In part I of our series on hip impingement, we discussed key themes for initial management with runners. If you have not had a chance to read that post yet, check it out HERE.
After we have removed the aggravating positions or movements, and began challenging the hip with more “hip-friendly” exercise variations, we want to expand on the ways we are challenging the hip musculature. The hip joint is responsible for a wide array of movements in athletics. With running, the hip range requirements are much less then sports such as gymnastics. However, our body has to be able to manage many different hip motions to run.
The video below shows a few of the different motions the hip joint is responsible for. As previously discussed, isolated motion solely at the hip does not occur with running, but is more combined motion between the hip, pelvis and lumbar spine. This video also displays how actively isolating pure motion at the hip, as opposed to combined motion of the lumbopelvic complex, is challenging.
RESTORING HIP MOTION FOR RUNNERS
It is well published in the literature that patients with symptomatic FAI display decreased hip extension ROM with day to day activities. Often, this is assumed to be due to a loss of actual joint or soft tissue range/extensibility. However, research tells us that even though the ROM might be less, patients with FAI do not actually have less available ROM in their body. They are simply using less of that motion. This is a sensitivity issue, not a mobility/flexibility issue. This changes how we approach getting patients back to the ROM requirements of their sports. We should not be approaching this from a “I need to lengthen tissue” standpoint, it should be a “Let’s get them comfortable using different hip positions and movements”.
When we go to program exercises for runners, it can’t be emphasized enough that the focus is on dynamic extension of both the hip and pelvis (anterior pelvic tilt) together. When our leg progresses behind us, our pelvis will dip forward and we should be allowing that with the exercises we program.
When dealing with many low back, or lower extremity injuries, many people are told that anteriorly tilting their pelvis is a bad thing and some underlying flexibility or stability issue needs to be resolved for their problem to be cured.
With running, the pelvis HAS to move with the hip joint. The idea of an anterior pelvic tilt with running is often vilified, but it is a motion that is necessary for us to progress our leg behind us and propel our body forward. We should not be focusing on isolating one versus the other because they move together with running.
Here are drills I like to use to promote dynamic, pain-free hip extension. I will incorporate these during the warm-up section of a workout prior to beginning the strengthening drills we will discuss later in the article. Keep the repetitions low as the goal here is to improve tolerance to the position, not further irritate the hip.
Comprehensive Hip Warm Up
Complete 2 sets of 5 reps on each exercise
As discussed in Part I of this series, hip flexion is often painful for runners dealing with FAI. Because of this, training hip flexion is often left out of most rehab protocols as it is a movement that can elicit pain. In the previous drills, when we are working on hip extension, the opposite hip is going through hip flexion and posterior pelvic tilt. We have already begun improving the runner’s ability to tolerate and maintain these positions as we work on restoring extension. Now our focus should be on building capacity of the hip flexor group.
Being able to create force into hip flexion is important for any runner, especially when we are talking about performance. Our focus with the drills listed below is to building up the abilities of the hip flexors while slowly working into more hip flexion. These drills are broken into three levels based on level of difficulty placed.
Level I Drills
Level II Drills
Level III Drills
Comprehensive Loading Drills for the Hip
As much as we view running as a sagittal plane sport, the actual kinematics of the sport are much more varied. The hip joint has to undergo motion in all three cardinal planes during running. Because of this, we want to challenge the hip complex in with various contraction types, force vectors and loading strategies. We want to build up the abilities of the hip with all motions.
Hip Internal/External Rotation
Once runners have mastered the principles and drills discussed above, we then can begin progressively returning them to running and making sure their running mechanics, and training plan, will put them in the best possible position to return to full sport participation. In our next post, we will cover gait assessment, training plan construction and strength training principles for runners with hip impingement. Thanks for reading!
Nathan Carlson PT, USATF
Part II: Loading Progressions
Part III: Plyometrics, Training Progression and Running Mechanics
Part IV: Long-term prevention, Strength Training and Drills
Griffin DR, et al. Br J Sports Med 2016;50:1169–1176. doi:10.1136/bjsports-2016-096743
Schache A, Blanch P, Murphy A.Relation of anterior pelvic tilt during running to clinical and kinematic measures of hip extension Br J Sports Med 2000;34:279–283
Neumann D. Kinesiology of the Hip: A Focus on Muscular Actions. JOSPT Feb 2010; 40: 82-94.
King MG, et al. Br J Sports Med 2018;0:1–16. doi:10.1136/bjsports-2017-097839