In the first two parts of this series, we discussed initial management of runners with FAI and how to progress them back to exercise. You can read those HERE and HERE. Now that we have the runner up and moving, and hopefully feeling better, we shift our focus to progressing them into actual running.
We want to remind ourselves that hip impingement tends to not like exaggerated ranges of motion, which helps us figure out how to build up their running volume. The three things I am mindful of are that managing hills requires more hip flexion, faster running requires more hip flexion and dynamic valgus positions place increased load on the hip joint.
REINTRODUCING HIP FLEXION WITH RUNNING
Not a lot of hip flexion is required during the running gait, but that motion if often the portion of the running gait where runners will feel their symptoms. This is different from almost every other running related injury where pain is reported when your foot is on the ground. With that in mind, I tend to progress running in this fashion.
Conversational pace running
Easy running + strides
Progressing in this order slowly takes the runner into greater levels of hip flexion. The idea is we are slowly increasing demand on the hip while always evaluating the individual response.
ANTERIOR PELVIC TILT AND HIP FLEXION
I talked in the last post of this series about how anteriorly tilting our pelvis while running is normal, and essential, for allowing our leg to progress behind us. With that being said, hip impingement is one condition where it might be appropriate to make a short term change in pelvic position.
"Level" or "Neutral" Pelvis
Anteriorly tilted pelvis = More hip flexion
When we tilt our pelvis forward, we are placing our hip in more relative hip flexion as shown above. Because of this, teaching runner to be tall, especially as they run faster and manage inclines, is an important consideration because it will give them more "wiggle room" into hip flexion by changing the position of their lumbar spine and pelvis. This does not have to be a PERMANENT change. Long term, many runners will resume their previous mechanics while remaining pain free. It's simply another option we can choose to put them in the best possible situation for returning to training.
So, how do we change this?
Instead of just yelling at a runner to keep their pelvis level. Lets put them in drills that condition them in that position.
DRILLS FOR UPRIGHT POSTURE
We can begin to teach runners to maintain this upright position, and put a little less stress on their hip, by building up their abilities to maintain upright positions.
Marching Dowel Overhead
Dynamic valgus is something I remember discussing early on in my orthopedic classwork during PT school. The idea is that if someone has a lot of weakness in their lateral hip, they will display increased lateral pelvic motion and other "bad" movements from the hip, knee, foot/ankle an so on. We then like to associate that with whatever hurts in a patients lower half. This movement = the cause of your pain.
I think this is the wrong approach. Dynamic movement is not something we can relate to someone's individual strength or flexibility assessed by orthopedic or movement screening and their are certainly a lot of runners with dynamic valgus that do not have pain. Read this article HERE.
Now that is not to say we should not strengthen someone's hip when dealing with hip pain. We want to condition the entire leg to be ready to deal with the demands of running.
Managing dynamic valgus in runners
Similar to pelvic position, changing dynamic valgus can be helpful because it will stress the hip in a different manner. We know this position places more stress on the hip joint so lets stress it the least amount we have to in the early stages of running. The most effective way I've found for managing dynamic valgus with hip impingement (or knee pain, achilles teninopathy, etc.) is to get them in and out of the position quicker.
You can get them strong as an ox and it probably won't change the way they run. Blaming one muscle, or even a group of muscles, for how a runner runs is just not helpful when returning them to training.
Increasing a runner's cadence
Cadence manipulation is the most common gait modification I use for runners with many different ailments. If a runner comes in with a step rate in the 160s, and maybe even 170s, it is an easy adjustment to load their body in a different manner.
Heiderscheit et al found that “it appears that running with a step rate greater than preferred reduces the biomechanical demands incurred by the hip in the frontal and transverse planes of motion, and therefore may be useful in the clinical management of running injuries involving the hip.”
This was running at 10% greater step rate than normal.
By increasing someones step rate, while keeping their speed the same, we are placing the hip under load for a shorter period of time. Since many runners will be taking thousands of steps when they run, we are decreasing the cumulative affect as they transition back to running.
I normally have them run with the Run Cadence app which can be found HERE.
Learning from my mistakes
Everything I have mentioned in this article, and in the previous article, I have been guilty of in the past.
Assuming I can isolate specific weak/tight muscles based off of dynamic movement such as running?
Assuming gait changes must be permanent to succeed?
Thinking my strength and flexibility assessment will tell me how someone runs?
Over time, the way I manage FAI patients has evolved and I hope it will continue to evolve over time. If it doesn't, I'm being complacent. Hopefully this article series has given you some new strategies for managing this condition.
Thanks for reading! The last part of our series on hip impingement will cover long term management strategies.
Part II: Loading Progressions
Part III: Plyometrics, Training Progression and Running Mechanics
Part IV: Long-term prevention, Strength Training and Drills
Effects of Step Rate Manipulation on Joint Mechanics during Running Bryan C. Heiderscheit1,2, Elizabeth S. Chumanov1, Max P. Michalski1, Christa M. Wille2, and Michael B. Ryan1 Med Sci Sports Exerc. 2011 February ; 43(2): 296–302
The Warwick Agreement. 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
Willy, Richard & Davis, Irene. (2011). The Effect of a Hip-Strengthening Program on Mechanics During Running and During a Single-Leg Squat. The Journal of orthopaedic and sports physical therapy. 41. 625-32. 10.2519/jospt.2011.3470.