Welcome back to Squat University! For the past few weeks we’ve been discussing the topic of groin pain. This week we’re going to discuss another common cause of anterior hip pain in athletes called Iliopsoas syndrome.
A hip flexor injury often starts a little differently than your classic pulled groin. As we discussed last week, an adductor strain will often occur at one specific time. You’ll be able to pinpoint one jump, cut, squat or deadlift where you felt a sharp pain in the inner groin (this is the point of the muscle tearing).
Iliopsoas syndrome however is often an overuse problem. This means it doesn’t start at one specific time but instead slowly becomes an issue over weeks and months. This injury usually presents a few different ways as well:1
- Iliopsoas tendinopathy (inflammation and/or degrading of the tendon)
- Compression of the underlying bursa sac
- Snapping of the muscle over bony areas of the pelvis causing a “pop” feeling
How to Fix
If you found stiffness in your hip flexors during the Thomas Test, your first line of treatment should be to work on improving this flexibility. We can go about this two ways: stretching the hip flexors and releasing tension with soft tissue mobilization tools.
½ Kneeling Stretch
The stretch I want to show you is called the ½ kneeling hip flexor stretch. Start in a lunge position with one knee on the ground. Place your hands in a “C” shape around the sides of your hips so you can get a good feel for the position of your pelvis (your 1st and 2nd fingers should be positioned on top of the bony part of your pelvis that is in front called your ASIS). To perform this stretch correctly you’re going to have to really hone in on the position of your pelvis.
Start by arching your low back and tipping your pelvis forward excessively. This is called an anterior pelvic tilt. If you did it correctly the bony nub your first two fingers covered (ASIS) should be pointing more towards the ground and lower than the position of your thumbs on the back of your hips. This is a bad position to be in, but will help you understand what a good position (what we’ll go to next) will feel like.
Next, perform the exact opposite movement. Flatten your back and pull your hips under your body while you squeeze your butt muscles and core muscles. This is called a posterior pelvic tilt. If you did it correctly your first two fingers should now be much higher than the position of your thumbs. When you do this motion and squeeze your glutes, it should have brought out a good stretch sensation to your hip flexors. You can also lean forward for a deeper stretch as long as you maintain your posterior pelvic tilt! Hold this stretch for 10 -20 seconds before relaxing.
Recommended sets/reps: 10 reps for 10 second holds
Prone Leg Lift Stretch
Another way to stretch tight hip flexors is with an ‘active stretch’. This type of stretch can increase flexibility of tight muscles while at the same time ‘turning on’ muscles that are often inactive (like the glutes) in order to re-establish balance to the hip muscles and fix the root cause for the original tightness.3,4
The active stretch I want to show you is called a Prone Leg Lift. Start by lying on your stomach. Next, bend your knee of the leg you want to stretch to 90 degrees. Try to relax your hamstring as much as possible and lift your thigh off the ground by squeezing your glutes. Hold your thigh off the ground for 3-5 seconds before lowering your leg. Make sure your torso doesn’t twist during this movement. You can also perform this same active stretch with your leg completely straight if the first method causes cramping in your hamstring.
Next, we can perform some soft tissue mobilization. Using a small ball or the edge of a foam roller can be a great way to decrease tension in stiff muscles and release myofasical trigger points that limit flexibility and cause pain.2,5 One of the most common trigger points can be found just to the inside of the ASIS.1
Grab a lacrosse or tennis ball and lay on your stomach. Position the ball just to the inside of the ASIS. This area will often be a little painful to put pressure on. Slowly roll the ball around until you find the tender area of muscle. Apply direct pressure for 1-2 minutes before slowly moving forward and back over this area in a wave like motion.
Core Stability & Hip Strength
The hip flexors have two functions. They can raise your thigh (called hip flexion) and they can be used to stabilize the pelvis/low back. They are ‘turned on’ during activities while lying on our back, sitting and standing. For this reason, we need to perform our corrective exercises that improve strength and proper core stability and coordination in a number of different positions and activities.
In my experience, a number of hip flexor injuries occur because the body is over-relying on the Iliopsoas to create core stability. The low back (lumbar spine) as a whole, is an area that requires a ton of stability especially when barbell training. As we lift the barbell, all of the muscles that surround the spine must work in coordination to keep our back from buckling in two. In other sports, like throwing a shot put or swinging a baseball bat, a stable core allows for proper transfer of power from the lower body into the upper body. Unfortunately the low back also has a tendency to become unstable. And when this happens our body develops negative compensations.
If the core isn’t doing its job of stabilizing the spine, the body will search for stability elsewhere in an attempt to avoid serious injury. Because the Iliopsoas is the only muscle group that connects the spine to the lower body, its proximity makes it one of the first go-to’s to try and create this stability. This is a big reason why the Iliopsoas becomes stiff/tight and eventually pain develops. Therefore, if we never address how to correctly create core stability in our rehab programs, we miss the big picture and may never find lasting results with Iliopsoas syndrome.
