Women's Health
Hip Pain
If your hip is limiting how you move, run, or live, the cause is usually identifiable. A structured assessment can tell you what's actually driving it and guide a plan that fits how you move and what you want to do. Here's what's typically going on, and what's specific to women.
Book Your First VisitHip pain in women over 40 often involves the gluteal tendons (greater trochanteric pain syndrome), the sacroiliac joint, or referred pain from the lumbar spine. GTPS is three times more common in women than men, related directly to pelvic width and how load travels through the hip. Perimenopause can worsen it. Getting the diagnosis right before treating matters more than starting quickly.
Why hip pain in women deserves its own framing
Hip pain can come from the joint itself, surrounding tendons and muscles, or referred from the lumbar spine or sacroiliac joint. These have different patterns, different exam findings, and respond to different treatment approaches.
For women, the picture has some important additions. A wider pelvis changes the angle at which the gluteal tendons attach and run, which means those tendons are under greater compressive load with activities that bring the legs toward midline (sitting with legs crossed, side-lying directly on the hip, walking with excessive hip adduction). This is the main mechanical reason why greater trochanteric pain syndrome (GTPS) is approximately three times more common in women than men (Segal et al., 2007). Add in oestrogen's role in tendon health, and you have a condition that is genuinely more common in women, more likely to appear or worsen around perimenopause, and often misdiagnosed as "bursitis."
Common causes
- Greater trochanteric pain syndrome: lateral hip pain over the bony prominence on the outside of the hip. The gluteal tendon is the primary structure involved in most cases, not the bursa. This distinction matters for treatment: loading-based rehabilitation, avoiding compressive positions (crossing legs, hip adduction, sitting with knees lower than hips). Approximately three times more common in women, primarily related to pelvic mechanics; oestrogen's role in tendon health may also contribute, particularly around perimenopause. For most runners, modifying load rather than stopping entirely is both achievable and effective.
- Hip flexor tendinopathy and tightness: very common in women who alternate between long desk hours and running or exercise. Prolonged sitting is associated with hip flexor tightness, which may contribute to anterior pelvic tilt and increased lumbar load. In my experience, this typically responds well to targeted mobility work, strengthening, and adjusting how you transition between sitting and activity.
- Sacroiliac joint dysfunction: referring to the posterior hip and buttock. Women have a slightly different SI joint anatomy and are more prone to SIJ-related pain (Ulas et al., 2023), particularly after pregnancy. Relaxin-mediated laxity during pregnancy resolves after birth, but altered movement patterns, pelvic floor weakness, and reduced gluteal strength often persist and continue to affect joint control.
- Femoroacetabular impingement (FAI): bony contact between the femoral head and acetabulum during movement. Common in active patients with restricted hip rotation and groin pain. Some cases need imaging and specialist input.
- Hip osteoarthritis: gradual joint space loss, most common over 50. Conservative management can reduce pain and maintain function (Bannuru et al., 2019), but realistic expectations matter. Manual therapy and exercise won't reverse structural change, but they can meaningfully reduce pain and improve how you move.
- Bone stress injuries (stress fractures): pain that builds gradually in the groin or thigh with loading, often in active women who are running or training consistently. The femoral neck is a high-stakes location. This is one presentation where I do not defer assessment, because a missed stress fracture that progresses to a complete fracture is a serious injury. If bone stress injury is a possibility, I will refer you promptly for imaging. Low bone density and insufficient energy availability (under-fuelling relative to training load) are the main modifiable risk factors. Menstrual irregularity or loss of periods is a key warning sign, though this refers to training-related disruption rather than the normal hormonal changes of perimenopause.
What helps
Chiropractic care for hip pain includes joint mobilization of the hip itself, lumbar and sacroiliac joint treatment when they're contributing, soft tissue work for hip flexors and gluteal muscles, and rehabilitation exercises targeting hip stability and strength. The specific approach depends on what the assessment finds.
