Data from short- and long-term follow-up studies indicate that thigh pain is a significant complication after apparently successful cementless total hip arthroplasty. In most cases, reported symptoms are mild to moderate, resolve spontaneously or do not progress, and require little or no therapeutic intervention. However, persistent thigh pain may be a source of dissatisfaction or may present as severe, disabling pain. Possible causes include bone-prosthesis micromotion, excessive stress transfer to the femur, periosteal irritation, or a mismatch in Young's modulus of elasticity that increases the structural rigidity of the prosthetic stem relative to the femur. Thorough diagnostic evaluation of thigh pain is essential to rule out prosthetic infection or loosening, stress fracture, or spinal pathology as the primary source. Treatment options in the aseptic, well-fixed femoral component include medical management, revision of the femoral component, or cortical strut grafting at the tip of the implant.