In the first two parts of this series, we discussed the initial management of runners with FAI and how to progress back to exercise. You can read those HERE and HERE. Once a runner is up and moving, we advance them back to running.
We want to remind ourselves that hip impingement tends not to like excessive ranges of motion, which helps us figure out how to build up their running volume. Three key ideas to remember are that inclines and faster running requires more hip flexion and dynamic valgus positions place increased load on the hip joint.
REINTRODUCING HIP FLEXION WITH RUNNING
Hip flexion or “swing phase” is when most runners will feel their symptoms. With that in mind, I tend to progress running in this fashion.
Conversational pace running
Easy running + strides
Tempo running
Inclines
Intervals
Sprinting
Methodically progressing in this order gradually reintroduces greater hip flexion range of motion.
ANTERIOR PELVIC TILT AND HIP FLEXION
In the last post of this series, I talked about how anteriorly tilting our pelvis is normal, expected, and essential. Hip impingement is one condition where making a short-term change in pelvic position is helpful.
“Level” or “Neutral” Pelvis
Anteriorly tilted pelvis = More hip flexion
When we tilt our pelvis forward, we place our hip in more relative hip flexion. Teaching a runner to be tall is a helpful tip to give them more “wiggle room” into hip flexion by changing the relationship between the hips, pelvis, and lumbar spine. This is NOT 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, let’s put them in drills that condition them in that position.
DRILLS FOR UPRIGHT POSTURE
Marching HOH
DYNAMIC VALGUS
I remember discussing dynamic valgus early in my orthopedic classwork during PT school. The typical approach to this movement is assuming if someone has a lot of weakness in their hip, they will display faulty movement at the pelvis, hip, knee, and foot. We like to associate this pattern with whatever hurts in a patient’s lower extremity.
The faulty movement is the cause of the pain.
I think this is the wrong approach. Dynamic movement is not something we can relate to someone’s strength or flexibility assessed by orthopedic or movement screening. There are lots of runners with dynamic valgus that do not have pain. Read this article HERE.
Managing dynamic valgus in runners
Similar to pelvic position, changing dynamic valgus can be helpful because it will stress the hip differently. We know this position places more stress on the hip joint, so let’s stress it the least amount needed in the early stages of running. The easiest way to counteract dynamic valgus is to get in and out of the position faster.
Increasing a runner’s cadence
Cadence manipulation is the most common gait modification I use for runners with many different ailments. It is an easy adjustment if a runner comes in with a step rate of 160-170 steps per minute.
Heiderscheit et al found “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.”
That article prescribed running at 10% greater step rate than normal.
Increasing someone’s step rate places the hip under load for a shorter period. Runners take thousands of steps on a training run so decreasing the cumulative effect of running can be helpful.
Learning from my mistakes
I’ve been guilty of many of these mistakes with my patients.
Assuming I can isolate specific weak/tight muscles based on dynamic movement such as running?
Guilty.
Assuming gait changes must be permanent to succeed?
Guilty.
Thinking my strength and flexibility assessment will tell me how someone runs?
Guilty.
The way I manage FAI patients has evolved and will continue to evolve through my career. If it doesn’t, I’m being complacent. Hopefully, this article series has given you some new strategies for managing this condition. If you found this helpful, be sure to sign up for my newsletter below, and check out the next post in this series on how to manage FAI long-term.
Nathan Carlson
Part I: Initial Management of FAI in Runners
Part III: Plyometrics, Training Progression, and Running Mechanics
Part IV: Long-term prevention, Strength Training, and Drills
References
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.