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Hip Impingement / FAI / AIS: Mobilization and Strengthening of the Medial Rotators

PillarofBalance

PillarofBalance

Strength Pimp
Feb 27, 2011
17,066
4,635
#1
Over the last month I have had four experienced powerlifters complaining of a burning or stabbing pain in their anterior hip. Each one has found squatting to be painful; sometimes almost too painful to perform, particularly at the point they break parallel. One of the four actually included myself.

In each case, I took note of the description of the pain, the location of discomfort, when symptoms appear, whether this has been a chronic, recurring or acute pain and then performed a very basic study of their posture and hip ROM.

After assessment I noted only one of the four had a significant postural issue due to an eversion of the foot, where the sole of the foot is tilted laterally. He was cued to correct this and perform a squat. With a stable neutral ankle, the pain persisted during the squat.

All four individuals however had moderate to severe limits to range of motion. As a wide stance squatter, and sumo deadlifter I have a very strong ability to laterally (externally) rotate my femurs, however my own medial (internal) rotation was actually the most limited.

Additionally, each of the four had very weak adduction particularly in relation to the powerful abductors each had.

Strong imbalances surrounding a joint will almost inevitably create problems with articulation and cause pain. Each of the four interviewed separately also described the pain using the same description – a “hip impingement.” While I am the only one of the group that understands what an actual hip impingement is, it was important in figuring out what was going on. To the average lifter who is generally in tune with their own anatomy, what they describe is that it feels as though the joint is restricted by material in the joint capsule itself.

A true hip impingement has two common names. Acetabular Impingement Syndrome (AIS) or Femoral Acetabular Impingement (FAI). There are two types of FAI, Cam and Pincer.



You can see in the above image the difference between the two. In a Pincer Impingement the acetabular lengthens around the head of the femur. In a Cam Impingement, the head of the femur begins to “mushroom.” In either case as the additional bone or deformation occurs, the femur becomes restricted. Both have the same cause as well. When the head of the femur repeatedly crashes into the acetabular the bone is signaled to adapt and growth occurs.
In the interest of full disclosure there is growing evidence that FAI is not actually a skeletal problem and detection in x-ray/ct-scan/MRI is not adequate for diagnosis. But that the problem is in fact muscular. I would tend to agree based on the evidence. In several studies of thousands of individuals, imaging was studied and signs of FAI were noted with no pain or limited ROM. It appears that FAI has more to do with the supporting musculature that causes, or allows the femur to articulate.

That aside, I set out to accomplish two things. First was to figure out how to get the four out of pain so they can resume training their squat. Second is to develop a strength program that addresses the weakness and imbalance.

Step One – Pain Relief, Resumption of Training:

The head of the femur should sit towards the back of its socket. With the overpowering external rotators and weak internal rotators one can imagine the position the head of the femur is in. It would look close to a subluxation and would put strain on the illiofemoral and pubofemoral ligament. Taking the leg through its normal range of motion without causing significant pain or worsening of the symptoms requires doing so with the femur pushed back where it belongs. To accomplish this I used band distraction around the front of the thigh with the leg raised in the air as pictured below.



As you can see in the picture, the band is pulling the femur towards the posterior portion of the joint. In this first step, each lifter expressed almost immediate relief from their symptom.

With the femur seated properly, I was able to then mobilize the surrounding tissues with very little discomfort. As seen in the image below, I was able to “break parallel” bringing the knee to the ribcage without pain.



Next I began increasing the internal range of motion by bringing the leg to end range and having them push against my hand – contracting the internal rotators momentarily, and then forcing additional range when they relax (contract-relax method). I took great care to support the knee joint when doing this by bracing with one hand at the top of the knee.



Finally; and mostly just because I was there, I also worked their external rotation using the same contract-relax technique as above.



After only a few minutes, each was able to then jump right into their squat workout pain free. Of course, symptoms would return within a day or two as the underlying causes were left untreated.

Step Two – Strengthening

This process is quite simply, but requires diligence of each lifter. Many of us focus so much on the large skeletal muscles that really put in the work, and pay little attention to the smaller supporting muscle groups. This is something I aim to change over time with everyone I work with.

To strengthen the adductors, it is as simple as performing exercises that require you to close your legs. I generally have people perform this with bands rather than using the “good girl” machine. Machines as we know generally do not require the stabilizing muscles to assist to a great degree.

So for this, I used a red mini band (light tension) choked off at ankle height. The band loops around the lifter just above ankle height and then step into light tension. Holding a pole for stability they simply let the tension take their leg out and away from midline and then swing the leg back and across midline with a brief hold at the end range. Angles can be changed from slightly behind, swinging in and out in front of the body.

I have asked each to perform this on 3 training days per week doing 5 sets of 20 repetitions for each leg.

Progress will be monitored, but I’m fully expecting this issue to be resolved with the strengthening of the adductors. After all, the solution to every problem is to put strength first.