Learning to Brace
This first exercise is one I have demonstrated before in prior articles. It is based on the teachings and research from renowned expert Dr. Stuart McGill. The goal is to improve your sensation and perception of stability. Basically, I want you to feel the muscles that should be activated when you correctly brace your core.
Just because you have a shredded stomach with rippling 6-pack abs does NOT mean you know how to brace your core correctly. Bracing involves activating all of the muscles that surround your spine (back, abs, diaphragm, and pelvic floor) to create 360° of stiffness.6,7
Step 1: Lie on the ground with your back to the floor. Your knees can stay bent for comfort.
Step 2: Place your hand on the side of your stomach (into your obliques). Next, brace your core like you’re about to get punched right in the stomach. This should create a firm feeling of stiffness around your entire stomach. If you did this correctly you should feel tension under your hands. If you did this incorrectly, your stomach will balloon out (this means you only activated your 6-pack or rectus abdominus). Hold this brace for 10 seconds before relaxing.
Recommended sets/reps: 2 sets of 20 reps for 10-second holds
Isometric Hip Flexion
Once you have the ability to create proper core stability, we then need to re-introduce strengthening of the hip. I want to show you an exercise progression that I got from Dr. Jacob Harden.
Step 1: Lay on your back with your knees bent and feet up at a 90° angle. Place a small resistance band loop around your feet.
Step 2: Brace your core like you learned in the first exercise and then straighten one of your legs. Make sure your other leg remains in a bent position. Hold the extended leg for 3-5 seconds before returning to the start position. This exercise creates an isometric contraction (activation with out joint movement) of the hip flexors in order to maintain the top leg from moving. Isometric contractions can be a great way to strengthen injured tissues without pushing them into pain during the early phase of the healing process.
Recommended sets/reps: 2-3 sets of 10 kicks with a 3-5 second hold.
Marching Resisted Bridge
Next, we can progress to a more dynamic resistance movement. This exercise requires you to maintain your brace, while at the same time activating your posterior chain and strengthening your hip flexors.
Step 1: Lay on your back with legs extended and heels resting on a bench. Keep the resistance band loop around your feet.
Step 2: Brace your core and raise your hips from the ground in a bridging movement. Squeeze your glutes hard in this position.
Step 3: Next, pull on knee to your chest at a time while the other remains on the bench. Keep your core braced during the entire movement.
Recommended sets/reps: 2-3 sets of 10 alternating reps
Side Plank Clamshell
The last area we want to concentrate on is the lateral rotators of the hip. Research has shown that athletes with Iliopsoas syndrome can often present with weak hip rotation strength and coordination (poor muscle timing).8 To work on this possible weak muscle group, I want to share the side plank clamshell exercise with you.
Step 1: Lay on your right side, with your legs bent and a resistance band loop around your knees.
Step 2: Keep your right elbow and right knee in contact with the ground as you raise your hips and hold then in a side plank position.
Step 3: While maintaining this side plank, rotate your left leg open against the band resistance. Hold it for two seconds before lowering it back down. I will often cue my patients to imagine their legs are the mouth to a clamshell opening and closing.
Recommended sets/reps: 2 sets of 15 reps on each side
Most experts believe Iliopsoas syndrome is due to overuse. For this reason, treating this injury requires both rest and addressing the root cause for the overuse in order to find lasting relief. This comprehensive treatment approach requires soft tissue mobilization, pain free stretching, and purposeful strengthening.
I hope this article helped shed some light on Iliopsoas syndrome. Remember, none of these exercises should create or worsen your current pain symptoms. If you are unable to find any relief with these exercises, I recommend going to a medical professional (doctor or physical therapist) to assist in your recovery.
Until next time,
- Tyler TF, Fukunaga T & Gellert J. Rehabilitation of soft tissue injuries of the hip and pelvis: invited clinical commentary. IJSPT. 2014 Nov; 9(6): 785-797
- Ingber RS. Iliopsoas myofascial dysfunction: a treatable cause of “failed” low back syndrome. Arch Phy Med Rehabil. 1989;70(5):382-386
- White SG, Sahrmann SA. A movement system balance approach to management of musculoskeletal pain. In: Grant R, eds. Physical Therapy of the Cervical and Thoracic Spine. New York, NY: Churchill Livingstone Inc; 1994:339-357
- Winters MV, Blake CG, Trost JS, et al. Passive versus active stretching of hip flexor muscles in subjects with limited hip extension: a randomized clinical trial. Phys Ther. 2004;84(9):800-807
- Paolini, J. Review of myofascial release as an effective massage therapy technique. Athletic Therapy Today. 2009; 14(5):30-34
- Grenier SG & McGill SM. Quantification of lumbar stability by using 2 different abdominal activation strategies. Arch Phys Med Rehabil. 2007; 88:54-62
- Gardner-Morse MG & Stokes IAF. The effects of abdominal muscle coactivation on lumbar spine stability. Spine. 1998;23(1):86-92
- Johnston CA, Lindsay DM, Wiley JP. Treatment of iliopsoas syndrome with a hip rotation strengthening program: a retrospective case series. J Orthop Sports Phys Ther. 1999;29(4):218-224
28 thoughts on “Fixing Hip Flexor Pain”
Thank you so much for posting this. I injured my hip flexor while squatting back in February and have since been diagnosed with iliopsoas syndrome. It’s been an incredibly arduous process to heal, and I have been at it for nearly 8 months and still not able to squat. I’ve gone through much physical therapy and dry needling. This article explained everything I have been experiencing and I appreciate knowing that what I have can be managed. It’s been a long process to determine what my injury is and have definitely felt frustrated. I will absolutely incorporate these movements into my regimen. Thank you!!!
