This guide is part of Upwell's evidence-based musculoskeletal content cluster. After reading, explore the related guides below.
Related reading from Upwell Health:
• The Complete Runner's Guide: From First Steps to Sub-2-Hour Half — the full running performance and injury prevention framework, including training load management, strength for runners, and gait optimisation.
• Runner's Knee (PFPS): The Kneecap Is Not the Problem — if your hip pain has come with anterior knee pain, this guide explains the hip-driven mechanism behind patellofemoral pain and why treating the knee alone fails.
• Knee Osteoarthritis: Australia's Most Comprehensive Guide — hip weakness is a primary driver of medial compartment OA progression. If you've been told you have knee OA, this guide covers the full picture.
• IT Band Syndrome: The Myth of the Tight IT Band — lateral knee pain in runners is frequently attributed to the IT band, but hip abductor weakness is the underlying driver. This guide explains why.
• Lower Back Pain: Australia's Most Comprehensive Guide — hip and lower back pain frequently coexist. Weak hip flexors, tight posterior chain, and poor pelvic control all load the lumbar spine.
• Achilles Tendinopathy: Why Rest Is Making It Worse — the tendinopathy evidence base that underpins the gluteal tendinopathy management framework in this guide.
• 2026 ACL Atlas: Australia's Most Comprehensive Guide — hip abductor and external rotator weakness is the primary biomechanical driver of ACL injury risk in female athletes. If you know a female runner or athlete, share this guide.
Updated May 2026. Written by the Upwell Health Collective clinical team. Clinically reviewed May 2026. Next review November 2026. For educational purposes only.
Here is the most important thing you will read in this guide: in the majority of runners who present with knee pain, the primary driver of that knee pain is not the knee. It is the hip.
The knee is the victim. The hip is the criminal.
This is not a metaphor. It is biomechanics. The hip abductors — gluteus medius and gluteus minimus — are the primary controllers of pelvic position and knee alignment during the single-leg stance phase of every running stride. When the hip abductors are weak or fatigued, the pelvis drops toward the unsupported side (the Trendelenburg sign), the stance-leg femur internally rotates, and the knee collapses inward into a valgus position. This is the exact mechanism that drives patellofemoral pain, IT band syndrome, medial compartment knee OA progression, and ACL injury in runners.
A 2024 RCT (Lashien et al., Journal of Orthopaedic Surgery and Research) found that adding hip abductor functional strength training to a standard physiotherapy programme for runners significantly reduced dynamic knee valgus and contralateral pelvic drop. The authors concluded that hip abductor weakness is the main reason for dynamic knee valgus in runners.
If you are a runner with knee pain who has had knee-focused treatment without a thorough assessment of your hip abductor strength and pelvic control, you have had incomplete management. Your knee may well be a symptom. Your hip is the source. See also: Runner's Knee (PFPS): The Kneecap Is Not the Problem.
The hip joint is a ball-and-socket articulation between the femoral head and the acetabulum. It is one of the most inherently stable joints in the body — designed for power, endurance, and multi-directional load transmission.
The structures runners most commonly injure or irritate:
Gluteal tendinopathy is the most prevalent lower limb tendinopathy in existence. It is the most common cause of lateral hip pain. It predominantly affects women aged 40 to 60 and is frequently misdiagnosed as trochanteric bursitis — leading directly to management strategies (anti-inflammatories, cortisone injections, rest) the evidence has comprehensively shown to be inferior to exercise-based care.
A key insight from Dr Alison Grimaldi's 2025 masterclass paper (Musculoskeletal Science and Practice): the primary provocateur of gluteal tendinopathy is compressive load applied to the tendon insertion. Compression occurs when the hip moves into adduction. The everyday positions that most reliably provoke the condition:
Stop stretching your glutes if you have gluteal tendinopathy.
