Causes, Effects, and Prevention of Hip Alignment Issues in Runners

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Photo Credit: Twisting My Head and Tilting My Pelvis by Flickr user Patrick Oscar Boykin, used under a Creative Commons license.

Photo Credit: Twisting My Head and Tilting My Pelvis by Flickr user Patrick Oscar Boykin, used under a Creative Commons license.

While I lack specific data to justify this belief, a condition that I suspect is more common than realized among runners is hip alignment issues.  Given the role of the pelvis as a fulcrum in each of the three planes of motion of the body (frontal, sagittal, transverse), there are numerous potential drivers of alignment issues, as problems tend to propagate to the hips.

The symptoms of pelvic misalignment can take quite some time to show up (and can be quite broad in nature), and the condition is often first recognized as a leg length discrepancy.  Such discrepancies can be mistakenly attributed to permanent biomechanical issues when in fact they are often a temporary condition brought on by poor pelvis alignment. Thus the tendency is to leap quickly to orthotics in such a situation, when in fact appropriate corrective and preventative exercises may address the true issue.

Hip alignment is a concern because it (or rather the functional leg length discrepancy it tends to introduce) is a source of many potential injuries. If you can visualize the impact of running with one leg slightly longer than the issue, you may be able to imagine some of these injuries:

On the “longer leg” (raised side of the hip), which experiences greater impact and torsional forces:

  • Hip injuries or soreness – this seems the most obvious, as the increased force of impact gets transmitted all the way up to the hip.
  • Hamstring strains and piriformis syndrome – the longer leg can very well end up bearing slightly more of the work in propelling you forward, thus making the hamstring more vulnerable to strains.
  • IT Band Syndrome – ITBS is being increasingly seen as an issue originating from weak hips & glutes, but the increased loads from a seemingly longer leg can have the same effect.
  • Patellofemoral Pain Syndrome (Runner’s Knee) – the knee is another joint that bears excessive forces on the longer leg, and can therefore be subject to injury.

On the “shorter leg” (lowered side of the hip), which typically ends up experiencing more of a midfoot landing, the most common issue is Achilles tendinitis (or plantar fasciitis) – the situation is similar to the runner who transitions too quickly to minimalist running – without the proper strength and mobility in the lower leg, injuries become more likely.

There are several potential causes of pelvic alignment issues, and there are often several involved in each specific case.  Running-related drivers include:

  • Strength imbalances (or asymmetries) – this can cause a runner to favor one side over the other, which ultimately pulls the hip out of alignment.
  • Injury history – this can be a source of the asymmetries driving form hitches that cause misalignment to develop.
  • Cambered roads – since we have all be taught to run (or walk) against traffic, we tend to go to the left (in the US) side of the street.  This causes our left leg to have to reach down a little further than our right, since roads have a slight camber to help water drain off.

There are also non-running contributors to hip misalignment:

  • Poor posture – this is a “low intensity, high frequency” contributor that can build over time.  It can happen as we sit cocked slightly to one side, when we tend to lean against a counter or table while standing, and while driving – the very nature of having to use one foot can be a factor in misalignment.
  • Habits of imbalance – many of us have a tendency to always carry our purse or laptop bag on the same side, or to use the phone with the same ear (and hold it in place with our shoulder because we are, after all, busy).
Shoes from a runner with hip misalignment - the "longer" leg is the left shoe (shown on the right).

Shoes from a runner with hip misalignment – the “longer” leg is the left shoe (shown on the right).

Hip misalignment can best be diagnosed by a professional, who will typically have you relax while laying down with your knees pulled up and then extend them fully but gently to see how they lie. You may also get an indication of this issue if you see different wear patterns on the soles of your shoes.  Often the shoe with greater heel and toe wear will be the side that is slightly longer, since it may overextend and lead to more heel-striking.

Once an alignment issue is identified, the goal is to ease the muscle tightness and imbalances that are causing the problem. This is again most effectively done through at least the initial efforts of a professional such as a sports chiropractor, massage therapist, or physical therapist.  Massage or active release techniques can help loosen up the muscles most often responsible for the misalignment – the hip adductors, the iliopsoas, and the quadratus lumborum (QL).  Additionally, they can form other manipulations to help “pop” the hip back into place, though my experience is that quick fixes aren’t typically effective.

General strength and mobility work focused on the hips such as the Bia routine from the Runners Connect Strength Training package or Jay Johnson’s myrtl routine can help address muscular imbalances that create hip alignment issues.  And any of the wide range of stretching activities, ranging from passive to dynamic approaches, can also help loosen up the tight muscles driving the misalignment.

One specific exercise that can specifically target getting the hips back in alignment was demonstrated by Leo Kormanik at Ohio Sports Chiropractic.

  • Lay on your back with your feet flat against the wall.
  • Forcefully and quickly thrust the foot of the “shorter leg” against the wall, keeping it flat.
  • Push down on your hip on the same side with your hand, and hold the foot against the wall and hand on the hip for 10 seconds.
  • Relax and repeat 10 times.

This is a good exercise to do any time, but particularly as part of your warm-up routine prior to running.  Over time, your hip will gradually return to better alignment. You may notice some change in your soreness patterns as your form corrects itself, particularly if you’ve been running with the misalignment for some time.

Prevention of hip alignment issues or recurrences involves avoiding some of the behaviors mentioned above, through such steps as:

  • Strength training – single leg exercises such as pistol squats are particularly helpful for working through muscular imbalances
  • Regular massage – prevent muscular tightness from having effects on your form by regularly working out adhesions
  • Run on flat surfaces – this can be tricky, but you should run in the middle of the road when possible (a good reason to be a predawn runner).  When it’s not possible, at least try to alternate sides of the road when possible.
  • Watch your posture – maintaining good posture is one of the things we can do during our work day (or everyday lives) that helps with our running.
  • Be conscious of your patterns – if you instinctively carry heavy loads on the same side all the time (purses or other bags), get in the habit of alternating sides.

