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Why Your Outside Hip Hurts During Long Runs (And It May Not Be IT Band Syndrome)

Updated: Jul 24

So here's the rub: as we get older and become more "mature" runners, maybe even entering into the Master's category...


Unfamiliar and uninvited aches and pains can join the party.


And as a runner of 15+ years and Doctor of Physical Therapy for over 8, I know our front-line attack is: rest. ice. foam roll. stretch.

Maybe if you're a real go-getter, you have some other fancy recovery tools hiding in your running shoe closet.


And while rest sounds good in theory, it's NOT best.

Because as runner's get older, injuries trend more towards tendon rather than soft/muscle related.


This is actually why rest makes things feel better for 1-2 days, and you repeat the ouch-cycle all over again. Because typically with soft tissue, rest and mild load can be adequate for healing.


But tendons...it's a whole different healing story.


Especially if you've been struggling with outside / lateral hip pain during marathon training where weekly mileage is increasing as is the frequency of speed or hill workouts.


The catch: the internet will commonly diagnose you with IT band pain.

(foam rolling enters the chat. again. but with no improvements.)


So if you're a runner in the midst of a mileage build or summer marathon training, here are my 2 pennies as a physical therapist who works primarily with runners.

Let's consider a different source: glute medius tendinopathy.

Marathon Training With Outside Hip Pain? Read This Before Foam Rolling Again


Not sure this whole glute med thing is you?


Let's use this diagnostic checklist:

"*" indicate special questions that will obviously not apply to everyone, but answer if applicable.


  1. Are you a runner who is 40+ years old?

  2. Have you recently begun increasing mileage?

  3. Does your outside hip pain frequently come on between or around mile 6-9?

  4. Have you rested or taken a week long break from running but continue to still experience symptoms within that 6-10 mile range?

  5. Can you consistently point to and poke the your area of pain and reproduce similar symptoms that occur with running?

  6. *Are you a female entering or near peri-menopause or menopause?

  7. *Are you a female who typically runs at what's considered faster paces?


If you answered YES to at least 4 of those questions, I'd say continuing to read this blog post would probably be beneficial.


QUICK NOTE on question 6 and 7: if you are a female experiencing peri-menopausal or menopausal symptoms who answered yes to these particular questions, definitiely continue reading this blog post. Menopause 101: estrogen declines which affects tissue health and tendon elasticity, making tendon-like aches and tendon-related injuries more prevalent. Thanks, declining hormone levels. The good news: you don't need to stop or give up running. Despite plummeting estrogen levels, our tendons will still respond to the correct physioligical stimuli, telling it to increasing in strength (called stiffness) and we can still achieve muscle hypertrophy, or growth, with heavy, slow resistance training.


Outside Hip Pain While Running? It Might Not Be Your IT Band


We typically think of IT band symptoms presenting in our hip, which is possible, but more often runners experience a persistent tightness or deep ache around the outside of their knee, even traveling the front aspect of their knee.


I've also heard a good number of runners describe a craving to stretch their knee when searching for relief (I think that's what makes reaching for a foam roller automatic, despite it rarely providing lasting relief).


Contrasting this with glute med tendinopathy which is described more as a deep ache, that occurs after a fatiguing number of miles (6-10) or after a particularly challenging workout. Runners are also more likely able to point to a specific spot on their hip (typically around the greater trochanter where the glute med inserts).


Usually this is discomfort is NOT vague although it can still be described as a deep soreness, maybe even tightness.


Nuanced? Yes.

Impossible to tell the difference? No.


Let's jump into some exercises.


Exercises for the Hidden Cause of Outside Hip Pain During Marathon Training


Circuit:

2-3 sets each// body weight to medium weights


Mobility Focused

Single Leg Foam Roller Step Over

  • 2x8 ea side

Elevated Split Squat with Hip Internal Rotation

  • 2x8 ea side


Strength Focused: 2-3 rounds as tolerated

"Break the Ground Apart" Squat

  • non-weighted: 2 sets x5 reps with 2-3 sec hold at the bottom of squat, holding "break the ground apart" tension (good for warming up)

  • weighted: 2-3x8 reps

Single Leg Squat

  • 10-30 secs as able x 2 rounds

Bulgarian Split Squat: Glute Med Focused

  • 3 sets ea leg x 6-8 reps (use medium heavy to heavy weighted as able to based on discomfort levels)


How to Stop Your Hip Pain from Coming Back After Every Long Run


Single Leg Foam Roller Step Over

  • If you're thinking "where did this come from?"...

