Hip Pain

What is Hip Pain?

Hip pain is pain felt in or around the hip, and where you feel it helps point to the cause. Pain at the front of the hip or groin often comes from the joint itself, pain on the outer side often comes from the tendons and bursae there, and pain at the back can be referred from the lower spine or from nerves.^[1]

Common symptoms

In the joint, osteoarthritis causes stiffness and pain with weight-bearing, and labral tears and impingement cause pain that is often felt deep in the groin.^{[1, 2]} Outer hip pain, called greater trochanteric pain syndrome, is often worse when lying on that side, sitting for a long time, climbing stairs or after high-impact exercise.^[3]

Hip pain that feels like it starts in the buttock or travels down the back of the leg can come from the lower spine or from a nerve in the deep buttock.^[1]

Causes and risk factors

In younger adults, intra-articular hip pain is often caused by a labral tear or femoroacetabular impingement, and in older adults by osteoarthritis. Greater trochanteric pain syndrome is the most common cause of lateral hip pain and includes gluteal tendon problems and bursitis.^[1] The hip bears 6 to 8 times body weight in daily activity, and repetitive stress or injury commonly triggers the lateral pain.^[3]

Researchers have proposed that abnormal hip shape such as impingement contributes to hip osteoarthritis.^[2]

How it is diagnosed and treated conventionally

Diagnosis rests on your history and examination. Radiography of the hip and pelvis is the usual first imaging test, and ultrasound or MRI may be added.^[1]

Treatment depends on the cause. For lateral hip pain, standard care is anti-inflammatory medicines, physical therapy and stretching, with surgery reserved for cases that do not respond.^[3] For hip and knee osteoarthritis, a large network meta-analysis found that some oral and topical anti-inflammatory drugs reduced pain, but that opioids did not give a benefit that outweighed their harms.^[4] Hip pain from a labral tear, impingement or a tendon tear often has good surgical results, so early referral may help.^[1]

Why Hip Pain calls for a whole-person approach

Hip pain rarely comes from one thing. The joint, the muscles and tendons around it, the spine and pelvis above, and the way the nervous system processes pain all play a part, and they differ from person to person.

Care that looks at more than the painful spot can therefore be a reasonable addition to treatment aimed at the hip. The factors below are the ones the research literature most often describes.

Load and shape of the joint

The hip carries 6 to 8 times body weight during everyday activity, which makes it vulnerable to wear and tear.^[3] Differences in hip shape, such as femoroacetabular impingement, are thought to contribute to osteoarthritis.^[2]

Tendons, bursae and surrounding muscles

Lateral hip pain often involves the gluteal tendons and the bursa over the greater trochanter, which cushion the movement of the hip muscles.^{[1, 3]} In a network meta-analysis of trials for lateral hip pain, structured exercise gave the best short-term improvement in function.^[5]

Referred pain from the spine and nerves

Back problems and nerve entrapment in the deep buttock can produce pain that feels like it comes from the hip.^[1] A careful examination of the spine as well as the hip is part of a sound diagnosis.

Inflammation and pain processing

Trochanteric bursitis involves inflammation of the bursa, commonly triggered by repetitive stress.^[3] Laboratory studies describe how inflammatory pain involves both nerve endings in the tissue and pain processing in the spinal cord and brain, which are also the pathways acupuncture research studies.^[6]

Acupuncture for Hip Pain

What the research shows

The research suggests acupuncture may add little beyond sham for hip osteoarthritis, although it may help some people when added to routine care. A Cochrane review of 6 trials with 413 participants found moderate-quality evidence that acupuncture probably has little or no effect on pain or function compared with sham acupuncture. The two sham-controlled trials were small, so the result does not rule out a moderate benefit.^[7]

The same review found low-quality evidence that adding acupuncture to routine physician care brought clinically relevant improvement in pain and function in one unblinded trial. The authors cautioned that this was likely due at least partly to higher expectations of benefit.^[7] A large trial of knee or hip osteoarthritis, in which 357 people were randomized to up to 15 acupuncture sessions over three months, found better WOMAC scores than in a group receiving routine care only. The control group received no sham treatment, and the trial did not separate hip from knee in its summary results.^[8]

For outer hip pain and other hip problems, research is thinner. A systematic review of seven randomized trials of trigger point dry needling, a related technique that uses needles at muscle trigger points, included hip osteoarthritis, greater trochanteric pain syndrome and piriformis syndrome. It found that dry needling may relieve pain and improve function, but strong evidence was lacking and the trials were small with short follow-up.^[9] A network meta-analysis of 13 trials for greater trochanteric pain syndrome found that platelet-rich plasma and shockwave therapy gave short-term pain relief and structured exercise improved short-term function, while no treatment significantly outperformed the no-treatment group for pain at 6 to 12 months.^[5]

How acupuncture may work

Researchers propose that acupuncture acts on pain at several levels. A review of inflammatory pain studies describes effects on immune cells and nerve endings in the tissue, on opioid and cannabinoid signaling, and on pain processing in the spinal cord and brain.^[6] These explanations come mostly from animal and laboratory work. The sham-controlled hip trials suggest that part of any benefit may come from non-specific effects such as expectation.^[7]

What treatment involves

Treatment uses fine, sterile, single-use needles placed at points around the hip, buttock, thigh and elsewhere on the body, usually left in place for about 20 to 40 minutes. The hip osteoarthritis trials in the Cochrane review measured results 4 to 9 weeks after randomization.^[7] We reassess after a short course of visits.

