Muscles, tendons and ligaments in the hips and pelvis

Anatomy: Strength and support system around the hips and pelvis

The movement system at the hip and pelvis consists of muscle groups with their tendon attachments (entheses) and strong ligaments. On the outside, the gluteal muscles (gluteus medius and minimus) lead the leg into abduction and stabilize the pelvis when walking. In the front, the hip flexor iliopsoas pulls from the lower back and pelvis to the thigh; The adductors run medially, originating from the pubic bone; behind are the hamstrings with attachment to the sciatic tuberosity. The tensor fasciae latae (TFL), together with the iliotibial tract, tensions the lateral fascia. The piriformis connects the sacrum to the thigh and externally rotates the hip.

Tendons transmit muscle force to bone; Their transition zone (enthesis) is particularly subject to biomechanical stress. Connective tissue ligaments such as the iliofemoral, pubofemoral and ischiofemoral ligaments passively secure the joint. There are bursae around prominent bone points (e.g. greater trochanter = greater trochanter, ischial tuberosity) as sliding bearings - these can also react secondarily.

• Lateral stabilizer: Gluteus medius/minimus, TFL/tractus
• Front stabilizer: Iliopsoas (hip flexors)
• Medial guidance: adductors (adductor longus/brevis/magnus, gracilis)
• Posterior Chain: Hamstrings (Semitendinosus, Semimembranosus, Biceps femoris)
• Deep external rotator system including piriformis
• Passive stability: hip capsule and ligaments (ilio-, pubo-, ischiofemoral)

Typical symptoms of muscle, tendon and ligament problems

• Lateral hip pain over the trochanter, tender when lying on the side
• Groin pain when exerting weight, starting or lifting the leg quickly (e.g. stairs, getting into the car)
• Buttock pain when sitting (especially proximal hamstring)
• Snapping or rubbing in the groin (iliopsoas snapping)
• Start-up pain, feeling of stiffness in the morning or after rest
• Loss of strength/pelvis buckling when walking (Trendelenburg sign)
• Stress-dependent pain, often with rapid increases in load or unusual activity
• Radiation to the side of the leg or groin without typical tingling (distinction from nerve causes)

Causes and risk factors

As a rule, tendon problems (tendinopathies) are caused by overload reactions and rarely by acute tears. They are often accompanied by suboptimal load control - too much, too quickly, too often or after a long break from training. Everyday factors such as sitting on hard surfaces for long periods of time (ischial bones), sleeping on your side at night or monotonous workloads also play a role.

• Sudden increase in training, tempo runs, uphill running, jumping sports
• Hip abductor/extensor weakness and lumbopelvic instability
• Leg length differences, foot misalignments, limited hip mobility
• obesity, metabolic factors; hormonal changes
• Previous operations, scars, biomechanical chains (lumbar spine/SI joint)
• Certain medications (e.g. fluoroquinolones) – clarification makes sense
• Accompanying bursa irritation due to friction/compression

Delimitation: If it's not just a muscle/tendon/ligament

People with hip and pelvic problems benefit from a clear differential diagnosis. If symptoms are similar, joint and bone causes, bursitis or nerve compression can also be considered.

• Osteoarthritis, labral/cartilaginous causes (especially groin pain)
• Bursa (trochanteric bursa, iliopsoas)
• Stress reactions/fractures, bone marrow edema
• Sacroiliac joint dysfunction, lumbar radiculopathies
• Inguinal hernia, urological/gynecological causes (for groin pain)

Further information: Joints/cartilage, bursa, bones and nerves are linked below.

Diagnostics in orthopedic practice

The diagnosis is based on anamnesis, functional examination and targeted imaging. What is important is the time course, typical stress triggers, pain location with palpation (e.g. trochanter, sciatic tuberosity, adductor insertion) as well as functional and provocation tests.

• Clinic: Abductor/extensor strength tests, Trendelenburg sign, stretch and resistance tests for adductors/hamstrings/iliopsoas
• Movement analysis: gait/running pattern, pelvic stability, step width
• Sonography: dynamic for assessing tendons, entheses and bursa, infiltrations possible using ultrasound
• X-ray: if bony causes or osteoarthritis are suspected
• MRI: for unclear courses, suspected tears, chronic tendinopathy, differentiation from intra-articular causes

Imaging is used in accordance with guidelines and in a targeted manner - not every tendon irritation requires an MRI immediately. What is crucial is the interaction between findings, function and symptoms.

