Hip Impingement is a major frustration with significant restraints placed on any active lifestyle. It’s poorly understood, misdiagnosed, and symptoms can vary from just a dull irritable ache in the anterior hip, referred pain to the lower back, and stiffness in the hip joint worsened by more hip flexion range of motion. In this learn we will discuss how common Femoral Acetabular Impingement (FAI) is, the surgery discussion, and the three biggest areas to address to manage and overcome it.
But first some real quick anatomy. The hip is a ball-and-socket joint. The socket is formed by the acetabulum, which is part of the large pelvis bone. The ball is the femoral head, which is the upper end of the femur (thighbone). A labrum sits inside the socket to assist with cushioning the two bones as well as providing added stability by deepening the socket given the large freedom of movement.
There are 3 types of hip impingement:
- CAM Lesion – Excessive bone growth noted on image to the femur
- PINCER Lesion – Excessive bone grown around the socket on image
Like most things in healthcare, it doesn’t matter until it matters. In saying that, a well known study highlights the number of boney changes within the hip with asymptomatic populations. So we shouldn’t create unwarranted stress and fear associated with these changes unless symptoms and movement limitations are presents.
“Even though FAI is considered to be a pathology associated with hip osteoarthritis; it is very common in asymptomatic population. In this respect, our study showed that prevalence of radiological FAI findings in asymptomatic adult population was 29.6%”
Of 2,114 asymptomatic hips:
-37% CAM deformity
-67% PINCER deformity
-68% LABRAL injury
So if we have a problem of decreased space within a joint it would make sense that with surgery we could shave the bone down, create more space, and then we would have less pain; problem solved??
Unfortunately from a number of surgeries that have been performed over the last 10 years or so this does not appear to be the case. As the long term success rates of this surgery is actually pretty poor. Furthermore, when you consider the individuals who reported short term relief within the first 1-2 years you have to remember that this persons activity levels is likely greatly reduced the first 1-2 years due to the length of time it take to recover from the injury being generally between 6 months to a full year! So how can we realistically say that surgery is successful if stress to the hip joint and activity is reduced?
HOW TO ADDRESS HIP IMPINGEMENT
Modify before omit. In order to decrease sensitivity and get you on the road to the right kind of adaptations we have to remove those painful triggers. So if sitting in a deep squat is painful we need to find a better alternative. If cycling for 1-2 hours consecutively is irritating your hip, we need find another alternative. We can give you the best corrective exercises and treatment available but if you’re still “poking the bruise” then those tissues will remain irritated and we will be moving on a treadmill; going nowhere.
Since hip impingement is prevalent in populations that perform loaded squats at high frequency we can analyze the mechanics of a squat for example to give you some more freedom within the hip
POSITION 1: A front rack position allows for a more vertical trunk. This will take demand off the hip and get you out of those end ranges of loaded hip flexion.
POSITION 2: A high bar position will create more of a balance between the hip and knee regions but you will be in more hip flexion. We can assess your symptoms and see if this is more ideal place for you to begin.
POSITION 3: The most aggressive squat position as it relates to the hip joint in the the low bar. You can see how angled his trunk is and how demanding that would be on the hip.
Aside from altering biomechanics we can also modify depth, range of motion, volume/intensity, and frequency within your training to get ahead of your symptoms.
We could make the argument this is the most important step in managing hip impingement. This is the main reason why surgery should be the last line of defense. We have to address the relationship of how the head of femur and the socket coordinate movement and control together. If positional control focused interventions can better help you to organize the joints into positions which allow the joint to experience more space; then we can decrease symptoms and load the right tissues. The body responds to load by adapting and making tissues more resilient. If we have abnormal joint loading then abnormal bone can be generated which results in the CAM or PINCER lesions within the hip. We need to teach the body how to coordinate and organize itself in a fashion that distributes the loading across the entire articular surface as well as across the kinetic chain.
We need to consider specificity in training. It’s really important that our training efforts match the intensity and movement patterns seen in our sport or activity. But the negative side of this is that we can develop this box around our movement and then it becomes hard to move outside of that box or comfort zone. If the movements we train in constantly encourage an elevated rib cage and more anteriorly tilted pelvis then we become biomechanically efficient if we try to train movement patterns that encourage the opposite. This may lead to compensations and abnormal loading to joints and tissues.
If we can get away from bilateral movements for a training block or time period and focus more on unilateral movements that forces you to have more co-contraction and stability around a joint as well as being more positionally aware; we can address many of the primary causes of your pain and limitations. Someone that has a really hard time controlling one pelvis and two femurs may find it more joint friendly to have to worry more about controlling just one femur in a unilateral movement. As mentioned we know that someone who has a rib cage that is migrated forward or a pelvis that likes resting forward in the sagittal plane will display a center of mass which is more forward. This causes many of the prime movers in the lower chain to change their length-tension relationship which further makes an already complex movement; more complex. We can simplify by changing the orientation of pelvis and ribcage we better fit the movement for this individual.
With all this talk about biomechanics, positional control, and coordinated movement; I have to get back to the basics. If we constantly chase picture perfect technique we likely will never reach a load that is large enough to create a true strength adaptation in the joint and musculature. There is no such thing as perfect movement, only a range of acceptable and unacceptable depending on ones movement preparedness, symptoms, and current capabilities.
ADDRESS the PSOAS
Most people with hip impingement will have a constant sensation of tension and tightness in the anterior hip. It’s natural to think that tension comes from being overly tight; which our solution to that would be to lengthen it via soft issue releases, foam rolling, and stretching. But this is likely only further exacerbating that perceived tension because the psoas isn’t actually tense from a shortened standpoint but a reduced capacity and weakness standpoint. This tension can be constantly pulling your pelvis anterior and reducing the activity of the larger posterior chain muscles. Like most things if you have the right INPUT the body will produce the right OUTPUT. Our solution needs to be to address the strength of the psoas. Since hip extension is more trained we tend to neglect strength training hip flexion.
IMPROVE ANKLE MOBILITY
Ideally we should be able to allow our knee to comfortably track over and beyond our foot. Place your feet about a hands width away from a wall and see if you can push your knee over your mid-to lateral foot (not inside, thats cheating) and keep the heel down. This is an unloaded position so if we can’t do it here we’ can’t expect to do it in a loaded weight-bearing position. If we go back to the image of the three different squat positions; we can see that the more upright trunk (front squat and high bar) will decrease loading of the hip joint. Is this the most important thing to address; nope, but it’s part of the puzzle.
Hip Impingement is more common that we realize. Surgery should not be our first line of defense because this does nothing to address the primary causes. If we can remove the painful triggers and keep you moving through activity modifications, address positional control of the lumbopelvic-hip relationship, introduce movement variability and enhance capacity we are well on our way to being pain free and back to 100%. We can’t underestimate the importance of addressing PSOAS strength and ankle mobility as well.
If you’re having hip issues and would like to work with us through a more individualized approach just contact us below!