Hip Pain: Causes, Diagnosis and Rehabilitation

By the myphysiohelp.it team

Summary

Introduction: Hip Anatomy and Function
Hip Replacement: Rehabilitation Pathway
Bilateral Hip Arthroplasty
Trochanteritis (Trochanteric Bursitis)
When to Consult a physical therapist
Frequently Asked Questions (FAQ)

Introduction: Hip Anatomy and Function
Hip pain: The hip is the joint that connects the trunk to the lower limb, and its integrity is essential for walking, running, climbing stairs, and performing all daily activities that require weight-bearing on the lower limbs. Hip pathologies, often underestimated in their initial stages, can have a profound impact on quality of life and personal autonomy.
The coxofemoral joint is a ball-and-socket joint: the spherical head of the femur articulates with the acetabulum of the pelvis. This conformation gives it intrinsic stability and ample mobility across all planes of movement. Stability is further guaranteed by the acetabular labrum (a fibrocartilaginous ring that deepens the socket), robust capsular ligaments, and powerful musculature that includes the glutes, adductors, psoas-iliacus, and deep rotators.
The hip bears enormous loads during daily activities: up to 4-5 times body weight during running and 8 times during a jump. These stresses explain the frequency of hip osteoarthritis (coxarthrosis), which represents one of the main indications for joint replacement. But hip pathologies are not limited to osteoarthritis: tendinopathies, bursitis, femoroacetabular impingement, and labral tears are frequent causes of pain that a physical therapist must be able to recognize and treat. In this guide, we will analyze the most common pathologies, with a focus on evidence-based rehabilitation strategies.

Hip Replacement: Rehabilitation Pathway
Hip replacement (arthroplasty) is one of the most successful surgical procedures in the history of modern medicine. When coxarthrosis reaches an advanced stage, with severe pain, marked stiffness, and significant limitation of daily activities despite conservative treatment, prosthetic replacement offers excellent results in terms of pain reduction and functional recovery.
Surgical techniques have evolved enormously in recent decades. The direct anterior approach (minimally invasive) allows for faster recovery compared to traditional approaches, with less muscle damage and accelerated rehabilitation protocols. However, regardless of the surgical technique, physiotherapy remains the determining factor for the long-term outcome.
The rehabilitation pathway ideally begins before surgery with prehabilitation: muscle strengthening exercises, joint mobility, and learning the movements to perform post-operatively. After surgery, rehabilitation follows progressive phases: early mobilization and verticalization within the first 24-48 hours, assisted ambulation with crutches, recovery of joint mobility, progressive muscle strengthening (with particular attention to the gluteus medius and abductor muscles), and return to functional activities. Patients who meticulously follow the rehabilitation pathway achieve the best results, often returning to activities such as swimming, cycling, hiking, and golf.
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Bilateral Hip Arthroplasty
Bilateral hip arthroplasty represents a particular rehabilitation challenge that deserves dedicated attention. When both hips are severely osteoarthritic, the question arises whether to intervene in a single surgical stage (simultaneous bilateral replacement) or in two separate stages (sequential bilateral replacement, typically 3-6 months apart).
In clinical practice, the choice between the two strategies depends on the patient’s age, comorbidities, activity level, and individual preferences. Simultaneous bilateral replacement reduces the number of anesthesias, hospital costs, and the total recovery period, but involves a more demanding surgery and a more complex initial post-operative period. Sequential replacement allows for gradual recovery but exposes the patient to a second surgery and a second rehabilitation period.
The rehabilitation pathway after bilateral arthroplasty requires particular attention to load symmetry, gait pattern re-education, and balanced strengthening of both sides. Patients with bilateral replacements must also pay attention to managing daily activities in the first few months, when the periprosthetic musculature is still recovering full efficiency. The ultimate goal, achievable in the vast majority of cases, is autonomous and symmetrical ambulation without aids.
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Trochanteritis (Trochanteric Bursitis)
Trochanteritis, traditionally called trochanteric bursitis, is one of the most common causes of lateral hip pain. The more current and correct term is “Greater Trochanteric Pain Syndrome” (GTPS), as studies have shown that inflammation of the trochanteric bursa is only one component of a more complex picture that also involves the gluteus medius and gluteus minimus tendons.
The pain is localized in the lateral hip region, at the level of the femoral greater trochanter, and typically manifests in lateral decubitus (sleeping on the affected side becomes impossible), when climbing stairs, getting up from a chair, and during prolonged walking. The condition is more frequent in women between 40 and 60 years old, in runners, and in patients with associated lumbar problems.
Physiotherapy treatment has evolved significantly in recent years. The traditional approach based on stretching and foam rolling has been largely abandoned, as lateral compression worsens the underlying gluteal tendinopathy. Modern evidence-based treatment includes: patient education (avoid lateral compression positions), isometric and then isotonic strengthening exercises for the gluteal muscles, pelvic stabilization, and correction of dysfunctional movement patterns. In clinical practice, this approach produces much superior results compared to anti-inflammatory or infiltrative therapy alone.
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Hip Exercises: Strengthening and Mobility Program
The following exercises represent a basic program for improving hip mobility and strength. Before starting, it is advisable to consult your doctor or physical therapist to ensure that the exercises are appropriate for your condition. In case of acute pain during execution, stop immediately.
Phase 1 — Joint Mobility

