General Guidelines — Hip Pain & Pathologies
- Pilates is an ideal form of exercise for clients with hip pathologies because it imposes low load.
- Hip pathologies are often related to lumbar pathologies.
- Hip pain/dysfunction is often caused by a weak core and weak gluteal muscles (especially gluteus medius).
- Maintaining ROM throughout life is very important — Hip Work in Straps and stretching are very beneficial for most diagnoses.
- Weakness in hip muscles is often related to knee, ankle, and foot pathologies.
Hip Osteoarthritis (OA / DJD)
A thinning and wearing away of the cartilage and underlying bone in the hip. The second most common form of OA after the knee. Typically affects people over 50; by age 60, 50% of people have OA in at least one joint. More common in those who are overweight (weight loss tends to reduce symptoms). Contributing factors include traumatic hip injuries and fractures around the joint; there is a genetic predisposition. Osteophytes (bone spurs) often form. Unless there is a bony block, ROM increases are possible.
- 2nd most common OA site (after knee)
- By age 60, ~50% have OA in ≥1 joint
- Weight loss reduces symptoms
- Low-impact exercise (Pilates) & aquatics can delay need for replacement
Symptoms: Stiffness and pain in the groin, buttock or thigh on waking or after long activity (walking/running). Pain may radiate to the knee. As it progresses, pain does not subside with rest and a limp may develop. Limited ROM; difficulty squatting, dressing, climbing stairs; discomfort when sitting.
- Pilates is ideal — it imposes low load on the joint.
- Sessions are well-suited later in the day once morning stiffness has eased; allow extra warm-up time if the client is stiff on waking.
- Build in mobilizing and stretching early in the session to reduce stiffness before loading.
- Encourage weight management conversations where appropriate (reduces joint load).
- Limit unilateral (single-leg) weight-bearing exercises to reduce load on the hip.
- Avoid anything that provokes inflammation or joint pain — work within a pain-free range.
- Respect a bony end-feel: if a bony block (osteophyte) limits ROM, do not force range.
Reduce load on the hip, maintain or increase strength and ROM without causing further inflammation, and emphasize lots of stretching and mobilizing.
Mobility / ROM & Stretching
Gluteal / Abductor Strengthening
Bridging / Lumbopelvic Stabilization
Total Hip Replacement (THR)
Surgical replacement of a hip joint severely damaged by arthritis, fracture, or other conditions that limit activities of daily living. Damaged bone and cartilage are replaced with prosthetic components. Two approaches: Posterior/Posterior-Lateral (muscles cut & detached — higher dislocation risk, more post-op precautions) and Anterior (smaller incision, no muscles cut — minimal trauma, faster recovery, often no restrictions). The 2nd most common joint replacement after the knee.
- 2nd most common joint replacement (after knee)
- Posterior approach = higher dislocation risk, more precautions
- Anterior approach = often no post-op restrictions
- Always consult surgeon/PT for the specific rehab protocol
Symptoms: Limited ROM, stiffness, muscle tightness, muscle weakness (primarily abductors and extensors), gait abnormalities and/or balance problems, pain.
- Often clients arrive at Pilates without previous PT — be conservative.
- In the studio, best to avoid combination positions long-term and avoid power/propulsive exercises.
- Traditionally weight-bearing precautions lasted 6–8 weeks; many modern surgeons now allow no weight-bearing restrictions — confirm with the client's surgeon.
- Prioritize balance and proprioception work, building confidence gradually.
- Posterior approach: avoid hip flexion greater than 90°, internal rotation, and adduction past neutral.
- Anterior approach: some surgeons advise avoiding combined extension + external rotation; more often there are no precautions.
- Avoid power and propulsive exercises.
- Avoid combination positions long-term.
Restore ROM (mobilization & lower-extremity stretching), strengthen hip and lower-extremity muscles, improve balance and proprioception, and increase core strength and stability.
Mobility / ROM & Stretching
Gluteal / Abductor Strengthening
Functional / Balance & Loaded Strength
Greater Trochanteric Pain Syndrome (GTPS)
Lateral hip pain encompassing trochanteric bursitis, gluteal tendinopathy, and gluteal tears. Bursal inflammation is often secondary to repetitive friction between the greater trochanter and the tendons. Most common between ages 40–60 and more common in women (pelvic biomechanics, hormonal influences); also affects younger athletes (runners, skiers, dancers). Contributing factors: weak hip abductors (especially glute med), altered gait mechanics, wide pelvis or leg-length discrepancy, high BMI, diabetes, inflammatory arthritis.
