Fixing Hip Impingement

Do you have groin pain that feels like a pinch in the front of your hips as you move into a deep squat? This symptom is one of the most common complaints of those who have a hip impingement (called femoroacetabular impingement or FAI).

Hip Impingment.jpeg

If you think you have this injury, make sure to check out THIS ARTICLE and perform the three tests I describe. If you only had one positive test out of these three, the chances of having a hip impingement is fairly low. 1,2 However, if you tested positive for all three tests (C-Sign, log roll and FADIR test), the likelihood of having this injury is high and you may benefit from the following corrective exercises listed today.

Finding The Cause

Hip impingement usually presents in young-adult athletes (early 20s to mid-30s), who experience a slow onset of groin pain due to a repetitive pinching between the femur and the front of the hip socket (acetabular rim). This contact between the two bones usually occurs in movements that require a ton of hip flexion (such as sitting into a deep squat).

As you squat, the femur rotates inside the hip joint. For those with normal “textbook” anatomy, the femur always maintains a little space (about 9mm) from the front rim of the hip socket.5

shutterstock_147789482

There is often a degree anatomical variation from person to person. Simply put, not everyone has a “textbook” bone structure (especially when it comes to the hips). Changes in the way our bones align can lead to a “blockage” of movement when you try to get into certain positions (like a deep squat or lunge).

Hip_Socket_3

For example, if we look at the pelvis we find that some people have hip sockets that open more to the side and others that open at a more forward angle. A hip socket that opens laterally (called acetabular retroversion) creates more coverage around the front of the femur (which can lead to an impingement between the two bones in a deep squat).

Retroversion

The shape and alignment of the femur as it connects to the pelvis can also lead to an impingment.3 For most of us, our femurs normally align with the pelvis at a slight forward angle. However, some of us have femurs that are twisted slightly forwards or backwards. A more forward angled femur is called an anteverted femur. A more flattened angle is called a retroverted femur.4 Research has shown that a retroverted femur can often increase pressure at the front of the hip joint with certain movements and cause impingement.6

Anteversion
The femur on the left is showing femoral retroversion (a very flat angle) where the femur on the right is showing a more pronounced femoral anteversion. 

Getting to Know Your Anatomy

We can start our screening process by simply observing how someone stands. Stand in a comfortable stance with your feet around shoulder width. Look for the position of the feet and which way the toes are pointing.

Retroversion

A “duck stance” or exaggerated toes out stance is often seen with those with retroversion. This position feels normal because the backward twist of their femur leaves them with the appearance of having excessive external hip rotation. This position however isn’t due to limited flexibility but rather because their bones are shaped in a way that sets a new “normal” for their movement capabilities.

We however can’t stop our evaluation at this point and definitively say someone has retroversion just because they stand like this. Turning the toes out excessively can most certainly be a sign of poor hip mobility (something we can modify). There will also be those with hip impingements who will not show a toed out foot position in their normal stance. For this reason, we need to perform some testing to find what is truly at fault.

A test you can easily perform at home to check for femoral retroversion is called Craig’s test. Start by lying on your stomach with your knees bent at 90°. Have a friend take their hand and feel for the where the notch of the femur (greater trochanter) is located on the side of your hip. With their other hand, begin rotating your lower leg in and out. As the leg rotates, the tester will begin to notice the notch of the femur becoming more and less prominent against their hand. Stop moving the lower leg when they find this position to be most prominent.

‘Normal’ anatomy will leave the lower leg pointing slightly away from the body (within 15° from a vertical position). If the athlete has their lower leg now positioned directly vertical or angled slightly in towards the rest of the body, they have a retroverted femur. This method of assessing hip anatomy has been shown in research to be extremely reliable (even better than taking an X-ray).8,9

We can now perform a test to give us a better understanding of the position of your hip socket. Start by lying on your back. Have a friend bring your knee towards your chest in a straight line. See how far your thigh can move before feeling a “blocked” sensation. Next, perform the same movement but allow the thigh to move out to the side and the foot to rotate inwards slightly (an abducted and externally rotated position of the hip).

Were you able to now move the knee further towards the chest without a pinching or blocked sensation? Research as shown that those with retroverted hip sockets will often be able to bring their knee closer to their chest with the knee out to the side.10

Can We Fix It?

If you have a hip impingement and found it to be related to your anatomy, there are two non-surgical options to decrease your pain:

  1. Change your stance
  2. Try to Improve hip capsule mobility

Stance Considerations

While most people should be capable of performing a bodyweight squat with their toes relatively straight forward (5-7° toe out angle) that does NOT apply to everyone. If you suspect your body has femoral or acetabular retroversion, it is going to be “normal” for your body to have a more exaggerated toe out angle (>30°) when you squat, catch a clean/snatch or dead lift.

Toe Out angle

If you found a possible retroverted hip socket or femur in the previous tests, try this squat test. Assume a bodyweight squat stance with your toes relatively straight forward. Try to squat as deep as possible. Next, point your toes out to approximately 30° and perform the same deep squat. Patients with retroverted hips will often feel an uncomfortable and painful sensation in the front of their hips that limits depth during the squat with toes forward.7

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What this means is your body has a bone structure that does not allow for a straightforward foot squat. It is normal and natural for your body to squat with your toes angled out and no amount of mobility work will significantly change this.