Serious problems from acupuncture are rare. In prospective studies, about 9 in 100 patients had a minor reaction such as bleeding, pain or redness at a needle site, and serious events occurred in about 1 in 10,000 patients.^[10] Tell the practitioner first if you have a bleeding disorder, take blood thinners, are pregnant, or have a pacemaker (relevant to electroacupuncture).

Ayurvedic medicine for Hip Pain

The Ayurvedic view

Ayurveda describes degenerative joint pain as Sandhigata Vata, a disorder of Vata, the principle said to govern movement, settling in a joint.^{[11, 12]} Hip pain from the back or from the nerves would be described differently. These are traditional categories for choosing treatment, not biomedical diagnoses.

Therapies that may be used

Care is chosen for the individual and traditionally combines:

• Diet and daily routine intended to calm Vata, such as warm, regular meals and steady sleep hours
• Warm oil massage and local heat over the hip and thigh
• Herbs such as Boswellia (shallaki), guggulu-based formulas and ashwagandha, which have been used in studies of Ayurvedic joint care^{[11, 12]}
• Basti, a medicated enema therapy from Panchakarma, which has been included in multimodal Ayurvedic programs for osteoarthritis^[12]
• Transdermal medication therapy, in which an herbal preparation is applied to the skin

Panchakarma procedures are not appropriate during pregnancy, acute illness or frailty, or before red-flag symptoms have been medically assessed.

What the research shows

The research on Ayurveda for hip pain is very limited. A PubMed search found no studies specific to the hip, so the evidence below comes from osteoarthritis in general, including the knee.

A study of 56 patients with Sandhigata Vata given Boswellia resin reported symptom improvement but had no placebo group.^[11] A 50-patient study of a multimodal program including oil therapy, sweating, a mild laxative, small oil enemas, leech therapy and oral herbs reported improvement in most patients, also without a control group.^[12] An 80-patient double-blind trial in India found that a polyherbal Ayurvedic capsule was not inferior to the anti-inflammatory drug diclofenac over 12 weeks, though both groups were small and the trial was reported from two hospitals.^[13]

Studies without a comparison group cannot show that the treatment caused the change.

Herbal medicine for Hip Pain

Herbs and formulas that have been studied

No trials of herbal medicine specific to hip pain turned up in our search, so the research is drawn from osteoarthritis in general. Boswellia (Boswellia serrata) is the most studied herb, and turmeric and curcumin have been studied in joint pain as well.^{[14, 15]}

What the research shows

The evidence is limited and is not specific to the hip. A meta-analysis of seven trials with 545 patients found that Boswellia extract may reduce pain and stiffness and improve function in osteoarthritis compared with control treatments, though the review did not separate hip from knee.^[16] A Cochrane review of 49 trials of oral herbal products found high-quality evidence from two small studies that an enriched Boswellia extract reduced pain compared with placebo over 90 days, and described trends toward benefit for other products that warrant more study.^[14]

A meta-analysis of supplements for hand, hip or knee osteoarthritis found that several, including Curcuma longa extract, curcumin and Boswellia extract, had large short-term effects on pain, but the quality of evidence was very low and no supplement had clinically important effects on pain at the long term.^[15]

Safety and herb-drug interactions

Herbs are active substances and can interact with medicines. Case reports describe serious bleeding or clotting problems when warfarin was combined with herbs including dang gui (Angelica sinensis), dan shen (Salvia miltiorrhiza), ginger, ginseng and Boswellia.^[17] People taking blood thinners or anti-inflammatory medicines need a practitioner's review before using herbs for pain.

In one study, about one fifth of Ayurvedic products bought online contained detectable lead, mercury or arsenic.^[18] Herbs should come from tested sources and be prescribed individually. Tell us if you are pregnant or breastfeeding, have liver or kidney disease, or have surgery planned.

Translating traditional medicine into modern biological language

The links drawn here are interpretation, not equivalence. Chinese medicine describes hip pain as blocked flow of qi and blood in the channels of the hip and leg, sometimes with cold, dampness or weakness of the kidney system. Researchers studying acupuncture measure things that loosely parallel the first idea: local tissue effects, nerve signaling and the way the nervous system amplifies pain.^[6]

Ayurveda's aggravated Vata describes dry, stiff, aching joints that worsen with cold and movement. No study has shown that a dosha corresponds to a specific biological process. The best-supported biological view of hip pain depends on the cause: joint wear and shape in osteoarthritis, and overloaded tendons and bursae in lateral hip pain.^{[2, 3]}

How this care fits with your medical care

Integrative care for hip pain is complementary. Keep your physician, orthopedic specialist or physical therapist, and do not stop or change prescribed medicines without your prescriber. We do not diagnose the cause of hip pain, so new or worsening pain should be medically evaluated.

Please bring your diagnosis, any X-ray or MRI reports, a full list of medicines and supplements, and details of any injections, hip surgery or planned replacement.

When to seek urgent medical care

Some hip pain needs urgent assessment because it can signal a fracture, joint infection or another serious cause.^[1]

• Sudden severe hip pain after a fall or injury, or being unable to put weight on the leg
• A hot, red, swollen hip or a painful hip with fever
• Severe hip pain with no clear cause, especially with a history of cancer or unexplained weight loss
• New numbness in the groin or inner thighs, or new trouble passing urine or controlling the bowels
• A leg that looks shortened or turned out after an injury
• Hip pain with swelling, redness or pain in the calf, especially after surgery or long travel

If any of these occur, call 911 or go to the nearest emergency department.