The hip joint is a complex, weight-bearing ball-and-socket structure that allows for a wide range of motion necessary for walking, running, and standing. Stability and movement rely heavily on numerous powerful tendons, which are dense, fibrous connective tissues. Tendons connect muscle to bone, transmitting force from the contracting muscle to the skeletal system to produce movement. The hip is surrounded by a network of these structures that manage the immense forces placed upon the joint during daily activities.
Major Tendon Groups of the Hip
The hip’s complex movements are controlled by three primary functional groups of tendons, each situated in a different area of the joint. These groups are responsible for movements like bringing the knee toward the chest, extending the leg backward, and moving the leg away from the body’s center line.
The flexor group, located at the front of the hip, is dominated by the strong iliopsoas tendon. This structure is the combined tendon of the iliacus and psoas major muscles, attaching deep within the pelvis to the lesser trochanter of the femur. It acts as the strongest hip flexor, responsible for lifting the leg forward during walking or climbing stairs.
On the side of the hip, the abductor group is comprised mainly of the gluteus medius and gluteus minimus tendons. These tendons attach to the greater trochanter, the prominent bony point on the upper, outer thigh. Their primary role is to move the leg out to the side (abduction) and to stabilize the pelvis when standing on one leg.
The extensor group, found along the back of the hip and thigh, includes the proximal hamstring tendons. These three tendons—the semimembranosus, semitendinosus, and the long head of the biceps femoris—originate from the ischial tuberosity, commonly known as the “sit bone.” They are the primary movers for hip extension, pulling the leg backward, and are utilized during activities like running and jumping.
Common Tendon Overuse Conditions
Repetitive activity can lead to chronic tendon problems around the hip, broadly grouped under the term tendinopathy. This must be distinguished from tendinitis, which implies acute inflammation. True tendinitis, characterized by inflammatory cells, is rare and typically short-lived, resulting from a sudden, acute overload.
In contrast, tendinopathy describes a chronic condition involving the degeneration and breakdown of the tendon’s collagen fibers, usually without significant inflammation. Gluteal tendinopathy causes pain on the outer side of the hip, often misdiagnosed as trochanteric bursitis. This condition involves the tendons of the gluteus medius and minimus, which become compromised from chronic, repetitive compression or tensile stress.
Iliopsoas tendinopathy, affecting the hip flexor tendon at the front, is often seen in athletes whose sports require repeated hip flexion, such as dancers or runners. Chronic stress on this tendon can lead to internal snapping hip syndrome. This “snapping” occurs when the iliopsoas tendon catches and then slides abruptly over the underlying bony prominence of the pelvis, the iliopectineal eminence.
Another common overuse issue is external snapping hip syndrome, which involves the iliotibial band or the gluteus maximus tendon snapping over the greater trochanter on the outside of the thigh. While often painless, the repetitive friction can cause irritation or inflammation in the surrounding tissues. This extra-articular snapping is distinct from intra-articular snapping, which involves a mechanical issue inside the hip joint, such as a labral tear.
Acute Tendon Injuries
While overuse causes the gradual degeneration seen in tendinopathy, acute tendon injuries involve sudden, structural damage, most commonly tears or avulsions. These injuries result from a single, forceful event that exceeds the tendon’s tensile strength, distinct from the chronic, repetitive microtrauma that characterizes tendinopathy.
Gluteal tendon tears, affecting the gluteus medius and minimus, can range from partial-thickness to full-thickness ruptures. Although the final tear event may feel sudden, these injuries often occur in tendons already weakened and degenerative from long-standing tendinopathy. A full-thickness tear can severely impair the hip’s abductor function, leading to significant weakness and a noticeable limp.
High hamstring tendon tears, also known as proximal hamstring avulsions, are traumatic injuries where the tendon is suddenly detached from its bony anchor on the ischial tuberosity. This severe tear typically happens during a high-energy movement, such as sprinting or a sudden, forceful slip that causes the hip to flex rapidly while the knee is extended. Patients often report a sharp, sudden pain in the buttocks, sometimes accompanied by a palpable defect or significant bruising down the back of the thigh.
An avulsion injury represents the most severe form of tendon damage, requiring the muscle to contract so forcefully that it pulls the tendon completely away from the bone. The resulting loss of function often necessitates surgical intervention to reattach the tendon. This acute, traumatic presentation contrasts sharply with the slow onset of pain typical of chronic hamstring tendinopathy.
Identifying and Treating Hip Tendon Problems
Identifying a hip tendon problem begins with a detailed physical examination, where a physician tests muscle strength and provokes pain through specific movements. Imaging studies are commonly used to confirm the diagnosis and determine the extent of the damage. An X-ray is often the first step to rule out a bony issue, such as a fracture or arthritis, but it cannot visualize soft tissues.
To assess the tendons, an ultrasound or Magnetic Resonance Imaging (MRI) scan is utilized, as these clearly show structural changes like degeneration, fluid accumulation, or tears. Ultrasound is particularly useful for a dynamic assessment, allowing the clinician to visualize the tendon’s movement in real-time, such as in snapping hip syndrome. This information guides the appropriate treatment strategy.
The initial management for nearly all tendon issues is conservative, focusing on non-surgical methods. This typically includes activity modification to reduce mechanical load on the affected tendon, coupled with the use of non-steroidal anti-inflammatory drugs (NSAIDs) for pain relief in acute cases. However, the long-term use of NSAIDs for chronic tendinopathy is discouraged due to concerns about hindering the collagen repair process.
Physical therapy is the foundation of long-term recovery, aiming to restore the tendon’s ability to handle stress through a gradual loading program. Treatment focuses on exercises that strengthen the surrounding muscles and improve movement patterns, starting with gentle isometric contractions and progressing to dynamic strengthening. In cases of severe, acute tears or injuries that fail to respond to months of conservative care, surgical intervention may be considered.