Conservative treatment: evidence-based and relevant to everyday life

The majority of muscle, tendon and ligament problems can be treated conservatively. The aim is to reduce pain, rebuild the resilience of the tendon and optimize the movement pattern - without over- or under-demanding.

Shock wave therapy (ESWT) can be considered as an adjunct for selected tendinopathies (e.g. trochanteric region, proximal hamstring). It does not replace active training, but can modulate the stimulus state.

Interventional and regenerative options – with a sense of proportion

If conservative basic measures have been consistently implemented and symptoms persist, targeted interventions can be useful. Decisions and information are made individually – benefits, risks and alternatives are weighed up.

• Ultrasound-targeted injections: Cortisone can provide short-term pain relief from painful bursitis or peritendinous irritation; cautious, indication-based use
• PRP (platelet-rich plasma): discussed as an option for certain tendinopathies; Study situation varies; only after careful indication
• Needling/fenestration: for chronic tendinopathies in individual cases, always combined with a rehabilitation program
• Surgical procedures: rarely required for ruptures of the gluteal tendons, recurrent snapping or treatment-refractory courses - specialized assessment

Regenerative processes are discussed transparently. They do not replace the foundation of education, stress management and training.

Self-help: What you can do to help yourself

• Adjust load: pain scale 0-10 as a guide; Dose activities so that pain remains moderate and reduced during/after exercise
• Relieve strain by lying on your side: pillow between your knees; Check soft mattress topper
• Sitting times vary: if you have buttock pain, avoid pressure peaks and change positions regularly
• Care for calf/hip muscles: easy mobilization, no aggressive stretches in acute phases
• Check footwear: sufficient cushioning, if necessary running analysis
• Plan for patience: Tendons adapt slowly - progress becomes visible in weeks to a few months

Prevention and relapse prevention

• Progressive increase in training (10-15% per week) instead of jumps
• Maintain strength base: 2-3 sessions per week for hip abductors/extensors
• Variability in training: vary surfaces, distances and speed
• Warm-up and technique: Optimize stride width/running technique, pay attention to pelvic stability
• Plan for regeneration: take sleep, changes in load, and nutritional factors into account

When should I seek medical advice?

• Fall/trauma with acute inability to bear weight
• Rest pain/night or fever accompaniment
• Increasing swelling/redness or significant loss of strength
• Numbness/tingling, failure symptoms
• Persistent symptoms despite adequate rest and basic therapy for several weeks

If there are warning signs or unclear symptoms, an orthopedic examination should be carried out promptly.

Common clinical pictures: subpages at a glance

• Gluteus medius tendinopathy: lateral hip pain, tenderness on the trochanter; Central pelvic stability
• Gluteus minimus tendinopathy: Similar to medius, often combined findings
• Trochanteric tendinosis / trochanteric syndrome (GTPS): collective term for irritation of tendons and bursa on the outside
• Iliopsoas tendinitis: groin pain, hip flexion pain, sometimes snapping
• Iliopsoas snapping (Coxa saltans interna): noticeable/audible snapping in the front of the groin
• Adductor tendinopathy: medial groin pain, v. a. when changing direction
• Hamstring tendinopathy (tuber ischiadicum): buttock pain when sitting/walking
• Tensor fasciae latae irritation: lateral pain, tract involvement possible
• Piriformis syndrome: buttock pain with possible pseudoradicular radiation
• Enthesiopathies of the trochanter and pelvis: irritation of the tendon attachments

On each subpage you will find detailed information on causes, diagnostics, therapy and exercises.

Related topics about hips and pelvis

• Bursa on the hip/pelvis: role as a sliding bearing and typical irritation
• Joints/cartilage: Differentiation from intra-articular causes
• Bones: stress reactions and fractures
• Nerves: Differential diagnoses for radiation/neurological signs
• Pelvic floor/soft tissues: influence on pelvic stability and pain

Orthopedic care in Hamburg – transparent and personal

In our orthopedic practice at Dorotheenstrasse 48, 22301 Hamburg, diagnostics are guideline-oriented and close to everyday life. We prioritize conservative therapy with clear information, an individual exercise program and sensible supplementation with physiotherapy and manual therapy measures. Interventions such as ultrasound-targeted injections or shock waves are discussed when appropriate - without blanket promises.

The aim is to accompany you safely and sustainably back into everyday life, work and sport. For complex processes, we coordinate steps on an interdisciplinary basis and, if necessary, involve imaging or specialized partners.