#StrengthFirst
 
E

EastCoast1

Senior Member
Jul 20, 2015
216
101
#3
Good post. Very Donnie Thompson eque :)

I have this among other shit going on right now, big time. I have some issues with my TFL, piriformis and surrounding tissue causing me a lot of headaches. Squatting is brutal. Probably going to get an MRI after my next meet. I don't even want to know right now..lol

EC1-
 
TenaciousA

TenaciousA

TID Lady Member
Mar 31, 2013
1,240
433
#4
Really appreciate this, as I am having "something" in my L psoas area as well, only when I lean forward or break parallel. Crossing L leg over right and using any resistance to mobilize is just awful.
Squatting has been excruciating---my vastus medialis is crazy tight from the demand and I am sure poor ankle mobility is also contributing. Will try these methods of relaxing and more accessory work-when I traded LELC for mad lunges didn't help (also wasn't running or going as hard)....
 
hawkeye

hawkeye

VIP Member
Sep 19, 2011
2,832
612
#5
Brother, incredible read. I, too, experience this type of pain and have been really frustrated with it. It's nice to know that I wasn't alone. Sometimes the pain would be just ridiculous and I couldn't understand why because the weight wasn't crazy heavy. It was more about an irritation and then the fear of injury that would not allow me to continue. I really want to try this rehab and see what will work.
 
PillarofBalance

PillarofBalance

Strength Pimp
Feb 27, 2011
17,066
4,635
#7
Good post. Very Donnie Thompson eque :)

I have this among other shit going on right now, big time. I have some issues with my TFL, piriformis and surrounding tissue causing me a lot of headaches. Squatting is brutal. Probably going to get an MRI after my next meet. I don't even want to know right now..lol

EC1-
If only I had Donnie's knowledge when I started. My body is mostly destroyed because I had no idea how to take care of it. Now my time is often spent chasing these solutions down instead of just preventing them.
 
PillarofBalance

PillarofBalance

Strength Pimp
Feb 27, 2011
17,066
4,635
#8
Really appreciate this, as I am having "something" in my L psoas area as well, only when I lean forward or break parallel. Crossing L leg over right and using any resistance to mobilize is just awful.
Squatting has been excruciating---my vastus medialis is crazy tight from the demand and I am sure poor ankle mobility is also contributing. Will try these methods of relaxing and more accessory work-when I traded LELC for mad lunges didn't help (also wasn't running or going as hard)....
I would say a couple other things would be good here.

First is the "couch stretch." Look that up on youtube if you aren't familiar. Only difference is instead of doing it on the couch you will do it on the floor with a small platform behind you. Actually 2 differences. On the leg you are stretching behind you, have a band around the back of the thigh just under your buttcheek (sorry for the clinical terms). The band should be choked off in front of you. This will assist in pulling the leg forward and bringing the pelvis into neutral. Also raise up the arm on the side you are stretching, twist across the body and stretch out the obliques until you feel that psoas grab on.

This might also help you figure out how to squeeze your ass.

From there stand up and turn around. Now the band is looped across the front of the thigh. Put your feet inside shoulder width. Slightly bend the knee of the leg without the band. Keep the other knee locked. Now do a good morning and hold at the bottom. Basically want the back flat, while you push your ass backwards. You will feel a good stretch on the hamstring especially behind the knee. That band will hold the femur in place while you are bent over.

To strengthen these areas start doing light split squats.

If those descriptions make no sense let me know and I will put up a vid on IG and tag you.
 
PillarofBalance

PillarofBalance

Strength Pimp
Feb 27, 2011
17,066
4,635
#9
Good post. Very Donnie Thompson eque :)

I have this among other shit going on right now, big time. I have some issues with my TFL, piriformis and surrounding tissue causing me a lot of headaches. Squatting is brutal. Probably going to get an MRI after my next meet. I don't even want to know right now..lol

EC1-
Hopefully nothing is torn or damaged. In the OP where I am twisting my training partners leg into external rotation is something you should try. Do it after you get into those areas with a lacrosse ball.

Do you get low back pains almost like back pumps or a burning pain in the knee towards the outside?
 
Nitro

Nitro

Senior Member
Nov 19, 2014
123
0
#10
Excellent post bro. I too am having problems with my right hip joint and have been working with my chiropractor to get it resolved. He's sure that the hip issue is what caused my back to go out this past April. I've been doing a lot of myofascial release, stetching and foam rolling trying to get it corrected and although it has gotten better, more range of motion and more flexabilty it still hurts like hell some days. Squatting is out of the question for me but I was to the point where I couldn't even leg press because of it.

Gonna give this a try and see if it helps. Appreciate you sharing this brother.
 
PillarofBalance

PillarofBalance

Strength Pimp
Feb 27, 2011
17,066
4,635
#11
Excellent post bro. I too am having problems with my right hip joint and have been working with my chiropractor to get it resolved. He's sure that the hip issue is what caused my back to go out this past April. I've been doing a lot of myofascial release, stetching and foam rolling trying to get it corrected and although it has gotten better, more range of motion and more flexabilty it still hurts like hell some days. Squatting is out of the question for me but I was to the point where I couldn't even leg press because of it.

Gonna give this a try and see if it helps. Appreciate you sharing this brother.
If you want to pm me some details on what the pain feels like, where it is, at what point in the squat and leg press it happens I would be happy to help you try and figure this one out Nitro
 
Nitro

Nitro

Senior Member
Nov 19, 2014
123
0
#12
If you want to pm me some details on what the pain feels like, where it is, at what point in the squat and leg press it happens I would be happy to help you try and figure this one out Nitro
Absolutely brother, that would be great! I have an MRI and my chiro says its just some mild arthritis and even though it has gotten a little better it still limits me on leg days.

Thanks!!
 
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