. At eight weeks, 77 per cent of the exercise group reported being at least moderately better, compared with 58 per cent after injection and 29 per cent with wait-and-see. Improvements were largely maintained at one year, with the exercise group reporting less frequent pain.
What relieves it
A firm pillow between the knees and ankles at night. Stopping the compressing positions: crossing the legs, standing hanging on one hip, deep cross-body stretches. Isometric holds pressing the leg outwards against a wall, then progressive hip strengthening over 8 to 12 weeks.
Limits and cautions
Foam rolling the bony point and stretching the outer hip both compress the tendon and reliably make it worse. This is the single most common self-management mistake in this condition.
Why it ranks first
It is the most common cause of outer hip pain, it is frequently mislabelled as bursitis or arthritis, and it has the clearest evidence-based treatment of any hip problem here.
What it is
Wear-related change in the hip joint itself, affecting the cartilage and the bone underneath, producing pain and stiffness that build over years.
Who it affects
Most commonly people over 50, and earlier in anyone with a previous hip injury or a hip that has always been shaped differently.
How it presents
Deep groin pain, sometimes referring to the front of the thigh or the knee. Stiffness first thing that eases within half an hour. Difficulty putting on socks and shoes or getting out of a low car. Rotation is restricted on testing, which is the most reliable sign.
What the evidence supports
NICE guideline NG226 makes therapeutic exercise and weight management the core treatments for osteoarthritis, alongside information and support. It also tells clinicians to warn people that joint pain often increases when exercise starts, and that continuing is what produces the benefit, which is the piece of advice most often missing.
What relieves it
Regular walking or cycling, hip and thigh strengthening two or three times a week, and heat for morning stiffness. Where weight loss is relevant it changes symptoms more than most people expect. Surgery is a genuinely good option when conservative management has been given a proper run and is no longer enough.
Limits and cautions
An X-ray showing changes does not tell you how much trouble the hip will cause, since the correlation between what a scan shows and what a person feels is loose. Rest is what makes an arthritic hip stiffer.
Why it ranks second
It is the most common cause of true groin-based hip pain, it has clear national guidance behind its treatment, and it is the diagnosis people most often assume they have when they actually have number one.
What it is
Pain felt around the hip and buttock that is generated in the lower back, a nerve root, or the joint between the spine and the pelvis.
Who it affects
Anyone with a history of back trouble, anyone who sits for long periods, and a large proportion of people who present convinced they have a hip problem.
How it presents
An ache spread across the buttock rather than pointed at one spot, often travelling down the back of the thigh. Worse with bending, sitting and coughing. Hip rotation is normal on testing, which is the finding that separates it from the joint itself.
What the evidence supports
Referred pain from the lumbar spine is one of the most common reasons a hip is investigated and found to be normal. The management follows back pain guidance rather than hip guidance, which is why identifying it early saves a great deal of time.
What relieves it
Regular movement and position changes, avoiding long unbroken periods of sitting, and treating the back rather than the hip. Symptoms travelling below the knee with numbness or weakness change the plan and need assessing.
Limits and cautions
Hip stretches for buttock pain that is actually nerve-related tend to irritate it. Where a stretch reproduces shooting pain down the leg, that is the signal to stop and get it looked at.
Why it ranks third
It is common enough to belong on any hip list, and it is the one most likely to send someone down the wrong treatment path for months.
What it is
A strain of the muscles that lift the thigh, most often where they cross the front of the hip.
Who it affects
Runners, footballers and anyone who has sprinted, kicked or accelerated uphill without building up to it.
How it presents
A sharp pull in the front crease of the hip when lifting the knee, kicking or getting out of a car. Usually a clear moment of onset. Tender to press in the crease itself.
What the evidence supports
Muscle strains follow a well-described healing course and respond to graded loading, with early gentle movement producing better outcomes than complete rest. The evidence base here is largely from hamstring and groin strains in sport, applied by extension.
What relieves it
A few days of avoiding the aggravating movement, gentle range within comfort, then graded strengthening from isometric holds towards resisted knee lifts. Most settle in two to six weeks.
Limits and cautions
Deep stretching in the first fortnight tends to prolong things. Front-of-hip pain in an older adult that came on without an obvious moment deserves a closer look, since a few less common causes present that way.
Why it ranks fourth
It is common in an active population and uncommon outside it, and it is one of the few hip problems with a clear beginning that people can date.
What it is
Extra bone at the rim of the socket or the top of the thigh bone catching at the end of hip movement, sometimes with irritation of the cartilage ring around the socket.
Who it affects
Typically people in their 20s to 40s, often sporty, and often those who did a lot of hip-loading sport as teenagers.
How it presents
Deep groin pain with a pinching quality at the end of range, worse in deep squats, prolonged sitting and getting out of a low chair. People often make a C shape with the hand around the hip when describing where it is.
What the evidence supports
Physiotherapy focused on hip and trunk strength alongside modifying the positions that pinch is the standard first-line approach, with surgery considered where that has been given a fair trial. The findings that show on imaging in this group are also present in many people with no symptoms at all, which is why the decision is made on the clinical picture.
What relieves it
Reducing time in the deep positions that catch, building hip and trunk strength, and adjusting squat depth and seat height. Our hip exercise sheet covers most of the loading side.
Limits and cautions
Aggressive stretching into the pinching position is the mistake here, because the pinch is a mechanical block rather than tightness.
