Is a Tight Pelvic Floor Causing Your Hip Pain?

Do your hips feel deeply tight in a way that stretching never seems to change? Have you been doing PT exercises for hip pain or upper hamstring pain and they just aren't doing the trick? You might be dealing with a hidden pelvic floor issue.

How has no one mentioned this to you before? Many fitness trainers — and even orthopedic physical therapists and doctors — fail to adequately screen for pelvic floor issues when a patient complains of hip pain. Even if they do screen for it, they may not have the training to address it properly.

If your stubborn hip pain has gone unsolved, talking to a pelvic floor specialist can be a game-changer. In the meantime, read on to learn about the connection between your pelvic floor and hips, and get some useful tips and exercises that can help relieve your pain, right away.

How is your pelvic floor connected to your hips?

The pelvic floor muscles create a bowl shape at the bottom of the entire pelvis, connecting to the pubic bone, sit bones, tailbones, and sacrum. But what many folks don’t know is that some of the muscles that make up the back part of the pelvic floor, such as the piriformis and obturator internus muscles, also connect directly to the hip joint, and participate in both stabilizing and rotating the hip outward (think turning out like a ballet dancer, pointing their leg to the side).

Just like any other muscles, these can get tight and painful, and because they go underneath the much larger and thicker glute muscles, they can be hard to release and stretch.

How does a tight pelvic floor cause hip pain?

The deeper external rotator muscles of the hip, like the piriformis, function in a way similar to the rotator cuff of the shoulder — they don't just move your leg, they also help keep the leg bone centered in the hip socket.

If these muscles are tight or weak, this can lead to the hip feeling pinched or stuck when going in a given direction, because it may be pushing up against one edge of the hip socket.

When the muscles that connect your hip to your pelvic floor become tight, they rotate the hip outward, so you may find that you walk a bit duckfooted. If the muscles of the pelvic floor are perpetually tight, they can also compress or irritate nerves that go through the pelvis, which can create shooting pain, numbness, or a deep ache that might radiate into the hips, sit bones, or down the side or back of the thighs.

What does pelvic floor-related hip pain feel like?

Hip pain is often described as a "pinching," "tightness," or even an "aching feeling." You might feel like your hips “aren’t as flexible as they used to be." You might feel like your hips feel "stuck" when you move from sitting to standing. Or you might have trouble bringing your knee up to your chest without feeling a pinch in the front of the hip.

Who is likely to get pelvic floor-related hip pain?

Anyone can get pelvic floor-related hip pain, but there are some times when this is more likely to happen. For example, during pregnancy or postpartum, there are changes in the joints holding the pelvis together. When coupled with the increased load on the hip muscles from carrying the baby, this can lead to pain.

Beginning a new exercise routine that uses the hip muscles differently (like running) can also be a trigger. Conversely, if someone starts to be more sedentary, such as when they start a new desk job, this can be aggravating because the hips are staying stuck in one position for hours at a time. And finally, when we experience an increase in pelvic floor tension (due to stress, or a UTI for example) that might also have the side effect of causing or worsening a hip problem.

5 Ways to relieve pelvic-floor related hip pain:

The steps you should take to relieve this pain will depend on the exact type of pain you have. The primary focus should be reducing tension in the tighter muscles, either by stretching or massaging/rolling on them, and strengthening them too if appropriate.

1. Lean into a figure 4 stretch.

A figure 4 stretch can help stretch a tight piriformis muscle. If your right hip is tight and painful, cross your right ankle over your left knee, then lean forward with a straight back. You can then experiment by rotating your right knee toward the floor or hugging it into your chest (pull it gently toward your left shoulder) to see what feels better.

How to do a figure 4 stretch:

Start seated in a chair with both feet flat on the floor.

1. Lift one foot off the floor and rest it on top of your opposite knee.
2. Keeping your back straight, lean your trunk forward, hinging at the hip.
3. Apply gentle pressure downwards into your bent knee for a deeper stretch.
4. Hold this position before sitting upright and returning your foot to the floor.

Where you'll feel it: In the outer hip of your top leg.

2. Stretch your hip flexors with lunges.

This classic lunge stretch is excellent for lengthening your hip flexors and can help reduce pain due to tightness in the hips and pelvic floor.

How to do a kneeling lunge:

Start on your knees, next to a chair or wall for support. Put a folded towel under your knee, if needed for comfort.

