While hip flexor pain with running might not top the charts of running-related injuries—it doesn't even crack the top 10 according to recent studies (1)—it's a sneaky adversary that demands your attention.
Like a stealthy predator in the running world, hip flexor pain can ambush even the most seasoned athletes, often masquerading as a simple muscle strain when it could be the harbinger of a more serious injury.
In this deep dive, we'll lace up our investigative shoes and talk through the common characteristics of hip flexor pain in runners. But we won't stop there. We'll also equip you with the knowledge to discern when that nagging discomfort might be signaling something more sinister than a simple strain.
By the end of this post, you'll be armed with the insights to protect your hips, safeguard your running future, and keep your passion for the pavement alive and kicking.
Hip Flexor Pain With Running
Diagnosis
True hip flexor pain with running is a muscular injury to one or both of the two primary hip flexor muscles: the iliopsoas, and the rectus femoris.
Muscle and tendon injuries are usually easier to rule in or out because contracting the muscle in question should reproduce the pain, while passive movement should not (more on that later).
Performing resisted hip flexion through a straight leg raise or self resisted knee to chest should reproduce symptoms of a hip flexor muscle strain or tendinopathy.
Symptoms of a hip flexor muscle/tendon injury may “warm” with activity to a certain extent. Generally speaking, it is common for muscle and tendon injuries to feel worse with the initiation of activity, but better after warming up.
The rectus femoris muscle is relatively superficial, which means that you may be able to recreate the symptoms by pressing on the painful area. The iliopsoas muscle is much deeper, and therefore harder to reproduce through external pressure.
Lastly, the mechanism of injury is relevant for identifying the source of hip pain with running. Remember, hip flexor strains are not the most common long distance running related injury likely in part because distance running doesn’t require a large amount of hip flexor activity relative to other muscle groups.
Hip flexor and groin injuries are much more common in sports like hockey, for example, which requires much more hip range of motion and multidirectional movement.
Having an acute mechanism of injury during sudden increases in speed/acceleration might increase suspicion of a hip flexor muscle injury.
Summary:
Reproduced with resisted hip flexion
May warm with activity
Easy to palpate or recreate symptoms by pressing on the area
Not painful with passive hip mobility
No significant change in symptoms with prolonged weight bearing
Treatment of Hip Flexor Pain with Running
Managing a hip flexor muscle or tendon injury related to running has similarities to managing any other type of muscle injury. An initial period of relative rest for 7-10 days, followed by a gradual progression of strength and mobility and investigation to why the injury happened in the first place is an effective general strategy.
Here is an example exercise progression for someone dealing with a hip flexor strain:
Hip flexor pain with running can sometimes be reduced and prevented by adjusting your posture while running. Having a significant anterior pelvic tilt while running can make you spend more time in end range hip flexion, which can strain the hip flexors and irritate the hips. Working on hip extension mobility and core postural awareness can be an effective strategy to combat this inefficiency.
Other Sources of Hip Pain With Running
While a hip flexor muscular injury can take a while to recover from, it is far less serious than a hip injury that is much more prevalent in distance runners than other sporting populations: femoral neck stress fractures (FNSF).
While these injuries only make up 3% of all sport related stress fractures, they are most prevalent in marathon and long distance runners. (2) More importantly, the potential downside of missing this diagnosis is far greater than missing a hip flexor tendinopathy diagnosis, as it can result in a full displaced fracture requiring urgent surgery to correct.
Characteristics of Femoral Neck Stress Fractures
The challenge with these injuries is that there are some characteristics of FNSFs that are similar to hip flexor injuries. See the chart below for a comparison:
Management of Femoral Neck Stress Fractures
The most important steps in managing FNSFs are risk management and early detection. Long distance runners or people training for a marathon who develop front of the hip pain should see a medical professional as soon as possible to rule out this injury.
While clinical evaluation can be helpful at assessing risk, the gold standard for ruling out FNSFs is an MRI. X-rays are often unable to detect these injuries in their early stages, and can therefore not be trusted to rule out these injuries.
The people at highest risk for developing a femoral neck stress fracture are female long distance runners who have low energy availability due to under fueling and have a sudden increase in their running volume or intensity.
One study found that of their subjects that sustained FNSF, 4.1% were female, while 1.8% were male. In addition, there have been multiple studies that have highlighted the connection between relative energy deficiency syndrome (REDs) and stress fractures.(2,3)
If a runner fits this risk profile and is experiencing a new onset of anterior hip pain, they should be instructed to be non weight bearing and should be referred to get an MRI immediately.
Runners with new onset of anterior hip pain who fit some or none of these criteria should still be evaluated by a medical professional to rule out a FNSF.
Final Thoughts
It’s important to remember that femoral neck stress fractures are not the most common running related injury. They are just more prevalent in runners compared to other populations, and the potential downside is high if they are not caught early.
But if you’ve been dealing with hip flexor pain with running and have been avoiding getting it checked out, let this be the nudge that you need to get help!
At Alterra, we specialize in helping runners get to the root cause of their injuries so that they can stay on track with their training and enjoy running without pain. If you're a local runner in Boston's Back Bay and are experiencing some hip flexor pain with running, we'd love to help! Book a free discovery call to chat with a therapist today.
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Disclaimer: The information in our blog posts is not a substitute for professional medical advice. Consult a healthcare provider before making decisions related to your health. Use our content at your own risk.
Sources
Lopes AD, Hespanhol Júnior LC, Yeung SS, Costa LO. What are the main running-related musculoskeletal injuries? A Systematic Review. Sports Med. 2012;42(10):891-905. doi:10.1007/BF03262301
Robertson GA, Wood AM. Femoral Neck Stress Fractures in Sport: A Current Concepts Review. Sports Med Int Open. 2017;1(2):E58-E68. Published 2017 Mar 15. doi:10.1055/s-0043-103946
Mountjoy M, Ackerman KE, Bailey DM, et al2023 International Olympic Committee’s (IOC) consensus statement on Relative Energy Deficiency in Sport (REDs)British Journal of Sports Medicine 2023;57:1073-1098.
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