Exercise 1: Supine Hip Flexion (Knee to Chest)
Difficulty: Easy | Equipment: Mat | Duration: 3 minutes

Starting position:
Lying on your back on a mat. Both legs are extended. Arms are along your sides. The lumbar region is in a neutral position.
Step-by-step execution:

Step 1: Slowly bend one knee and bring it towards your chest, grasping the back of your thigh with both hands (not directly the knee for those with knee joint problems).
Step 2: Gently pull the knee towards your chest until you feel a comfortable stretch in the groin region and the front of the hip. Hold the position for 20 seconds.
Step 3: Slowly release and return the leg to the extended position in a controlled manner. Repeat with the other leg.

Sets and repetitions: 3 sets x 20 seconds per side — 10-second rest between repetitions
Common errors to avoid:

Lifting your head and shoulders off the mat during the stretch
Pulling directly on the kneecap, overloading the knee joint
Lifting the lumbar region off the floor, arching your back

How to know you are doing it correctly:
You feel a gentle stretch in the front of your hip and thigh. The opposite leg remains extended and relaxed in contact with the mat. The lumbar region maintains contact with the floor.

Exercise 2: Supine Hip Rotations
Difficulty: Easy | Equipment: Mat | Duration: 4 minutes

Starting position:
Lying on your back with both knees bent and feet flat on the floor, slightly wider than hip-width apart. Arms are open laterally to stabilize the pelvis.
Step-by-step execution:

Step 1: Slowly let one knee fall outwards (external hip rotation), keeping the foot flat on the floor. Reach the point of maximum comfortable stretch and hold for 5 seconds.
Step 2: Bring the knee back to the center and then slowly let it fall inwards (internal hip rotation), partially crossing it towards the opposite knee. Hold for 5 seconds.
Step 3: Alternate external and internal rotation smoothly for the indicated number of repetitions. The pelvis remains stable and in contact with the mat.

Sets and repetitions: 3 sets x 10 repetitions per side (alternating external and internal rotation) — 30-second rest between sets
Common errors to avoid:

Lifting the pelvis off the mat during rotations
Forcing the knee to the point of maximum rotation: the movement should be pain-free
Performing the movement too quickly, losing control

How to know you are doing it correctly:
You feel a gentle mobilization sensation in the hip joint. The pelvis remains perfectly still and in contact with the floor. The range of rotation progressively improves over the repetitions.