  • THE POINT: hip internal rotation is one of those mobility directions that's always beneficial to address. You don't need massive amount, however, knowing and being a long distance runner myself, our hips can be stiff. So with any runner who comes to me here online or in the clinic, I always make sure we address any loss of hip internal rotation.

  • I particularly like this one since the foam roller gives you this visual cue and physical block so you MUST travel through hip internal rotation with intent and control and in something called a "closed chain position" meaning with the working foot on the ground. Closed chain position exercises are often found to be the most effective, and somehow the least used on the internet. Don't sleep on this one.


Split Squat into Hip Internal Rotation

  • Yup, more mobility

  • THE POINT: but good news, this one is fairly quick. And encourages you to travel through the entire depth of your hip joint.

  • I would highly suggest if you can tolerate it, to place your front working leg on a bumper plate, a short/small exercise step, or even a yoga block (if it wont' flip over). Elevating that front leg actually encourages even MORE hip internal rotation, creating a more effective mobility exercises.


"Break the Ground Apart" Squat

  • Here's where things get interesting.

  • THE REASON: I highly suggest finding a line running down your floor just as a visual aid. Pretend this is bisecting a sheet of tissue paper. I want you to push into the edges of your feet by imaging you're trying to "break the ground apart" along that seam or "rip a piece of paper". You should feel your glutes work, ideally with no pain.

  • This is a starter/beginning exercise. If you feel you're moving beyond it, pretty quickly, that's fantastic! That means it's time to progress it by adding a heavy weight. Continuing to "break the ground apart" descend slowly for 3 seconds and ascend for 3 seconds. This is part of slow, heavy resistance training that helps target tendon stiffness (strength) and muscle hypertrophy.


Singe Leg Wall Squat

  • Fun facts...

  • THE SCIENCE: Research suggests that a single leg wall squat actually activates your glute med and loads it's tendon most effectively in this exercises. That doesn't mean we only do THIS Exercise, especially because it can be difficult and awkward to progress it beyond time.

  • But I think it's helpful for you to know that so you have the "why" behind why this is included. Because I agree: wall sits, particularly single leg ones, are not my favorite either. But anything to get back to running sooner, faster, stronger, right?

BSS: Glute Med Biased.

  • Yes, this is bulgarian split squat. No, you may not skip it.

  • TOP TIP: bulgarian split squats clear up at least 25% of running injuries, I'm convinced. But for this one, I'm being very particular about HOW we set it up.

  • Your front leg will be your injured leg. Hold a heavy weight in the OPPOSITE hand. Be sure to "tip forward" or hip hinge forward slightly to place more stretch and emphasis on your glutes. Descend for 3 seconds, ascend for 3 seconds.

  • It's true that the hip hinge still biases your glute max more than your glute med however, it still makes the BSS more glute focused, rather than quad. It's the weight in the OPPOSITE hand that asks your glute medius, which is stabilizing this exercise, to take it up an extra notch and work harder. So pay attention to the details of this one.


WRAPPING UP

Before you jump into the exercises, this might also be helpful: adjusting your cadence.


Some research has found that increasing your cadence by just 10% can be helpful with increasing glute med activation, decreasing pain, and keeping a runner running.


I also suggest my runners check themselves to see if their "crossing midline" or stepping too close together.


How?

By running on a treadmill, preferable yours since you're going to need chalk.


With the treadmill running, find the exact middle of the belt (or as close as you can get it) and allow the chalk to mark a line straight down the center of the entire belt circuit. Then as you run, record yourself either from the front or back. Now you have 2 pieces of data to review.


Looking at your video, notice if one foot ever crosses over the chalk line while also observing your chalk-line post run. Is it smudged? In which direction? Looking at your shoe, do you have more chalk on one shoe than the other?


All of these can indicate that your crossing that chalk-midline.

This matters since it might give you a window into your biomechanic tendencies as this very tight adduction-biased gait pattern can place more stress on your glute med tendon, continuing your pain cycle.


Solution: be aware of your feet on the treadmill. Think "the chalk line is lava". And increase your cadence by 10%.

Oh, and do the exercises above.


Until next time running fit fam...


Dare to Train Differently,

Marie Whitt, PT, DPT //@dr.whitt.fit


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