One of my favorite patient interactions I’ve experienced as a Physical Therapist was when I was evaluating an older gentleman, with his wife accompanying him to the appointment. I asked him to “Tell me about when this pain in the butt began.” He sent a sly glance over at his wife and replied, “Well, about 38 years ago.” It was hilarious, and needless to say we always had fun in therapy.
All jokes aside, a pain in the butt is, well, a pain in the butt (okay, now all jokes aside). Hip and gluteal pain is quite common in runners and triathletes, both affecting training and in some cases shutting it down entirely. No matter if a pain sidelines you completely or not, it is a signal that something is awry and should be addressed.
As is common with most injuries, there rarely is a single cause or culprit behind the pain. We often think of hip strength/endurance as important in avoiding all lower body running injuries, and this holds true in the case of buttock pain. However, if we only address the hips, we might be missing an important piece of the puzzle.
“Hip stability” is a term that often graces the pages of magazines, running forums, and conversations between runners. The way I, as a Physical Therapist, think about hip stability is the muscular system’s ability to avoid excessive pelvic motion during running gait. What this means is that the muscles on the front, back, and sides of the hip work well together to propel you forward. For example, If the muscles in the front (i.e. hip flexors, quads, psoas, TFL) are tight and weak, the pelvis will tilt forward and place the glutes at a disadvantage. This leads to increased load on the hamstrings, lower back, and potentially the calves, as now there are needed more for forward propulsion. Similarly, if the hip abductors (glute medius, TFL,) don’t hold up their end of the bargain, the pelvis will drop to one side, infamously known as “hip drop”. Runners with moderate to severe hip drop often experience lateral hip and low back strain, as well as a change in mechanics down the chain, leading to eventual knee, ankle, or foot pain. The bottom (pun intended) line here is that dynamic control of the pelvis is important, in addition to strength. This is why I give my runners standing hip strengthening exercises, to practice that control in an environment that is running-specific.
However, if we want to fully solve the problem, we have to look both above and below the hips. The lower back and pelvis are linked in both structure and function. We absolutely cannot treat one without addressing the other. While the scope of this article is not to help with diagnosis, hip pain can be caused by the lumbar spine, and vice versa. Spinal mobility and core control are key to making sure this dream team keeps you injury-free.
Similarly, the way that force is attenuated up the lower leg, spine, and rest of the body begins with how the foot handles the load. A strong foot is the stable base that the rest of your body can work off of. Balance exercises, barefoot exercises, and proper footwear can help build foot strength and set your hips up for success.
Most athletes will experience some sort of hip discomfort, given high activity levels and training intensities. To keep this from becoming a problem, be diligent about using foam rollers, lacrosse balls, and other massage tools to keep those hard working muscles happy. I often compare foam rolling and other muscle maintenance to brushing your teeth-- it’s a routine that can prevent big issues in the future!
Physical Therapists are experts in movement, and can help you pinpoint issues in your movement patterns, running form, and mobility that may be causing your hip pain. You don’t have to live with a pain in the butt! (Note: PT’s are not experts in relational issues)
Keep going, you got this!
Kacy Seynders, PT, DPT, OCS