The cross-leg glute stretch compresses the gluteal tendon insertion against the greater trochanter. In gluteal tendinopathy, this is provocative, not therapeutic. Every time you do that stretch, you are loading the most sensitive part of the tendon in the most provocative direction. Put it down.
A 2025 systematic review (Bremer et al., Musculoskeletal Science and Practice, searches to August 2024) found exercise and education had the strongest evidence — medium to large effect on pain (SMD = 0.95) and function (SMD = 0.91). A 2024 meta-analysis (Patricio Cordeiro et al., Scientific Reports) confirmed exercise superior to minimal intervention in both short and long term, with higher treatment success rates than corticosteroid injections.
The LEAP trial (Mellor et al., BMJ, 2018) remains the landmark RCT: education and exercise superior to cortisone injection and wait-and-see at 8 and 52 weeks. Cortisone provided faster short-term relief but no benefit beyond one year. The 2025 Grimaldi masterclass is explicit: abandon anti-inflammatory treatments including cortisone as first-line management.
Phase 1 — Load management (weeks 1–2): Eliminate hip adduction positions. Sit with knees apart. Stand symmetrically. Sleep with a pillow between the knees. Stop the cross-leg glute stretch.
Phase 2 — Isometric exercise (weeks 1–3): Isometric hip abduction at 50–70% max effort, held 30–45 seconds, repeated 4–5 times.
Phase 3 — Heavy slow resistance (weeks 3–12): 3 sets of 8–15 repetitions at slow tempo. Hip abduction, hip thrusts, single-leg squats, step-downs.
Phase 4 — Running reintegration: Increase cadence to reduce hip adduction per stride. Avoid cambered roads. Avoid consecutive hard days initially.
FAI is one of the most surgically over-treated conditions in sports medicine. A 2025 multilevel meta-analysis of 21 RCTs involving 1,799 FAI patients (Ramadanov et al., Bone and Joint Open) found hip arthroscopy showed statistically higher hip scores at 12–24 months compared to conservative treatment — without reaching the minimal clinically important difference threshold. Patients may not perceive a meaningful real-world difference between surgery and physiotherapy in most cases.
Try genuine physiotherapy-led care for at least 12 weeks before considering surgery for FAI.
Not a few generic exercises. A proper, progressive, hip-strength-focused programme. Many patients achieve their functional goals without ever needing the operating theatre. Surgery adds general anaesthesia, a 3–6 month recovery, and procedure-specific complications. A structured physiotherapy programme carries essentially no risk.
Labral pathology on MRI is extremely common in people without hip symptoms. An MRI finding of a labral tear does not automatically mean that tear is causing your symptoms. A clinician who looks at an MRI showing a labral tear and immediately recommends arthroscopy, without correlating imaging to clinical presentation, is not following evidence-based practice.
The evidence-based pathway: implement an adequate conservative programme (minimum 8 to 12 weeks) before surgical referral. Attempting physiotherapy first does not compromise surgical outcomes for patients who ultimately require surgery. Hip arthroscopy with labral repair is appropriate when symptoms clearly correlate to imaging, conservative care has genuinely failed, and there is no advanced OA.
Also read: Your MRI Doesn't Tell the Full Story: The Imaging Paradox.
Deep anterior hip or groin pain not reproduced by the FADIR test often has its origin in the iliopsoas tendon. In runners, this typically develops through rapid volume increases (especially uphill), sprint training, or prolonged seated periods followed by sudden loading. Conservative management has a high success rate — StatPearls (2025) reports 100% response to conservative treatment in dancers.
The snapping hip: iliopsoas snapping is usually not pathological. The management target is pain and load tolerance, not the snap itself.
Hip abductors: Sidelying hip abduction (progress to cable), standing hip abduction, single-leg stance progression, step-ups with hip extension, lateral band walks.
Hip extensors: Hip thrusts, Romanian deadlift, single-leg hip thrusts, Bulgarian split squat.
Hip external rotators: Clamshells (early phase), monster walks, Copenhagen adduction.
