You stretched it, you rested it, and maybe you even had an X-ray that came back "fine." But that ache in your hip keeps coming back, and no one has quite explained why. If that sounds familiar, you are in good company, and I want to offer one place that often gets skipped: your pelvic floor.
I'm Lesley Rivera, PT, DPT, a pelvic floor physical therapist in Anaheim Hills. Hip pain isn't always a pelvic floor problem, but when it is, there are usually a few clues. Here are the three I look for.
They share more real estate than most people realize. One of your deep hip rotators, the obturator internus, sits on the inside wall of your pelvis, right next to the muscles of your pelvic floor. A 2023 anatomy study of 23 cadavers found that the two are in broad contact through a shared layer of fascia, and that this layer is where several layers of the pelvic floor actually attach [1]. So when one is tense, guarded, or working overtime, the other tends to feel it too.
I wrote more about this muscle in my post on groin pain in women, because it can send pain into the deep groin as well.
This is the biggest clue, and it is the one people are least likely to mention to the doctor looking at their hip. Leaking when you run or sneeze, feeling like you always have to pee, constipation, or pain with sex all point toward the pelvic floor.
The research here is early but interesting. In a small study of 42 women, those with urgency and frequency symptoms had noticeably weaker hip rotator and hip abductor muscles than matched women without those symptoms, even though their pelvic floor strength was about the same [2]. The authors were careful to say more research is needed, and I agree, but it's one more reason I check the hips of people who come in for bladder symptoms, and the pelvic floor of people who come in for hip pain.
Pain on the outside of the hip, the bony part you might sleep on, is often a tendon or bursa issue. Pelvic floor involvement tends to feel different. It shows up deep in the buttock, near your sit bone, or deep in the groin, and it often gets worse the longer you sit.
If you find yourself shifting from one side to the other in the car or at your desk, or you feel better standing than sitting, that is worth paying attention to. Tailbone pain can overlap with this picture too, and I wrote about that in tailbone pain that won't quit.
Pregnancy and birth ask a lot of your hips and your pelvic floor at the same time. A 2022 systematic review of postpartum hip pain found that in about two thirds of the reported cases, symptoms began during childbirth or after it, and most of those patients had a labral tear [3]. The evidence is still sparse, but it tells us hip pain after a baby deserves a real look instead of a "that's just postpartum" shrug. If you are still pregnant, my post on pelvic floor therapy during pregnancy covers what's safe and when to start.
The other version of this sign is hip pain that has already had good hip treatment. If you have done the clamshells and the stretches and it is still hanging on, it may be because no one checked the muscles on the inside of the pelvis.
You will see this advice everywhere, and I understand why it's appealing. The honest answer is that the hip and pelvic floor link is real anatomically, but the claim that hip strengthening fixes pelvic floor problems is repeated with more confidence than the evidence has earned. A 2025 review of hip and pelvic floor care for women with leaking during exercise described current practice as relying heavily on "hypothesized" synergies between the two [4].
The one trial I'd point to added glute and hip adductor exercises to pelvic floor training in women with stress incontinence. That group leaked less often on one of the bladder diaries, but not on the other, and there was no difference between the groups in quality of life or pelvic floor strength [5]. So I'm not telling you glute work is useless. I'm telling you it isn't settled, and I'd rather not hand you a tidy story the data doesn't support.
It matters in practice, because it means hip strength is usually one piece of the plan, not the whole plan.
Some hip pain needs an orthopedic look first. If your hip clicks, catches, or locks, if the pain wakes you at night, if it started after a fall, or if you have a fever or can't put weight on the leg, please see your doctor. Pelvic floor therapy and an orthopedic workup are not competing options, and I'm always happy to work alongside the rest of your team.
In my practice, I start on the outside, because it's the least invasive place to learn a lot. I watch how you stand on one leg, walk, and sit down, I check your hip rotators and adductors, and I ask about your bladder, bowels, cycle, and sex life, because those answers narrow things down quickly. If the picture points that way, we can talk about an internal pelvic floor assessment. That is always your call, and we can do a lot of good work from the outside if you'd rather start there.
From there, a plan usually blends a few things:
If you want to know more about what a session looks like, my post on what pelvic floor physical therapy is walks through it, and my post on SI joint pain covers a close cousin of this problem.
If your hip pain keeps coming back, it doesn't mean you did the rehab wrong. It may just mean someone needs to look a little wider, pelvic floor included, and I'd love to help with that.
You can reach Protea Physical Therapy at (909) 265-3584, and I see patients here in Anaheim Hills, serving Orange County. If you'd like to talk it through first, book a free 15-minute discovery call.
This article is for education only and is not medical advice. Please see a healthcare provider about your own symptoms.
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