Understanding hip flexor pain
As I dive deeper into learning the nuances of the human body and movement, I have been intrigued by certain patterns that emerge. I see similar symptoms when working with all kinds of athletes who range in body type, sport, and daily living. Although the choice of recreation and career varies, we all share a common framework and interact with our environment in similar fashions. That common framework, our structural make-up of bones, connective tissues, organs, and nervous system adapt to the demands we place on them, whether for better or for worse. Hip flexor pain is a common symptom that I see, especially with endurance athletes. Instead of only treating the symptoms with a focused manual release or stretch, understanding the larger picture has lead me to develop a more comprehensive program.
A common cause of hip flexor pain
The primary pattern I’d like to share with you in this post is what Shirley Sahrmaan, PT labels as a Movement Impairment Syndrome. The movement impairment syndrome that is most commonly seen from her clinical experience in regards to the hip complex is called Femoral Anterior Glide Syndrome. This pattern of dysfunction occurs when there is hip hyper-extension (commonly seen in distance runners, dancers, and gymnasts), a lengthened and weak iliopsoas muscle, limited hip flexion due to tight and weak glute max and glute medius muscles, with the most noticeable sign being a pinch or hip flexor pain with passive hip flexion (hugging your knee to your chest) as well as pain with active hip flexion (lifting your thigh to climb a stair). With femoral anterior glide syndrome, the pinch/pain is due to a faulty force-couple between the psoas and glute muscles common to what is seen in the shoulder complex. It’s called anterior glide syndrome because the glute isn’t activating enough to keep the head of the femur sitting in the center of the socket, so the head glides anteriorly, thereby putting pressure on the anterior joint structures (iliopsoas tendon, pectineus, and related bursae).
What I love about Sahrmaan’s approach to remedy this muscle imbalance is her 3-tier attack:
- Change the tissue physiology, meaning release the tight and short hyper-active tissues. These muscles are the ones creating excess tension because the iliopsoas (the primary hip flexor) should be lifting the thigh. Tensor fascia lata, sartorius, adductor longus and magnus, and rectus femoris are accessory hip flexor muscles, synergists to iliopsoas. The other important step to make is to shorten, activate, and strengthen any weak muscles, which in this movement impairment syndrome, is the iliopsoas. This is done by a simple knee hug into the chest without initiating ANY pinch sensation which is a sign of tendon impingement. Once the stretch is held, let go with your hands and try to isometrically hold your knee in place, or slightly lower, to fire the psoas muscles. Within 2 days of performing this for my right hip about 4-6 times per day at 20 seconds stretch and 10 seconds hold, I could feel the psoas activate. Another weak muscle is the glute medius muscle which acts to stabilize the hip while weight-bearing. Glute med also has anterior and posterior fibers which assist to flex and extend the hip respectively. Side lying leg lifts with the hip in slight extension and external rotation can isolate this muscle. Start with 3 sets of 10 reps to begin then progress from there.
2. Improve the muscle recruitment order to rely more on the prime mover and less on the accessory muscles. For example, lying prone with a pillow under the hips and one knee flexed to 90 degrees, extend the hip first by activating glute max. Progress to lifting with a locked knee making sure to not let your pelvis tilt anteriorly or rock/rotate by using your core to stabilize. Typically, through too much sitting and muscle imbalances in length and strength, the glute max becomes weak so the hamstring group initiates hip extension, whereas that’s the primary job of glute max. This dysfunction can lead to hamstring strains and faulty mechanics when running or lifting. Also, when taking a step during walking, make sure to activate glute max and med upon heel strike.
3. Align the body to promote optimal biomechanics. Saahrman notes that limiting hip hyper-extension is important, so ensuring adequate stance foot toe push-off (through the big toe) can recruit more foot plantar flexors and rely on the fascial recoil instead of hip hyper-extension when walking or running. Also, limiting hyper-extension of the hips when standing tall out of a deadlift or squat can limit aggravating the anterior hip joint structures and can reduce hip flexor pain.
It’s important to note that there are variations to this syndrome which include both medial and lateral rotation, so a thorough assessment is vital to ensure success in your program. I think the main takeaway is that glute activation will not fix everything, especially when one or both iliopsoas are also tight and weak from sitting too much. Taking the time to get-up at least every hour, ideally every 30 minutes if possible, to move around and activate key muscles can mitigate adaptive tissue shortening and lengthening to the position being held. Even if this hip pattern hasn’t been an issue for you, it can be useful to test your iliopsoas strength to ensure they are firing properly. Tyler can also help run through this assessment and treatment during a massage therapy session.
*Sahrmann, Shirley. Diagnosis and Treatment of Movement Impairment Syndromes.