1. Bring one leg forward, positioning your foot in front of your knee, so that your lower leg is at a greater than 90-degree angle to your upper leg.
2. Tuck your tailbone and shift your weight onto the forward leg, bringing your knee directly above your ankle. Tip: Avoid pushing your front knee forward past your toes.

Where you’ll feel it: In your front hip flexor.

3. Sit on a tennis ball. Yes, really.

You can also try using a tennis or lacrosse ball to release tension in the muscles located at the back of the pelvic floor.

To do this, sit on a chair that has a little padding on it and then place the ball so that it's tucked into the space under your tailbone and above where your anus is located. The ball should be centered between your two sit bones. Move it around a little so that it's not bumping up against your tailbone in an uncomfortable way. The goal is to feel some pressure on the muscle not create pain.

When you're ready to increase pressure a bit — which will release more tension — try doing this on the floor and leaning back on your hands with the ball in the same place. You can also rotate your hips while the ball stays in place to intensify the sensation.

4. Do gentle hip flexor strengthening exercises.

Sometimes strengthening the hip flexor can lead to even more pain relief than stretching it. Try this gentle hip flexor move to start. Working with a pelvic floor PT will help you find exercises you like doing that challenge your muscles at just the right level.

How to strengthen your hip flexors:

Sit in a chair with both feet flat on the ground hip distance apart.

1. Place your right hand on top of your right thigh and place your left hand beneath your left thigh, palm facing up.
2. Push your legs into both hands at the same time, so that your right leg us pushing upwards into your right hand, and your left leg is pushing downwards into your left hand. Tip: The force of your hands and legs should be equal and opposite so that your legs and arms barely move at all with this exercise.
3. Hold this tension before gently relaxing both your hands and legs to their starting position.

Reverse your hand placement and repeat the exercise.

5. Check for strength imbalances.

Making sure that the muscles surrounding your hips are equally strong on both sides can help reduce pain.

To suss out strength imbalances, ask yourself these questions:

• When you do single leg exercises, does one side fatigue more quickly?
• Can you do a million donkey kicks but fatigue after 5 reps of a hip flexor exercise?
• Does clamshell feel much easier than reverse clamshell, or vice versa?
• If you do a squat (or single-leg squat) in the mirror, are you planted evenly in both feet as you reach the bottom, or do you favor one side?

Even in patients who exercise regularly, hip flexors (front of the hip muscles that pull the leg forward) and adductors (inner thigh muscles that pull the leg across the midline) are often weaker than their counterparts, and this can contribute to tightening in the glutes and pelvic floor.

Other patients, such as those who just gave birth, might need a more global approach that emphasizes more core strengthening. A pelvic floor PT can determine exactly what your body needs to regain balance.

How can pelvic floor PT help relieve hip pain?

A pelvic PT can help you figure out which of these interventions is the most appropriate for you, based on your exact symptoms. They can also assess your pelvic floor more directly, either externally or internally if you are seeing them in person, and help you figure out exactly where the problem is.

A thorough PT session will include strength testing to determine which of your muscles might benefit from strengthening exercises. Your PT will also make sure any stretches or exercises you are doing are being performed correctly and not exacerbating problems, which will make your pain worse.

The way you move, sit, and sleep can also impact your pain levels. PTs can talk you through strategies to improve the ergonomics of your work setup and make sure your sleeping position is comfortable and as pain-free as possible.

What exercises should you avoid with hip pain?

Pay attention to how your pain is responding in any activity that you do. If you try a stretch and it feels good and makes a clear difference in terms of pain and range of motion, then it may be okay for you. If it feels a bit painful or pinched, and doesn’t make any noticeable positive change, it may mean you need to avoid that movement.

Similarly, if you try rolling on a ball or foam roller, start with a short amount of time (just a couple of minutes max to begin with) and make sure you feel better afterward — if you go overboard, you may just end up aggravating the problem. If you feel a zingy sharp pain when rolling over a certain spot, try to shift off of that area — nerves don’t appreciate direct pressure, but the tight muscles around them might.

How long does it take to treat hip pain with pelvic floor PT?

If you can identify and adjust your main triggers, and are consistent with your exercises or stretches, you should start to notice some improvement (even if it is slight) within a week or two.

Full recovery may take a couple of months, depending on the severity of the issue, or longer if there are other complicating factors, such as an injury to the hip joint or spine. Nerve irritation can take a little longer to resolve than muscle tension.

If your biggest problem is muscle weakness, it may take 6-8 weeks before you start to notice major changes. Ask a PT for help if you are having difficulty making progress! We can create a clear treatment plan for you that ensures you feel better as quickly as possible.