Persistent Pain After Hip Replacement: Is the Pelvic Floor the Missing Link?

Total hip arthroplasty (THA) is one of the most successful orthopedic procedures performed worldwide. It is widely recognized for reducing pain, improving quality of life, and restoring mobility in individuals with advanced hip pathology.

Despite these positive outcomes, persistent pain following THA is reported in up to 23% of patients and is typically defined as pain that continues longer than three months postoperatively. While prosthetic complications such as component loosening, hardware failure, or infection account for a portion of these cases, the etiology of persistent pain outside of prosthetic dysfunction remains poorly defined in the literature.

This lack of diagnostic clarity often leads to frustration for both patients and providers, contributing to prolonged care pathways, multiple consultations, and increased healthcare costs.

When the Implant Is Not the Problem

Once prosthetic complications have been ruled out, clinicians often consider other common musculoskeletal contributors to persistent hip pain, including:

• Lumbar spine pathology with or without radiculopathy

• Greater trochanteric pain syndrome (GTPS)

• Myofascial dysfunction of surrounding musculature

Even after these considerations, a subset of patients continues to report persistent symptoms with no clear diagnosis. Some reviews estimate that up to 9% of cases remain unexplained despite extensive evaluation.

Notably absent from most diagnostic frameworks is consideration of pelvic floor–related sources of pain.

A Clinical Pattern That Is Easy to Miss

Persistent pain following total hip arthroplasty does not always follow predictable patterns — and recognizing subtle symptom clusters may help identify overlooked contributors.

Patients experiencing persistent pain following THA frequently describe symptoms in areas such as:

• the ischial tuberosity

• the anterior hip region

• the lateral hip or greater trochanter region

• the posterior thigh

Pain may be aggravated by:

• sitting

• stair negotiation

• prolonged standing

• walking

Despite these persistent symptoms, imaging such as X-ray or MRI often confirms that the prosthetic components are well positioned and structurally intact.

When imaging fails to identify a clear structural cause, patients may cycle between providers—including orthopedic surgeons, physical therapists, and pain specialists—while continuing to experience significant functional limitations and reduced quality of life.

The Overlooked Role of the Pelvic Floor

When persistent pain following total hip arthroplasty remains unexplained, expanding the diagnostic lens to include pelvic floor anatomy introduces an often-overlooked but clinically relevant contributor.

The obturator internus plays a critical role in hip function as an external rotator of the hip. However, it also resides within the pelvis and shares a fascial and functional relationship with the pelvic floor musculature via the tendinous arch of the levator ani.

In addition, the pudendal nerve travels through Alcock’s canal, closely associated with the obturator internus fascia.

This unique anatomical relationship means that dysfunction within the pelvic floor complex can contribute to pain presentations that mimic—or coexist with—traditional orthopedic diagnoses.

Patients may report:

• pain near the ischial tuberosity

• discomfort with sitting, often described as feeling like “sitting on a walnut”

• symptoms reproduced with hip loading (e.g., step-ups or walking)

• pain in the perineum and/or proximal posterior thigh

In some cases, these symptoms may reflect pudendal neuralgia, pelvic floor hypertonicity, or neuromuscular dysfunction that has not been previously evaluated.

Why Pelvic Floor Assessment Matters

Integrating pelvic floor assessment into post-THA evaluation expands clinical reasoning and may reveal neuromuscular contributors that are not captured through traditional orthopedic examination.

Internal pelvic examination allows clinicians to assess:

• pelvic floor muscle tone and coordination

• obturator internus tenderness or dysfunction

• pudendal nerve irritation

• neuromuscular contributors to lumbopelvic stability

Understanding the interconnected nature of the hip, pelvic floor, and lumbosacral plexus allows clinicians to expand their diagnostic reasoning and identify potential pain generators that may otherwise remain undetected.

A Gap in the Literature

Current research exploring the relationship between hip pathology and pelvic floor dysfunction remains limited.

Existing studies largely focus on:

• sexual function following THA

• bladder and bowel symptoms associated with hip mobility impairments

However, clinical experience suggests that persistent pain following THA may involve pelvic neuromuscular contributors, even when traditional pelvic floor symptoms such as urinary or bowel dysfunction are absent.

Because many patients do not associate their hip pain with pelvic floor dysfunction, they may not seek care from pelvic health specialists unless specifically referred.

Expanding the Clinical Conversation

As pelvic health clinicians, we have a responsibility to broaden interdisciplinary awareness of the connections between the hip and the pelvic floor.

The shared lumbosacral plexus, overlapping neuroanatomy, and functional relationships between the hip rotators and pelvic floor musculature create a system that cannot be fully understood when assessed in isolation.

Persistent pain following THA should not be viewed solely through an orthopedic lens.

A whole-body, neuroanatomically informed approach may reveal contributing factors that allow patients to move beyond persistent pain and return to meaningful function.

Beyond Traditional Frameworks

Persistent pain following total hip arthroplasty challenges clinicians to think beyond traditional diagnostic frameworks. When imaging confirms that prosthetic structures are intact, the next step is not simply more imaging or repeated consultations—it is broader clinical reasoning.

The pelvis sits at the intersection of orthopedic and pelvic health systems. Recognizing the functional relationship between the hip, pelvic floor, and lumbosacral neural network allows clinicians to identify overlooked contributors to pain and dysfunction.

As interdisciplinary care continues to evolve, collaboration between orthopedic and pelvic health providers will be essential in addressing complex postoperative pain presentations.

Sometimes the missing link is not the joint itself—but the interconnected nature of the neuroanatomical systems surrounding it.