Given that hip misalignment is so easy to develop and therefore pretty common, all runners would do well to pay attention a bit to their habits that may contribute, and do what they can to avoid letting it happen.

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  • Tracie Rodriguez

    This article describes me exactly. I have always noticed one leg appears to be longer than the other but I’ve also always thought it was due to a problem with my hips. Since suffering from this current injury, I have come to realize what an essential role the hips play in running. If your hips are out of whack, then you open the door to a myriad of problems. In my non medical opinion, I think all of my running injuries stem from my hips. Great article and thanks for sharing!

  • Angela (SF Road Warrior)

    Thanks for this. I’ve had so much hip ish — rotated pelvis, slight leg length discrepancy, 4 months of PT for a strength imbalance…etc. These days I am super diligent about strength & mobility work but still have to have them snapped back into place every 4-6 weeks by a chiro. The pain is much better but still not gone, so I’m looking into maybe getting some regular ART / massage. (I also live near SMI in Palo Alto so that maybe an option.) My PTs definitely said they see a lot of that kind of thing.

  • Greg Strosaker

    Thanks Tracie, I’ve read that a vast majority of leg lengthy discrepancies are not anatomical but are rather due to temporary imbalances. With your work ethic, I have no doubt you’ll ultimately work through the issues and emerge stronger for it.

  • Greg Strosaker

    Hi Angela, I’ve been through similar experiences, so feel your pain. I think the ART / massage route is an essential part of the “maintenance” process, so hope you are able to find a good provider.

  • Adam

    Hits the nail right on the head with this read. My problem stems from a combination of weak glutes, and my pelvis. Everytime i go for a run, it feels as though bones in my pelvis are being dislodged and out of place,which consequently lead to other peripheral problems such as pain in knees. In addition to a pop i hear in my lumbar, which i suspect could be due to running, in addition to a weak core. Situation isn’t so grim though, there’s always room for improvement, so we live and learn.
    The search for good physiotherapy never ends

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  • Greg Strosaker

    Thanks Adam, and good luck sorting through your hip issues. My left leg/hip (longer leg) always pops when I do bicycles and extend the leg, so I’ve suspected alignment issues for a long time. It’s amazing the mechanisms we can develop to compensate, but there are consequences.

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  • Maddie Harrison

    Wow…an article written exactly for me. I was plagued by Achilles/peroneal tendonitis in my left leg all last year. I finally found a chiropractor and massage therapist that helped rework my right hip and found instant relief. One week later, it attacked my right Achilles/peroneal! Perhaps we didn’t get my hips as aligned as we thought. The accompanying article about transitioning to mid-foot too soon is also probably a big contributing factor for me, but I find it difficult not to now. I’m going to follow some of your recommendations from that article too and see if that helps. My biggest question is a chicken-or-the-egg concern, i.e. should I have the alignment corrected and then work on strength or vice versa. I’m concerned that strengthening the wrong side will compound the problem. Thank you for the timely advice.

  • Greg Strosaker

    Hi Maddie and thanks for your comments, I think this post resonates with a lot of runners because the alignment issues are pretty common. I agree that once you move to the midfoot, it’s hard to force yourself back, been finding the same thing lately as I’m trying to fend off some Achilles issues as well.
    In regards to your question, I’d do both in parallel. With the strengthening work, do single-leg exercises like hip thrusts, bridges, clamshells, etc., using the exact same resistance (if any) and reps for each leg – the weaker leg/side will limit the number of reps and over time the two sides will approach equivalence, and then you’ll be able to progress equally on both sides. If you do only one side, then you risk a constant game of leapfrog.

  • jg gd

    Hi Greg, the link to the demonstration by Leo Kormanik doesn’t seem to work. I can’t find any demonstration on his site. Is there such a demo video? I have difficulty visualising the exercice you describe.

    I do need to work on hip imbalance. Xrays showed a 3mm longer left leg and, yes, I had hamstring problem (proximal tendinopathy( in that leg and now I sense the early start of an achilles problem in the right leg exactly as you mentioned. I’ve been able to reduce by 90% the hamstring problem by doing a lot of ART but I got to do something before the problem comes back by compensating for the achilles problem.


  • Greg Strosaker

    Thanks for your comment – the link you mentioned isn’t to a demonstration but rather to the Ohio Sports Chiropractic site. I’m not aware of any videos that demonstrate the routine. I’ve tried to describe it as best as possible – maybe it would be best to visualize “stomping” your shorter leg (right leg in your case) into the wall and holding it for 10 seconds while allowing your left hip to rotate naturally up towards your shoulder.

    Good luck resolving the issue, it sounds like your situation is very similar to what mine was.

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  • Thomas Heusser

    Hi Greg,

    Overcame a bilateral adductor longus tenotomy and have been running for a few months now. Past few weeks (or possibly even longer) I began feeling some stiff/soreness maybe even crossing into light pain in my right knee after 25-30 minutes on any run (all on Towpath). I decided to finally do some searching and it sounded like PFPS. I had Fitz’s video bookmarked some time and used to do one or two of them daily during my initial recovery period. Only recently have I gotten back into it but haven’t been running in hopes to squash this sooner rather than later. Just commenting that there is excellent information here and have bookmarked for future readings. Also, hello from a fellow NEOhioan..

  • Greg Strosaker

    Thanks Thomas and good luck on the path back to running regularly, hope the strength routines and other work help.