Hip flexors: Resisted hip flexion marches, straight-leg raises progressing to weighted, cable hip flexion.
Dosage: 2 to 3 sessions per week. 3 to 4 sets of 8 to 15 reps. Minimum 8 weeks. For gluteal tendinopathy: heavy slow resistance (3s eccentric, 1s pause, 3s concentric).
The 24-hour rule: Pain that resolves within 24 hours and is no worse at the start of the next run is adaptive. Pain that is worse after each run, persists beyond 24 hours, or causes significant limping is maladaptive.
Gluteal tendinopathy: Reduce uphill running first. Run on flat surfaces. Increase cadence. Avoid consecutive days initially.
FAI: Generally well-tolerated during conservative rehabilitation. Longer strides may need temporary reduction.
Complete rest is rarely the right answer. Related: Why Rest Makes It Worse: The Deconditioning Spiral.
Increasing running cadence by 5 to 10% reduces peak hip adduction angle and hip flexion demand per stride. A runner at 158 steps per minute increasing to 168–170 produces meaningfully less compressive load on the gluteal tendon with every stride. Use a metronome app or cadence-tracking watch. See the full gait analysis section in: The Complete Runner's Guide.
The LEAP trial is definitive: cortisone injection provided faster pain relief than exercise at 8 weeks, but by 52 weeks the exercise group was significantly superior and the injection group had returned to baseline or worse. Cortisone for gluteal tendinopathy is a short-term loan you pay back with interest. Use sparingly, only in combination with a proper exercise programme beginning immediately.
Hip arthroscopy is appropriate when: clearly symptomatic pathology correlating clinical and imaging findings, genuine failure of adequate conservative care (minimum 12 weeks), significant functional limitation, and no advanced hip OA. Return to full running typically takes 4 to 6 months post-operatively. Pre-operative hip abductor strength is one of the strongest predictors of post-operative outcome.
Two sessions per week of hip-focused strength work, maintained through base, build, and race-specific phases, is the most reliable investment a runner can make in injury-free training. Runners who drop strength work when marathon volume increases are doing exactly the wrong thing at exactly the wrong time. Related: The Complete Runner's Guide.
Upwell Health Collective at 436 Burke Road, Camberwell manages hip pain in runners every week. We assess the hip, knee, and full lower limb kinetic chain as an interconnected system.
Book an assessment online or contact our team directly.
Q: How do I know if my lateral hip pain is gluteal tendinopathy?
A: The most reliable indicator is reproduction of lateral hip pain during a 30-second single-leg stance (positive LR = 12.2). If anterior groin pain reproduced by hip flexion and internal rotation, FAI or labral pathology is more likely.
Q: Should I stop stretching my glutes?
A: Yes. The cross-leg glute stretch places the gluteal tendon insertion in compressive load. Stop it.
Q: I have a cam deformity on x-ray. Does that mean surgery?
A: Not necessarily. Cam deformity is common in people who played high-level sport during adolescence. Many have no symptoms at all. Complete a 12-week physiotherapy programme before any surgical discussion.
Q: Can I keep running with gluteal tendinopathy?
A: Often yes, with modification. Reduce uphill running. Increase cadence by 5 to 10%. Avoid consecutive days initially. Use the 24-hour rule to monitor.
Q: Why does my knee hurt when my hip is the problem?
A: Hip abductor weakness allows the pelvis to drop and the femur to internally rotate during running stance, pushing the knee into valgus. The knee is the downstream consequence of a hip not doing its stabilisation job.
Q: I've had cortisone injections that wore off. Why?
A: The LEAP trial showed injection-first patients were no better than wait-and-see at 52 weeks, while exercise-first patients were significantly better. Cortisone suppresses symptoms temporarily but does not address tendon pathology or loading factors.
This article is for educational purposes only and does not substitute for individual clinical assessment. Information last reviewed May 2026.