Phase 2 — Strengthening Stabilizing Musculature

Exercise 3: Side-Lying Hip Abduction (Clam Shell)
Difficulty: Intermediate | Equipment: Mat, resistance band (optional) | Duration: 5 minutes

Starting position:
Lying on your side with your head resting on your extended lower arm. Your knees are bent at about 45 degrees and your feet are stacked one on top of the other. The pelvis is perfectly perpendicular to the floor (not tilted forward or backward). Your top hand can rest on your hip to ensure the pelvis doesn’t rotate.
Step-by-step execution:

Step 1: Keeping your feet in contact with each other, slowly lift your top knee towards the ceiling, opening your knees like a clam shell. The movement should originate from the hip, not the back.
Step 2: Reach maximum opening without the pelvis rotating backward (about 30-45 degrees) and hold for 2 seconds, actively contracting the glute.
Step 3: Slowly lower the knee to the starting position in 3 seconds, controlling the descent.

Sets and repetitions: 3 sets x 15 repetitions per side — 45-second rest between sets
Common errors to avoid:

Rotating the pelvis backward to increase the opening: the pelvis must remain still and perpendicular
Lifting the feet off each other during knee lift
Performing the movement with a quick jerk instead of in a controlled manner

How to know you are doing it correctly:
You feel muscle work in the lateral and posterior part of the glute (gluteus medius), not in the outer thigh. The pelvis remains completely still throughout the movement. With the addition of a resistance band placed just above the knees, the difficulty progressively increases.

Exercise 4: Single-Leg Glute Bridge
Difficulty: Advanced | Equipment: Mat | Duration: 5 minutes

Starting position:
Lying on your back with both knees bent and feet flat on the floor. Extend one leg towards the ceiling (or keep it raised with the knee flexed at 90 degrees if more comfortable). Arms are extended along your sides.
Step-by-step execution:

Step 1: Push with the heel of the supporting leg and lift your pelvis off the floor, extending your hip to form a straight line from your shoulder to your knee. The other leg remains raised. The lift lasts 2 seconds.
Step 2: Hold the high position for 3 seconds, actively contracting the glute of the weight-bearing leg. The pelvis must remain horizontal without tilting towards the side of the raised leg.
Step 3: Slowly lower the pelvis in 3 seconds without completely touching the ground, then immediately lift again for the next repetition.

Sets and repetitions: 3 sets x 8 repetitions per side — 60-second rest between sets
Common errors to avoid:

Allowing the pelvis to tilt (drop) towards the side of the raised leg: keep the pelvis perfectly horizontal
Arching the lumbar region excessively in the high position
Compensating by rotating the pelvis to facilitate the lift

How to know you are doing it correctly:
You feel intense muscle work in the glute of the supporting leg. The pelvis remains perfectly horizontal, as if you had a tray placed on top. You do not feel pain in the lumbar region or the groin region.

Phase 3 — Balance and Functional Control

Exercise 5: Side Lunge
Difficulty: Intermediate | Equipment: None | Duration: 5 minutes

Starting position:
Standing, with feet together and torso upright. Arms are joined in front of the chest or on the hips for balance.
Step-by-step execution:

Step 1: Take a wide step sideways to the right, bending your right knee and bringing your pelvis backward as if sitting on a chair, keeping your left leg extended. Your right foot remains completely flat on the floor.
Step 2: Descend until your knee is bent at about 90 degrees (or to a comfortable point). The knee remains aligned with the second toe of the foot. Hold for 1 second.
Step 3: Push off with your right foot to return to the starting position in a controlled manner. Repeat on the opposite side.

Sets and repetitions: 3 sets x 10 repetitions per side — 60-second rest between sets
Common errors to avoid:

Deviating the knee of the bent leg inward
Lifting the heel off the ground during knee flexion
Leaning the torso excessively forward, losing postural control

How to know you are doing it correctly:
You feel muscle work in the glutes and inner thigh (adductors) of the supporting leg. The extended leg feels a stretch in the inner thigh. The movement is controlled and does not cause hip pain.

