Hip Pain and Hip Alignment: What Causes It and How Is It Checked?
Hip alignment means how your hip joints sit in relation to your pelvis, spine, knees and feet. When alignment is off, your body makes up for it by shifting load to other areas. This often causes pain not only in the hip, but also in the lower back, knee or groin. A standing whole-body scan can show these patterns in a way that lying-down scans cannot.
Key points
- Hip alignment affects your whole posture chain, from your lower back down to your feet.
- Pain from a hip alignment problem often shows up somewhere else in the body.
- Lying-down scans relax the muscles and can hide alignment problems that only show when standing.
- EOS whole-body standing imaging uses about 90% less radiation than a standard X-ray, around ten times less.
- ScanAlign provides diagnostic imaging only. It does not provide treatment.
What is hip alignment and why does it matter?
Hip alignment is the position of your hip joints compared with the rest of your skeleton when you are upright and bearing weight. Your hips are the central link in a chain. This chain joins your spine above to your knees and feet below. When the hips sit level and balanced, your weight is shared evenly. When they do not, another part of the body has to take on the extra work.
Think of a building with a slightly tilted foundation. The walls, floors and roof all have to adjust. In your body, this adjustment is called compensation. A hip may sit slightly higher on one side, or rotate forward or backward more than the other. This changes the load through your lower back, your knee and even your ankle. Over time, these compensations can become painful in their own right.
What are the symptoms of hip misalignment?
Symptoms of hip misalignment vary a lot, because the problem rarely stays in one place. You may feel pain right in the hip. But it is just as common to notice it somewhere along the compensation chain.
A deep ache in the front of the hip that gets worse with walking or sitting for long periods.
The spine curves slightly to make up for an uneven pelvis, which loads the muscles unevenly.
An off-centre hip changes how force travels through the knee. This sometimes causes pain on the inner or outer side of the knee.
You may notice you lean to one side when walking, or others may tell you that your walk looks uneven.
If alignment was not optimised during or after surgery, pain may continue or appear in a new area.
Important. If you have sudden, severe hip pain with numbness, weakness in the leg, or loss of bladder or bowel control, get urgent medical help. Contact your doctor, call your local emergency number, or go to the nearest hospital emergency department.
What causes hip alignment problems?
Hip alignment problems usually develop slowly over months or years, rather than from a single event. Common causes include the following.
Even a small structural or functional difference shifts the pelvis and changes the load on the hip.
Tight hip flexors, weak glutes or uneven core strength can pull the pelvis out of position.
As cartilage wears on one side, the joint space narrows and the hip shifts under load.
Hip or knee surgery can change how you stand and walk, slowly shifting alignment elsewhere.
The body is a connected chain from head to feet. So a hip alignment problem rarely stays in one place. It can show up as lower back pain, knee trouble or even shoulder tension. This is why looking at one joint on its own often fails to explain symptoms that keep coming back.
How is hip alignment checked when standing up?
The most accurate way to check hip alignment is to scan the body while it is upright and bearing weight. When you lie down for a conventional X-ray, CT or MRI, your muscles relax and gravity stops pulling on your skeleton. Any tilt, shift or rotation in the hips can then partly or completely disappear. The scan may look normal, even though you feel far from normal.
An EOS imaging system captures the whole body, from head to feet, in a single standing scan. It uses about 90% less radiation than a standard X-ray, around ten times less. The image is taken while you stand. So it shows how your hips, pelvis, spine and legs actually line up under real, everyday load.
The image lets a clinician see whether one hip sits higher than the other, and whether the pelvis tilts forward or to one side. It also shows whether there is a leg length difference, and how these factors affect the knee and spine. This information is difficult or impossible to get from a lying-down scan alone.
Would you like to find out whether a standing alignment assessment could explain your hip pain?
Book a free video consultationWhat helps with hip alignment problems?
Good management of a hip alignment problem starts with understanding exactly what is out of position and why. Without that picture, treatment can be hit and miss.
Once the alignment pattern behind the problem is clear, your treating clinician may consider a range of approaches. These can include targeted physiotherapy to address muscle imbalances, orthotic insoles to correct a leg length difference, or changes to your exercise programme. In some cases, surgical planning benefits from whole-body alignment data, particularly before or after a hip replacement.
ScanAlign does not provide treatment. It provides detailed standing alignment imaging. This helps your physiotherapist, osteopath, orthopaedic surgeon or other specialist make better-informed decisions about your care. You can learn more about hip imaging and hip replacement planning on our dedicated page.
Before you start treatment, or change the one you are on, it is worth getting a detailed diagnosis. Knowing whether the cause sits in the pelvis, the legs or the spine changes what will actually help.
When MRI is the better choice. EOS shows bones, joints and alignment very clearly. If your clinician suspects soft-tissue damage, disc problems or nerve involvement, MRI is usually the better tool. The two scans answer different questions and often work well together.
Frequently asked questions about hip alignment
Yes. When one hip sits higher or rotates differently from the other, the spine has to curve or twist to keep you balanced. This extra load on the lower back muscles and joints is a very common cause of persistent back pain.
It can. The hip, knee and ankle work as a single mechanical chain. If the hip is out of position, the knee often takes extra or uneven force. This can lead to pain on the inner or outer side of the knee.
Common clues include hip or groin pain on one side, a feeling that your weight leans to one side, uneven wear on your shoes, or back or knee pain that does not respond to treatment. A standing whole-body image gives a clear, measurable answer.
EOS is a low-dose imaging system that captures your whole skeleton from head to feet while you stand. It shows how the hips, pelvis, spine and legs relate to one another under real weight-bearing conditions. You can find a fuller explanation on our EOS scan overview page.
EOS uses about 90% less radiation than a standard X-ray, around ten times less. It is considered very low dose. More safety and preparation details are on our FAQs page.
No. ScanAlign accepts self-referrals. You can book a free video consultation directly to discuss whether an alignment assessment is suitable for your symptoms.
The price for patients travelling from abroad is confirmed during the free video consultation, and you can find more details on our FAQs page.
When you lie down, gravity is taken away and your muscles relax. Any tilt or shift in the pelvis may flatten out. This can make the image look normal, even though the problem is very real when you are standing and walking.
Targeted exercises can help if the problem is mainly muscular. However, structural causes such as a true leg length difference or joint wear may need different management. Knowing the underlying pattern through imaging helps you and your clinician choose the right approach.
Very much so. Standing alignment data helps surgeons plan implant position and leg length balance before surgery. After surgery, it confirms that overall alignment has been restored. Our hip replacement planning page explains this in more detail.
Find out what is really going on with your hips
A free, no-obligation video consultation with our specialist radiographer can help you decide whether a standing alignment assessment at 19 Harley Street, London is the right next step before you plan your trip.
Book a free video consultationWritten by Abbas Dhami (Specialist Diagnostic Radiographer)
Sources
- Dubousset, J. et al. "EOS stereo-radiography system: whole-body simultaneous frontal and lateral radiographs with very low radiation dose." Revue de Chirurgie Orthopédique et Réparatrice de l'Appareil Moteur, 2005.
- National Institute for Health and Care Excellence (NICE). "Osteoarthritis: care and management." Clinical guideline CG177, updated 2022.
- American Academy of Orthopaedic Surgeons (AAOS). "Management of Hip Fractures in Older Adults." Evidence-based clinical practice guideline, 2021.
This page is general information and not a diagnosis.
ScanAlign is the trading name of CoreMed Solutions Ltd and operates under The Harley Street Hospital's CQC licence.