You’re so welcome Alyssa! I hope you’re able to find some relief of your injury soon!
I have been dealing with the same issue for a while and hopefully things will get better after following your tips. Allso I would like to ask that, can you point out most undesirable gym exercises that should be avoid during the hipflexor pain problems.
Good question! I think everyone that has this issue will have a little different presentation as to what exact movements cause pain. Sometimes it’s fast running, other times its heavy lifting. For that reason, I would avoid anything that leads to pain while rehabbing the hip flexor. I know that’s a little vague but that gives you the best chance for a full recovery. If you don’t find any changes with these exercises and activity modification, I’d recommend going to see a physical therapist for some help.
A few months ago whilst squatting I experienced a sharp pain , but origination was outer hip area , just below the GT bone . I had pain for several days, eventually subsided but I haven’t been able to go heavy in squats since. I did try heavy squats a few months later , atg , and felt the pain come on again so I stopped to cause any further damage . Is this the same issue I am dealing with here as you described ?
Thanks a lot! Is this correct: First stretching/dynamic stretch, than foam roll/lax ball and than strengthening exercises?
Ah, thank you so much for this article. I’ve been dealing with the hip pinch while squatting for a while now without any relief.
Is it possible that this could be caused by an inbalance between the glutes and the quads? I find that when my hip is bad, any glute stretch becomes a lot harder and I’m a lot more prone to pulling my really low-back muscle. Any suggestions on that particular imbalance? I can’t quite figure out if I need to be focused on strengthening my glutes and Hammies or if my quads are the issue now.
Thank you for this article. I have been experiencing pain for the past week after heavy dead-lifts and squats.
I am now working on correcting this.
Thank you so much.
Thanks so much for this information and everything else you do. I am primarily a long distance runner, but I lift as well. I have noticed pain not only in my groin and front of my hip, but also in my lower abdominal/pelvic region which gets worse the longer I run. In addition, sneezing causes a large amount of pain in the area. Is it possible that this is related to iliopsoas syndrome or is it likely more serious than that?
With your isometric hip flexion exercise, this wouldn’t actually be a true isometric exercise would it, with actual movement of the hip joint/femur? More of an concentric/eccentric strengthening of the hip flexors, with the isometric coming at the end with the quads? Wouldn’t a more accurate isometric be bracing the 90 degree position of the hip/knee position with a placement of the hand to the top of the knee and then trying to flex the hip without movement?
Excellent article! I will absolutely incorporate these movements into my regimen.
Here is also an article about stretching the hip fleors which I used for a long time.
Thanks so much for this information and this amazing article.
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Thank you so much! I’m dealing with pain in my front hip/groin since November. According to rebuilding Milo it all comes down to hip flexor injury. I incorporated the isometrics, which actually helped in dealing with the pain and then advanced on to the marching resisted bridge. I don’t know whether or not it is right, but the pain started again as soon as I started with the resisted bridge.
I’ll definetly continue on doing the isometrics since they help a lot. Would you recommend getting an MRI scan at this point or could pain occuring during resisted bridge be normal?
Thank you so much for all our work!
can you explain what we should be feeling when bracing our pelvic floor muscles before a squat
I can’t seem to play the videos can yiu send me a link Thank you
I have also been suffering with this for a long long time – 3 years… First diagnosis was hernia, then hip issues. I’ve been working with a good physio, who has come close to this diagnosis but not quite. Finally, today, a thoughtful NHS specialist narrowed it down to what he believes is a hip flexor issue. What I’ve read here fits! So frustrating to think of the time I’ve wasted… but I have hope now. I’ve subscribed and really appreciate the information you’ve provided!
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Thank you so much! I am feeling it off my left side while i am doing the deed stretching of slip practice. But it seems not effect my squad yet, should i stop squad and fix it first?
it helped me to understand
Thank you for sharing the article. I am also interested in this issue
Nice post, I’m impressed! Very helpful information especially the last step.
nice info thanks I will be interested in more similar topics. i see you got really very useful topics, i will be always checking your blog thanks.
Thanks for sharing informationi really like it . keep it up bro