Causes of hip and groin pain

by Nathan Wei, MD, FACP, FACR

Nathan Wei is a nationally known board-certified rheumatologist and author of the Second Opinion Arthritis Treatment Kit. It's available exclusively at this website... not available in stores.

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Pain in the hip joint can indicate various hip conditions.

Causes of groin pain or hip pain in athletes:

A specific cause is not identified in 30% of cases. Among the other common causes are adductor strain or adductor tendinitis (groin pull) most common in sprinters. The adductors are the muscles that bring the leg toward the midline.

Osteitis pubis is inflammation of the cartilage that joins the front bones of the pelvis. The cause is unknown. It is more common in women than men.

Myositis ossificans is a condition where the muscle calcifies. This develops after trauma to the muscle. It’s an uncommon condition but is seen in football players- particularly in the thighs.

Sports hernia and groin disruption may occur in athletes and present with groin pain and swelling.

Iliopsoas strain or iliopsoas bursitis are two common causes of groin pain. Typically the pain is felt in the front of the hip and groin and is aggravated by flexion of the hip –as with going up stairs.

Femoral neck stress fracture and pubic ramus stress fracture are another cause of hip and groin discomfort. Pain is aggravated by weight-bearing. The diagnosis can be made by bone scan and MRI.

Avulsion fracture are common in the adolescent athlete and are due to the pulling away of the tendons from the bone. Anterior superior iliac spine avulsion fracture comes about because of rapid sartorius contraction in jumping sports and responds to non-operative conservative therapy. Anterior inferior iliac spine avulsion fracture arises from strong rectus femoris contraction in kicking sports and responds to non-operative conservative therapy. Ischial tuberosity avulsion fracture is due to rapid hamstring contraction in sprinting and hurdling. If fragments develop as a result of the pulling away, surgery may be required.

Nerve entrapment disorders are another cause of hip and groin pain. Among these syndromes are: genitofemoral nerve entrapment, lateral femoral cutaneous nerve entrapment, ilioinguinal nerve entrapment, and obturator nerve entrapment. The diagnosis is difficult. Neurology consultation is advised. Sometimes nerve conduction studies are helpful. The character of the pain- burning with dysesthesia- may be a clue.

Pediatric causes (under age 10 years) include:

• Legg-Calve-Perthes disease, a congenital hip disorder requiring casting
• Septic joint, an infection of the hip capsule. This is a medical and sometimes surgical emergency. Hip or groin pain accompanied by fever and inability to bear weight are tip offs to diagnosis.
• Toxic synovitis, an uncommon condition characterized by groin pain, fever, and evidence of hip inflammation. This is difficult to distinguish from septic joint.


A relatively common adolescent cause is slipped capital femoral epiphysis, where the top of the femur becomes displaced from the underlying growth plate. Treatment will depend on the severity of the condition and requires careful attention by a pediatric orthopedic surgeon.

Adult causes include Osteoarthritis of the femoral head, avascular necrosis of the femoral head, and acetabular labral tear. Osteoarthritis is seen in middle-aged and older people. It is due to wearing away of cartilage and is characterized by limitation of internal rotation of the hip and groin pain. Avascular necrosis is death of the bone and commonly affects the head of the femur. Finally, tears of the labrum (the lip of cartilage that runs around the rim of the acetabulum) can cause groin pain.

Hip fracture also causes hip and groin pain. While the diagnosis is usually obvious, it sometimes is hard to diagnose if it is a stress fracture or insufficiency fracture in a patient with osteoporosis.

Cancer (primary site or metastases) is another cause of hip pain. Imaging studies will aid in diagnosis.

Among the joint causes are osteoarthritis, rheumatoid arthritis, septic arthritis (infected joint), gout, and a condition called osteoid osteoma. This latter problem is a benign tumor that causes a significant amount of night pain and responds top aspirin. Diagnosis is made on x-ray or MRI.

Muscle or tendon causes include iliotibial band syndrome, which is form of tendonitis pain felt on the outside of the hip and thigh. Trochanteric bursitis is an inflammation of the large cushion on the lateral part of the hip. Pain is aggravated by walking and by lying on the affected side. Iliopsoas bursitis is bursitis affecting the cushion that lies along the inner thigh. Pain is aggravated by flexing the hip. Piriformis Syndrome is a condition where the piriformis muscle that runs from the low back to the greater trochanter of the hip becomes inflamed or traumatized and pushes down on the sciatic nerve.

Among the neurologic causes are lumbar disc disease, spinal stenosis, coccidynia, and meralgia paresthetica. Many types of low back problems may cause referred pain to the back or front of the hip. Referred pain to the front of the hip is due to problems at L1 or L2. Pain referred to the buttock comes from L4-S1. Coccidynia is a painful tailbone and sometimes causes pain radiation to the buttock. Meralgia paresthetica is pinching of the lateral femoral cutaneous nerve and causes burning pain on the outside of the thigh.

Inguinal hernia , inguinal lymphadenopathy or lymphadenitis, nephrolithiasis (kidney stones), abdominal aortic aneurysm, appendicitis, diverticulitis, endometriosis, menstrual conditions,inflammatory bowel disease, abdominal malignancy, ovarian cysts, urinary tract infections, pelvic inflammatory disease, epididymitis, hydrocele, varicocele, prostatitis, testicular cancer are miscellaneous causes. A careful physical examination in the patient with groin and hip pain is important.

Different length legs may aggravate and sometimes even precipitate hip pain.

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