Exercise 6: Single-Leg Balance with Floor Touch (Simplified Single Leg Deadlift)
Difficulty: Advanced | Equipment: None (chair for safety) | Duration: 5 minutes

Starting position:
Standing on one leg, with the knee slightly flexed (about 10-15 degrees). The other leg is slightly raised off the ground behind you. Arms are extended in front of the body. A chair is placed nearby for safety.
Step-by-step execution:

Step 1: Lean slowly forward with your torso, keeping your back straight, while your back leg extends backward. Torso and back leg move as a single rigid block.
Step 2: Continue leaning until your hands are near the floor (or as far as possible without rounding your back). The back leg is parallel to the floor in the final position. Hold for 2 seconds.
Step 3: Slowly return to the upright position in 3 seconds, contracting the glute of the supporting leg to guide the upward movement.

Sets and repetitions: 3 sets x 6 repetitions per side — 60-second rest between sets
Common errors to avoid:

Rounding your back during the forward lean: the spine remains in a neutral position
Rotating the pelvis towards the side of the raised leg: the pelvis remains horizontal
Locking the knee of the supporting leg in hyperextension

How to know you are doing it correctly:
You feel intense work in the glute and hamstrings of the supporting leg. You feel a stretch in the back of the thigh of the same leg. Balance is maintained without excessive wobbling.

Important note: This program is for informational purposes only and does not replace individual assessment. For a personalized program, consult your doctor or physical therapist, who can adapt the exercises to your specific clinical condition. In particular, those who have undergone hip replacement surgery must exclusively follow the surgeon’s and physical therapist’s instructions regarding post-operative precautions.

When to Consult a physical therapist
Hip pathologies tend to develop gradually, and many patients get used to the pain before seeking professional help. Clinical experience shows that early intervention leads to better results and shorter recovery times.
Consult your doctor or physical therapist if:

You experience groin or hip pain during walking or climbing stairs
Hip pain limits your ability to walk normal distances
You have difficulty tying your shoes, cutting your toenails, or putting on socks
You can no longer sleep on your side due to lateral pain
You limp after a period of inactivity (morning stiffness)
You need to prepare for hip replacement surgery or are in the post-operative phase
Hip pain is associated with lower back or knee pain

Consult a doctor or the Emergency Room if:

You cannot bear weight on your leg after a fall (suspected femoral fracture)
Hip pain is accompanied by fever and general malaise
You have undergone hip replacement surgery and notice a sudden worsening of pain with marked limitation of movement (suspected prosthetic dislocation)
You experience intense and sudden groin pain without obvious trauma in young adults

Frequently Asked Questions (FAQ)
What is the difference between coxarthrosis and trochanteritis?
Coxarthrosis is osteoarthritis of the hip joint (cartilage wear) and primarily causes groin pain, worsened by weight-bearing and movement. Trochanteritis is an inflammation of the lateral hip structures (gluteal tendons and trochanteric bursa) and causes pain in the lateral region, especially in lateral decubitus and in activities requiring pelvic stabilization. The two conditions can coexist but require different treatments.
How long does rehabilitation last after hip replacement?
The standard rehabilitation pathway lasts 2-3 months for a return to normal daily activities. Most patients abandon crutches within 4-6 weeks, resume driving within 6-8 weeks, and return to normal walking within 3 months. Complete recovery of muscle strength and endurance can take up to 6-12 months. A long-term maintenance program is recommended to preserve the results.
Can I play sports with a hip replacement?
Many sports activities are compatible with hip replacement: swimming, cycling, walking, golf, cross-country skiing, pilates, and yoga (with adaptations) are generally permitted and even recommended. High-impact sports such as running, soccer, and competitive tennis are generally not recommended due to the risk of accelerated implant wear. The decision must be shared with the surgeon and physical therapist based on the type of prosthesis, bone quality, and fitness level.
Can hip pain originate from the back?
Absolutely yes. Referred pain from the lumbar spine to the hip is very frequent and represents one of the most common diagnostic pitfalls. An L3 or L4 radiculopathy can manifest with groin pain that perfectly mimics coxarthrosis. This is why a complete physiotherapy evaluation must always include an examination of the lumbar spine and neurological tests of the lower limbs. In clinical practice, it is not uncommon for the cause of hip pain to actually be a lumbar problem.
How can I prevent hip osteoarthritis?
It is not possible to completely prevent coxarthrosis, as genetic and structural factors play an important role. However, it is possible to slow progression and reduce risk through: maintaining an adequate body weight (every kg of excess weight increases the load on the hip by 3-4 kg during walking), regular low-to-medium impact physical activity, strengthening of the hip stabilizing musculature, and timely treatment of predisposing conditions such as femoroacetabular impingement and hip dysplasia.

