It starts as just a mild discomfort for a short period after training.
But the deep hip pain slowly builds until it lingers for days afterwards and affects your every day activities.
It is caused by excessive fatigue of one or more of the six small hip muscles that sit underneath the gluteal group (larger hip abductor muscles – your “bum” muscles).
These small muscles externally rotate the hip (sometimes referred to as “lateral rotation”) and assist with hip joint stability.
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, which means they aren’t able to stretch very far.
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.
So if one of the deep hip external rotators is overloaded relative to the others, it spells trouble.
Piriformis is the most prone to overload and pain. It’s also implicated in some forms of Sciatica.
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.
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) and/or generating force (eg. squats, walking upstairs).
Combining stretch and activation is usually the most provocative – hip pain in deep squats can produce the strongest pain.
Hip pain when sleeping is due to sore deep hip external rotators being stretched in side lying, regardless of which side you sleep on.
So how do you treat it?
Stretching can be effective ONLY if it’s gentle and comfortable! As the muscles involved are very short, they go from mild stretch to over-stretched very quickly.
Vigorous stretching causes a protective activation of the muscle, 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.
A trigger point ball is more effective than a foam roller as the muscles are positioned in a bony recess in the pelvis. That makes them hard to access with the broader surface of a roller.
This is one of those injuries that 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.
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
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 can be 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.
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 are not effective. The muscles are too deep to be affected by the thermal effects of ice and heat. So the best they can do is distract you from the pain in buttocks and hip – and for that 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.