Why it ranks fifth
It is much less common than the four above in the general population, and it is the diagnosis most likely to be given weight it does not deserve on the strength of a scan.
| Cause | Where it hurts | Night pain | Hip rotation restricted | Walking | Typical timescale |
|---|---|---|---|---|---|
| Gluteal tendinopathy | Outer hip, on the bone | Yes, lying on that side | No | Often worse | 8–12 weeks |
| Hip osteoarthritis | Groin, front of thigh | Sometimes, when advanced | Yes | Usually better | Managed long term |
| Referred from the back | Buttock, back of thigh | Variable | No | Often better | Follows the back |
| Hip flexor strain | Front crease | No | No | Usually fine | 2–6 weeks |
| Impingement or labral | Deep groin, C-shape grip | No | Often, in rotation | Usually fine | 3–6 months |
The night pain and the rotation columns do most of the sorting between them. An outer hip that cannot be lain on with normal rotation is a very different problem from a groin that is stiff in rotation.
If you cannot lie on that side at night and the bone is tender to press, work on the gluteal tendon: pillow between the knees, stop the compressing positions, and start isometric holds.
If the pain is in the groin and you struggle with socks and shoes, that is the joint. Regular walking or cycling plus strength work two or three times a week is the core of it.
If the ache spreads across the buttock and worsens with sitting or coughing, treat it as a back problem until proven otherwise.
If it started sharply during a sprint or a kick, that is a muscle strain, and it will settle in weeks rather than months with graded loading.
If you are under 40 and get a deep pinch at the bottom of a squat, reduce the depth, build hip and trunk strength, and give it three months before considering anything more.
If you fell and now cannot put weight through the leg, or the hip is painful at night with fever or weight loss, that needs same-day medical assessment rather than any of the above.
The question that comes up most often with hips is whether walking is helping or making things worse, and the honest answer is that it depends entirely on which of the five above you have. Buxted Park is a useful local test, because it offers a flat, surfaced circuit of a reasonable length with no cambers. A hip that feels better after a lap there and worse after a cambered pavement walk is telling you something specific: the sideways loading is the problem, which points at the gluteal tendon rather than the joint.
The clinical point that follows is that outer hip pain and hip joint pain need opposite advice about walking, and they are routinely confused with each other. An arthritic hip that is rested gets stiffer and more painful. A gluteal tendon that is walked hard on cambered roads stays irritated for months. Testing rotation and pressing the bony point takes about two minutes and separates the two, which is why so much time is saved by asking the question early rather than after a season of the wrong plan.
Where a hip has been sore for more than a few weeks and the pattern is not obvious, our musculoskeletal pain and injuries page sets out how it is assessed.
Why does my hip hurt when I lie on my side at night?
That is the signature of gluteal tendinopathy, the most common cause of outer hip pain. Lying on the sore side compresses the tendon against the bone underneath. Lying on the other side lets the top leg fall across the body, which squeezes the same tendon from a different angle. A firm pillow between the knees and ankles keeps the hip neutral and usually makes a noticeable difference within a few nights.
How do I know if my hip pain is coming from my back or my hip?
True hip joint problems produce deep groin pain and restricted rotation, which shows up as difficulty putting on socks and shoes or getting in and out of a car. Pain from the lower back or a nerve root tends to sit across the buttock and travel down the back of the thigh, and it is often triggered by bending, sitting or coughing. Pain that stops at the knee behaves differently from pain that goes past it.
What exercises should I avoid with outer hip pain?
Anything that pulls the leg across the midline compresses the tendon that is already sore. That means avoiding deep cross-body stretches, sitting with the legs crossed, standing with the weight hanging on one hip, and rolling directly on the bony point of the hip with a foam roller. Walking lunges and downhill walking tend to aggravate it too, at least in the early weeks.
What actually relieves gluteal tendinopathy?
Load management education combined with exercise has the best evidence. The LEAP trial randomised 204 people with gluteal tendinopathy to education plus exercise, a corticosteroid injection, or a wait-and-see approach. At eight weeks, 77 per cent of the exercise group rated themselves at least moderately better, against 58 per cent for the injection and 29 per cent for wait-and-see, and the improvements were largely maintained a year later.
Is walking good or bad for hip pain?
Good for most hip problems and specifically irritating for a few. Hip osteoarthritis usually improves with regular walking on level ground. Gluteal tendon pain often flares with long walks, hills and uneven cambers, because those increase the sideways compression on the tendon. Cycling is the usual alternative while an outer hip settles.
Do I need a scan for hip pain?
Usually not at the start. Most hip pain can be identified from where it sits, what makes it worse, and how the joint moves on testing. Imaging matters where the picture is unclear, where symptoms are not improving, or where surgery is being considered. Scans in this area also commonly show changes in people with no pain at all, so a finding on a report does not automatically explain the symptoms.
How long does hip pain take to settle?
Gluteal tendon pain typically takes 8 to 12 weeks of consistent loading, and it is one of the slower tendon problems. A hip flexor strain settles in 2 to 6 weeks. Osteoarthritis is managed rather than cured, and exercise programmes usually produce their benefit over 8 to 12 weeks. Referred back pain follows the course of the back problem causing it.
PhysioHub – Empowerment through Evidence-Based Education.
Every body is different. Book a thorough assessment and get advice that is specific to you and your goals.
Book an Appointment