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Also read:

Snapping Hip: Causes, Symptoms, and Treatment
Hip Dislocation: Femoral Head Necrosis: Femoroacetabular Impingement: Acetabular Labral Tear: Hip Osteoarthritis (Coxarthrosis): Symptoms and Exercises
Causes and Treatment
Femoral Fracture: Rehabilitation and Timelines
Diagnosis and Rehabilitation
Treatment and Recovery
Symptoms and Treatment
Groin Pain (Pubalgia): Causes, Exercises, and Recovery Times

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Sources and Scientific References

1. Kim B et al. (2020). Core Stability and Hip Exercises Improve Physical Function and Activity in Patients with Non-Specific Low Back Pain: A Randomized Controlled Trial. Tohoku J Exp Med. 251:193-206. DOI | PubMed
2. Cibulka MT et al. (2017). Hip Pain and Mobility Deficits-Hip Osteoarthritis: Revision 2017. J Orthop Sports Phys Ther. 47:A1-A37. DOI | PubMed
3. Sasaki R et al. (2022). Effect of exercise and/or educational interventions on physical activity and pain in patients with hip/knee osteoarthritis: A systematic review with meta-analysis. PLoS One. 17:e0275591. DOI | PubMed
4. Koc TA Jr et al. (2025). Hip Pain and Mobility Deficits-Hip Osteoarthritis: Revision 2025. J Orthop Sports Phys Ther. 55:CPG1-CPG31. DOI | PubMed
5. Šťastný E et al. (2016). [Rehabilitation after total knee and hip arthroplasty]. Cas Lek Cesk. 155:427-432. PubMed

Frequently Asked Questions

Why is early consultation with a physical therapist important for hip pain?

Early consultation with a physical therapist is crucial because hip pain can severely impact daily life and personal autonomy. Many hip conditions, beyond just osteoarthritis, benefit greatly from targeted physiotherapy interventions, leading to more effective treatment and better long-term outcomes.

What are some common causes of hip pain besides osteoarthritis?

While osteoarthritis (coxarthrosis) is a frequent cause, hip pain can also stem from conditions like tendinopathies, bursitis (e.g., trochanteric bursitis), femoroacetabular impingement, and labral tears. A physical therapist can help recognize and treat these various pathologies.

How does physiotherapy contribute to a successful hip replacement recovery?

Physiotherapy is vital for optimal recovery after hip replacement surgery, ideally starting with pre-surgical exercises to strengthen muscles and learn post-operative movements. Post-operatively, it guides progressive phases of mobilization, strengthening, and functional activity recovery, ensuring the best long-term results and return to daily activities.

What is ‘prehabilitation’ in the context of hip replacement surgery?

Prehabilitation refers to the rehabilitation pathway that ideally begins before hip replacement surgery. It involves muscle strengthening exercises, improving joint mobility, and learning the specific movements and precautions to perform post-operatively, which helps prepare the body for surgery and accelerates recovery.

When should I consider hip replacement surgery?

Hip replacement surgery is typically considered when coxarthrosis reaches an advanced stage, causing severe pain, marked stiffness, and significant limitation of daily activities, despite conservative treatments. In such cases, prosthetic replacement offers excellent results in terms of pain reduction and functional recovery.