- Lateral hip pain (bursitis + tendinopathy + tears)
- Most common ages 40–60, more common in women
- Key driver: weak hip abductors (glute med)
- Bursitis is often secondary to tendinopathy
Symptoms: Intermittent, chronic lateral hip pain that progresses gradually; deep and aching, tender at the greater trochanter. Worsened by prolonged sitting, stairs, walking/running (especially hills/uneven ground), high-impact activity, or lying on the affected side. May radiate down the lateral thigh/buttocks, occasionally to the lateral knee. ITB and hip-flexor tightness; hip abductor weakness.
- Avoid props/positions that load the painful side; check what the client sits and lies on between sessions.
- Start abductor work isometrically for pain relief, then progress to loaded, then to functional retraining.
- Cue minimizing adduction during any loaded work.
- Mind cumulative compression — alternate sides and avoid sustained side-lying on the affected hip.
- Avoid positions that compress the gluteal tendons: side-lying, standing with legs crossed, hanging on one hip, sitting with knees crossed or together.
- Avoid foam rolling over the area.
- Avoid stretches where the leg crosses midline or that involve extreme external rotation.
- Use caution with hip-flexor exercises — they can compress/strain the irritated gluteal tendons.
- Avoid or minimize sustained, repetitive, or loaded hip adduction.
Strengthen the hip abductors — start with isometric for pain relief, progress to loaded, then to functional re-training with emphasis on minimizing adduction during loading. Add core strengthening and hip-flexor stretches.
Gluteal / Abductor Strengthening
Mobility / ROM & Stretching
Functional / Balance & Loaded Strength
Piriformis Syndrome
A neuromuscular disorder in which the sciatic nerve is compressed or irritated by the piriformis muscle (the nerve runs just under, or sometimes through, the muscle). Often driven by inactive gluteal muscles — frequently from reciprocal inhibition by overactive, short, tight hip flexors. Common in people who sit all day or train predominantly in the sagittal plane (runners, cyclists, rowers) without lateral stretching/strengthening. Often related to SI joint hypomobility and/or foot overpronation.
- Sciatic nerve irritated by the piriformis
- Driven by inactive glutes + tight hip flexors
- Common in sagittal-plane athletes (runners, cyclists)
- Often linked to SI joint hypomobility / overpronation
Symptoms: Pain in the low back or hip radiating from the buttock down the back of one thigh and leg. May feel like a bad leg cramp lasting weeks. If symptoms travel all the way to the foot, disc pathology is more likely.
- Screen first: if symptoms travel all the way to the foot, follow disc precautions instead.
- Emphasize waking up the glutes and releasing the hip flexors — address the underlying imbalance, not just the piriformis.
- Be careful not to overstretch the irritated muscle.
- If symptoms go all the way to the foot, follow disc precautions.
- If not, be careful with overstretching.
Lower-extremity stretching, lumbopelvic stabilization exercises, and gluteal strengthening.
Mobility / ROM & Stretching
Gluteal / Abductor Strengthening
Bridging / Lumbopelvic Stabilization
Hip Labral Disorders
Injury to the labrum — the fibrocartilaginous 'gasket' that outlines the acetabular socket and deepens the joint for stability. Frequently seen in active people in their 20s–40s and in athletes of unilateral sports (dancers, hurdlers, kickers). Causes include indirect trauma (repeated microtrauma/overuse), direct trauma, capsular laxity, femoroacetabular impingement, congenital dysplasia, and joint degeneration. The classic traumatic mechanism is an external-rotation force in a hyperextended position (slip and fall). Most of the labrum is avascular, so healing potential is debated.
- Labrum = stabilizing 'seal' of the hip socket
- Common in dancers, hurdlers, kickers (unilateral sports)
- Classic injury: ER force in hyperextension (slip/fall)
- Mostly avascular — limited healing potential
Symptoms: Pain in the anterior hip and deep groin — dull with intermittent sharp episodes; worse with walking, pivoting, prolonged sitting, stairs, and high-impact activity. Often clicking, locking, catching; hip instability and stiffness; slight ROM limits (mostly rotation). May refer to anterior/lateral thigh, buttock, or knee. Often excessive hip adduction and internal rotation with function.
- Work in pain-free positions — stabilize hip, pelvis, and core there first.
- Emphasize precision and alignment of joint motion over range or load.
- If the client is post-op, follow the specific physician protocol (these vary greatly).
- Cue away from the faulty pattern (excessive adduction + internal rotation) during loading.
- Avoid the combination of hip flexion and internal rotation.
- Avoid hip-flexor work past 90° hip flexion.
- Avoid prolonged sitting, running, pivoting on a loaded hip, and stair climbing.
- If post-op, follow the surgeon's specific protocol.
Stabilize hip, pelvis and core in pain-free positions; optimize alignment and precision of joint motion; restore mobility and lower-extremity flexibility; increase hip strength and neuromuscular control with particular focus on glutes to reduce hip internal rotation and adduction.
Bridging / Lumbopelvic Stabilization
Gluteal / Abductor Strengthening
Mobility / ROM & Stretching