On GTPS and the perimenopause connection
Greater trochanteric pain syndrome often first appears or worsens in the mid-40s to early 50s. The timing frequently coincides with perimenopause, and the connection is real. Oestrogen is thought to play a role in collagen synthesis and tendon integrity. As levels decline, tendons that were previously coping with load may start to react. The evidence on direct hormonal effects is mixed: studies suggest a plausible biological mechanism,4,5 though results across trials are contradictory and inconsistent. The treatment approach is the same (progressive loading, avoiding compression), but the pace of rehabilitation may need to account for slower tendon recovery in this context. In a three-arm randomised trial (the LEAP trial, BMJ 2018), an education and exercise programme produced the best outcomes at both 8 weeks and 12 months. A corticosteroid injection gave meaningful short-term relief but did not match the exercise arm at one year. A wait-and-see approach showed the weakest results overall. Pain scores across the exercise and injection groups largely converged by 52 weeks, but global improvement rates favoured exercise at both timepoints.
Bone health and energy availability in active women
Relative Energy Deficiency in Sport (RED-S) describes the consequences of insufficient energy intake relative to training load. It affects bone health directly: low energy availability suppresses oestrogen, which reduces bone mineral density and increases stress fracture risk. The hip, particularly the femoral neck, is one of the most common sites.
RED-S can develop gradually in any active person, including recreational runners and gym-goers who are training consistently. When training load increases without a matching increase in how much you eat, the body starts to cut corners, and bone health is often the first casualty. Warning signs include menstrual irregularity, frequent stress injuries, fatigue disproportionate to training load, and poor recovery.
If this pattern sounds familiar, I can screen for it as part of the assessment using validated tools. Management typically involves a sports dietitian to address energy availability, with manual therapy addressing whatever musculoskeletal problems have developed in the meantime. The IOC Consensus on RED-S (Mountjoy et al., 2023) provides the current clinical framework I use for this.
How I approach hip pain
The first session includes lumbar screening, hip mobility testing, and specific orthopedic tests to identify the structure involved. For runners especially: the goal is to modify training load rather than stop running entirely. In practice that usually means reducing total weekly distance and avoiding positions that compress the tendon, such as steep downhills or long stretches with the hip crossing the midline, while flat or moderate-pace running is often tolerable from early on. Hip flexor tightness typically responds to a home stretching and strengthening programme alongside treatment, with timelines varying by individual. Greater trochanteric pain syndrome takes considerably longer, typically 3 to 6 months, because tendinopathy rehabilitation requires gradual progressive loading and the tendons adapt slowly.
Some presentations, including labral tears with mechanical catching, significant FAI with structural change on imaging, and hip osteoarthritis requiring joint replacement consideration, benefit from specialist input. I'll tell you honestly if your presentation is one of them. If you'd like to talk through your situation before booking, book a time to chat.
When to seek care promptly
See a doctor if you have:
- Hip pain after significant trauma or a fall, especially in women with known or suspected low bone density (possible fracture)
- Severe groin pain with limited movement and inability to weight-bear
- Hip pain with fever, night sweats, or unexplained weight loss
- Hip pain with a history of cancer or long-term steroid use
- Progressive bone pain or pain that wakes you from sleep without a clear mechanical pattern (note: night pain in GTPS is common and typically positional, related to lying on the hip, which is a different pattern to what is described here)
These warrant medical evaluation before conservative treatment. For most gradual-onset hip pain without these features, a chiropractic assessment is an appropriate first step.
Common questions
The pattern and location help. True hip joint pain usually presents in the groin or anterior thigh, and is reproduced by hip rotation and loading. Lumbar referred pain tends to be more diffuse, sits in the posterior hip or buttock, and is reproduced by lumbar movements rather than isolated hip tests. I'll run specific tests for both during the assessment. Getting this distinction right is one of the more clinically important parts of managing hip pain, treating the wrong structure wastes time.
Not before starting conservative care in most cases. Clinical assessment gives a lot of information. Imaging is useful if I suspect FAI with significant structural change, labral pathology that might need arthroscopic intervention, or early hip osteoarthritis that would change the management approach. I'll tell you after assessing you whether I think a scan would genuinely change what we do.
