It starts as just a mild discomfort for a few hours after training.
But the deep hip pain slowly builds until it lingers for days afterwards and affects your every day activities.
It’s this lingering pain that differentiates deep hip external rotator fatigue from an overload issue.
And once the issue becomes an overload, it tends to enter a recurring cycle of pain, delayed recovery and dysfunction.
The issue is caused by excessive fatigue of one or more of the deep hip external rotators, a set of six small hip muscles that sit underneath the gluteal group (larger hip rotator muscles – your “bum” muscles).
So…what are the deep hip external rotators?
These short muscles are external rotators of the hip and assist with hip joint stability.
Sometimes referred to as “lateral rotators of the hip”, these external rotators are responsible for bracing the hip joint during functional and weight-bearing movements.
Collectively known as the hip rotators muscles, this group of three larger gluteal muscles and six smaller deep hip rotator muscles generates a movement that moves the heel inwards, rotating the femur (thigh bone) away from the midline of the body.
It’s important to remember that the deep hip external rotators brace the hip as their primary function.
As muscles fatigue, other muscles kick in to assist with the movement they’re trying to generate.
As the gluteal muscles fatigue, the small deep hip rotators kick in to help.
But they fatigue quickly and there isn’t another muscle group as effective at bracing the hip joint – so tired or not, they need to keep working.
This is the main issue behind deep hip rotator muscle overload and why it’s so hard to overcome.
Tired muscles alone shouldn’t cause pain but in this case, it’s their specialised design that creates the trouble.
Why do deep hip external rotators cause so much hip muscle pain?
The answer is what makes them vulnerable and so very effective.
These muscles are short external rotators of the hip, which means they aren’t able to stretch very far by comparison to the longer and larger gluteal muscles.
They’re also small – that doesn’t matter when they work together but leaves them prone to overload if one is working harder than the rest.
Piriformis is the most prone to overload and pain. It’s also implicated in some forms of Sciatica.
So if one of the deep hip external rotators is overloaded relative to the others, it spells trouble.
It can also set off a sequential failure, where one hip external rotator becomes overworked and painful.
This causes more loading on the remaining deep hip rotators, leading to failure of the adjacent muscles.
And so the sequence continues until the deep hip external rotator group isn’t functioning at all.
What happens to the muscles during deep hip rotator overload?
As the individual deep hip rotator muscle accrues too much fatigue, a reaction within the muscle is initiated that results in deep hip pain and some muscle shortening (although the shortening is only temporary).
Remembering that deep hip external rotator muscles don’t have a lot of length to begin with.
The shortness causes additional restriction and further overwork, as the muscle activates to try and resist excessive stretch.
This creates a cycle of hip muscle pain and overload that can last for weeks.
It’s a frustrating cycle that feels like you can’t escape.
Why do the deep hip external rotators hurt during squats, running and sleeping?
Overloaded deep hip external rotators cause pain when they are stretched (eg. sitting) or generating force (eg. squats, walking upstairs), or both.
Combining stretch and activation is usually the most provocative for deep hip rotators.
Hip pain in deep squats can produce the strongest pain as it has a combination of stretch and force generation.
The pain during running typically occurs as the foot hits the ground and the deep hip stabilisers activate rapidly and with force.
An aching pain felt deep in the buttocks and hip will often peak the day after exercise due to the effects of fatigue.
Hip pain when sleeping is due to sore deep hip external rotators being stretched in side lying, regardless of which side you sleep on.
On the sore side, the lower leg is pushed towards the other leg by the mattress and the stretch causes pain.
Switch to the good side and the upper leg tilts down and rotates inwards, causing more stretching pain.
So how do you treat deep hip muscle pain?
#1 Stretching can be effective ONLY if it’s gentle and comfortable!
As the deep hip rotator muscles involved are very short, they go from mild stretch to over-stretched very quickly.
Vigorous stretching causes a protective activation of the muscles – the body’s natural defence to overstretch.
This means that the harder you stretch, the harder the muscle fights back and the more fatigue you’ll generate.
#2 A trigger point ball is more effective than a foam roller as the deep hip muscles are positioned in a bony recess in the pelvis (see image above).
That makes them hard to access with the broader surface of a roller.
The ball is able to target these deeper muscles without the force being absorbed by surrounding bony structures.
As a tip, the target leg can be positioned over the other leg to add a small amount of stretch to the deep hip external rotators and increase the effectiveness of the trigger point ball.
#3 This is one of those injuries where you can actually “run it out“, kinda…
Slow easy running can help restore normal muscle length.
But you have to be careful not to add to the overload with further fatigue.
Start with an easy run:walk to minimise fatigue from continuous running and avoid hills.
#4 Overloading the muscles or generating fatigue will make it worse but gentle exercise including easy yoga and walking can help gently stretch the muscles and relieve soreness.
Avoid these approaches as they’ll slow your recovery
Hard trigger point pressures
Trigger point pressures shouldn’t be painful – harder pressure isn’t better (see our point above on vigorous stretching and how your body responds to pressures it thinks might be damaging).
Firm pressure is OK if it feels uncomfortable but if you perceive it as pain, the protective response from the brain is to activate and tighten the muscle to avoid damage.
So it’ll actually have the opposite effect and worsens the issue.
If you can’t relax with the pressure on the deep hip external rotators, if it doesn’t ease after the first 15 seconds and if it feel more uncomfortable with each round of pressures, it’s too much force!
Strength exercises are not a solution for muscles that are already overloaded.
We can always be stronger but strengthening deep hip external rotator muscles while they’re fatigued and sore will only worsen the pain and extend your recovery.
You can perform gentle exercises of the area with lighter loads or less range of motion around the hip.
Here’s an example:
Ice and heat
Ice and heat are not effective solutions for this problem.
The “deep” hip rotators muscles are too deep to be affected by the thermal effects of ice and heat.
So the best that heat or ice can do is distract you from the pain in buttocks and hip.
And if you want a distracting sensation, you may as well use a heat cream like Dencorub or Tiger Balm.
Be wary of these conditions that can mimic hip muscle pain
Sciatica – Sciatic nerve irritations may be felt in the buttock but commonly progress to pain spreading down the leg.
Muscle tear – a pulled hip muscle can occur with the same overload but it’s often associated with sharp pain on initial loading.