Banded Joint Mobilizations

While we can’t change your bony anatomy, we can hope to improve the mobility of the tissues that surround the hip joint (hip capsule). Most researchers believe that those with hip impingements may also have restrictions in the lateral and posterior portions of the hip capsule fibers.

Image result for hip capsule

The first exercise I want to show you is the lateral banded joint mobilization.11 Place a long resistance band around your thigh (try to get it as high as you can towards your hip). Get a ton of pressure on the band as you assume a kneeling lunge, with the hip you want to work on in the forward position.

Once in the lunge, take your hand and pull your forward knee across your body and back to the start position. This movement (along with the pull from the band) will help stretch the lateral and posterior fibers that surround the hip. If the band is pulling hard enough, the inward knee movement should not bring out any pinch-like pain in the front of the hip but instead a possible light stretch to the side of the hip.

Next, with the band still around your thigh, take your forward knee and place it into the ground. Your thigh should be positioned around 90°. From this position pull your torso toward the ground and rock your hip to the side (towards the pull of the band). This posterior-lateral motion will bring out a stretch to the back and side of your hip. Hold this motion for ~10 seconds before returning back.

In this position you can also externally rotate your hip by moving your foot towards your stomach. This may increase the stretch feeling to the lateral hip.

Recommended sets/reps: 2 minutes of slow rocking movements

Pigeon Stretch

We can also stretch the posterior hip capsule without a banded joint mobilization with a stretch called the pigeon stretch. Find a high bench or bed and place your leg on top in an externally rotated position.

With your lower leg completely flat on the bed, lean your torso forward until you feel a light stretch in your hip. Make sure to keep your back from rounding during this movement. You can play around with this movement and lean your torso in different angles (towards your foot or your knee for example) to maximize the stretch in the back of your hips.

You can also perform this stretch on the ground if you don’t have access to a table.

Recommended sets/reps: 3 sets of 30-second stretch

Final Thoughts

Not everyone has ‘textbook’ bone structure and trying to conform to a squat stance that isn’t right for your body can be disastrous. If you have a hard blocking sensation or a pinching pain in your hips when lifting, this is your body telling you to move differently. Listen to it.

Just because you didn’t hit the genetic lottery with getting perfect hip anatomy doesn’t mean you should hang up your weightlifting shoes and quit training altogether. You only need to understand what technique adjustments and the necessary mobility modifications your body requires in order to reach your potential and stay pain free. If your pain continues to persist or worsen despite trying these interventions, I highly recommend seeking out a medical doctor to see if there is any serious issues that may need surgical intervention.

Until next time,

Author Photo
Dr. Aaron Horschig, PT, DPT, CSCS, USAW

with

Kevin Photo
Dr. Kevin Sonthana, PT, DPT, CSCS

References

  1. Laborie LB, Lehmann TG, Engesaeter IO, et al. Is a positive femoroacetabular impingement test a common finding in healthy young adults? Clin Orthop Relat Res. 2013 Jul; 471(7):2267-2277
  2. Tijssen M, van Cingel R, Willemsen L, et al. Diagnostics of femoroacetabular impingement and labral pathology of the hip: a systematic review of the accuracy and validity of physical tests. Arthroscopy. 2012 Jun;28(6):860-71
  3. Espinosa N, Rothenfluh DA, Beck M, Ganz R, et al. Treatment of femoro-acetabular impingement: preliminary results of labral refixation. J Bone Joint Surg Am. 2006;88:925-936
  4. Cibulka MT. Determination and significance of femoral neck anteversion. Physical Therapy. 2004; 84(6):550-558.
  5. Hossain M, Andrew JG. Current management of femoroacetabular impingement. Curr Orthop. 2008;22:300–310
  6. Satpathy J, Kannan A, Owen JR, et al. Hip contact stress and femoral neck retroversion: a biomechanical study to evaluate implication of femoracetabular impingement. Journal of Hip Preservation Surgery. 2015;2:287-294
  7. Sahrman S. Diagnosis and treatment of movement impairment syndromes. Mosby Verlag. 2002
  8. Ruwe PA, Gage JR, Ozonoff MB & DeLuca PA. Clinical determination of femoral anteversion. A comparision with established techniques. J Bone Joint Surg Am. 1992 Jul;74(6):820-30.
  9. Souza RB & Powers CM. Concurrent criterion-related validity and reliability of a clinical test to measure femoral anteversion. Journal of Orthopaedic & Sports Physical Therapy. 2009;39:586-592
  10. Reynolds D, Lucas J, Klaue K. Retroversion of the acetabulum a cause of hip pain. Journal of Bone & Joint Surgery, British Volume. 1999;81:281-288
  11. Reiman MP & Matheson JW. Restricted hip mobility: clinical suggestions for self-mobilization and muscle re-education. ISJPT. 2013 Oct; 8(5):729-740

**All bone images were used with permission from Paul Grilley

Published by

Dr. Aaron Horschig

Doctor of Physical Therapy, CSCS, USAW coach and athlete.

One thought on “Fixing Hip Impingement

  1. Awesome article, doctor! I wish I had read this three years ago when I reached my peak at powerlifting. Unfortunately, I’ve destroyed my hip joints and have constant stabbing pain every minute of every day… At 26 years old. I’m glad more information is coming out regarding abnormalities in hip anatomy, because I was instructed by several “coaches” to squat with my feet pointing forward. Now I realize I was forcing my hips into an unnatural range of motion and impinging myself.

    Like

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