The term "trochanteric bursitis" is used loosely, but current research suggests that in most cases of lateral hip pain, the primary structure involved is the gluteal tendon (tendinopathy), not the bursa itself (Grimaldi & Fearon, 2015). This distinction matters for treatment: tendinopathy responds to loading-based rehabilitation, while compressive positions (crossing the legs, sitting with the hip adducted) aggravate it. I'll explain the specific pattern that applies to your presentation and what that means for management.
It may well be contributing. Oestrogen is thought to play a role in tendon health and collagen synthesis, though the evidence on how directly that translates into clinical symptoms is still mixed. What is clear is that GTPS frequently appears or worsens in the mid-40s to early 50s, and the timing is often not coincidental. As oestrogen levels decline, tendons that have been managing load for years can become more irritable. In practical terms, this often means the pace of tendon rehabilitation is slower and the loading needs to be built up more carefully than it would in a younger patient. That is factored into how I approach the programme.
For many women, yes. Pregnancy-related hip pain usually involves the sacroiliac joint or the pubic symphysis, driven by relaxin-mediated ligament laxity combined with load changes as the body accommodates pregnancy. After birth, ligament tension typically returns, but altered movement patterns and weakened gluteal and pelvic floor muscles often persist (Sakamoto & Gamada, 2019). This can maintain hip and pelvic pain well beyond the pregnancy itself. An assessment can identify which structures are still contributing and what targeted work will actually help.
Related reading
References
- Segal NA, Felson DT, Torner JC, et al. Greater trochanteric pain syndrome: epidemiology and associated factors. Arch Phys Med Rehabil. 2007;88(8):988–992. PMC2907104
- Mellor R, Bennell K, Grimaldi A, et al. Education plus exercise versus corticosteroid injection use versus a wait and see approach on global outcome and pain from gluteal tendinopathy: prospective, single blinded, randomised clinical trial (LEAP trial). BMJ. 2018;361:k1662. PubMed 30385462
- Grimaldi A, Fearon A. Gluteal tendinopathy: integrating pathomechanics and clinical features in its management. J Orthop Sports Phys Ther. 2015;45(11):910–922. PubMed 26381486
- Frizziero A, Vittadini F, Gasparre G, Masiero S. Impact of oestrogen deficiency and aging on tendon: concise review. Muscles Ligaments Tendons J. 2014;4(3):324–328. PMC4241423
- Ganderton C, Semciw A, Cook J, Pizzari T. The effect of female sex hormone supplementation on tendon in pre and postmenopausal women: a systematic review. J Musculoskelet Neuronal Interact. 2016;16(4):331–338. PMC5114352
- Sakamoto A, Gamada K. Altered musculoskeletal mechanics as risk factors for postpartum pelvic girdle pain. J Phys Ther Sci. 2019;31(10):831–838. PMC6801337
- Mountjoy M, Ackerman KE, Bailey DM, et al. 2023 International Olympic Committee's (IOC) consensus statement on Relative Energy Deficiency in Sport (REDs). Br J Sports Med. 2023;57(17):1073–1097. PubMed 37752011
- Ulas ST, Diekhoff T, Ziegeler K. Sex disparities of the sacroiliac joint. Diagnostics. 2023;13(4):642. PMC9955570
- Bannuru RR, Osani MC, Vaysbrot EE, et al. OARSI guidelines for the non-surgical management of knee, hip, and polyarticular osteoarthritis. Osteoarthritis Cartilage. 2019;27(11):1578–1589. PubMed 31278997
This page is for general information only and does not constitute medical advice. Every person's situation is different. Nothing here should be used as a substitute for assessment and advice from a qualified health professional who can evaluate your specific circumstances.
If you are experiencing severe or rapidly worsening symptoms, loss of bladder or bowel control, progressive weakness, or any symptom that concerns you, seek medical care promptly rather than reading websites.
This page was written with AI assistance and reviewed by Erik Anderson for accuracy. If you find an error, please contact us and we will endeavour to correct it.
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