You’ve been diligently pursuing a new goal for weeks and it seems within grasp when BAM, your training becomes plagued by hip pain and your range of motion seems limited. You can’t remember a specific occurrence when you may have injured your hip, but suddenly it seems as though any movement can cause the most agonizing of pain. What gives?
You may have what is known a Femoral Acetabular Impingement of the hip joint.
In a normal hip, the head of the femur is rounded and it glides smoothly in the hip socket. With FAI, structural abnormalities can lead to pain.
There are three types:
Cam- The head of the femur is misshapen as in not perfectly spherical. Any bumpy protrusion can lead to a tear in the labrum, or cartilage, in hip.
Pincer- The rim of hip socket is abnormally shaped. Usually this presents as the rim being extended so that it makes contact with the femoral neck rather than allowing it to move smoothly in the joint.
Cam-Pincer– This is most typically seen in teenage boys. In this type of FAI, both the cam abnormality and the pincer abnormality are present.
Someone with FAI would describe it as deep pain, often cupping their hip to show the location while emphasizing the discomfort in the interior of the hip towards the groin. Every day movements like bending over to tie one’s shoe, crossing one’s legs, or getting out of the car can aggravate this condition. In athletes who are experiencing FAI, deep squats, pivoting, jumping movements, and some stretches pose a problem. The pain is significant enough to restrict some athletes from training and sports.
If a medical doctor or a doctor of physical therapy were to diagnose you with FAI, the prognosis wouldn’t be the end game for your athletic career. Though the structure of the hip joint can not be modified (unless surgery is performed, though it’s not always necessary), people with FAI are usually able to regain mobility and return to sport after adding corrective exercises to their routines.
The article titled “Training Considerations for Individuals with Femoral Acetabular Impingement” found within Volume 37, Number 3 of the June 2015 edition of Strength and Conditioning Journal states that, “Irrespective of the architectural changes present in the diagnosis itself, individuals with FAI are encouraged to participate in safe and pain-free exercise as a means of mitigating impairments and pursuing fitness attributes” (35).
It is only possible to diagnose an FAI by looking at an X-Ray, but a physical therapist can treat you for FAI if you test positive when they check the five pain provocative positions. This test is known as the “FADIR” test and it looks at flexion, adduction, and internal rotation of the hip as well as alignment of the lower extremity during squatting.
We spoke to Dr. Jordan August of Benedetto Sports Orthopedics in Elmwood Park, NJ to find out how someone with FAI would be able to return to training and resume full activity.
Dr. August explains that, ” A person with FAI should focus on strengthening hip external rotators, hip extensors, and abductors which all work to provide dynamic stability during activity such as squatting and jumping. Strengthening all three will enable the athlete to recruit the muscles necessary to maintain proper form during movements and avoid undesirable positions that exacerbate FAI pain.”
Many physical therapists suggest their patients do what is known as “clam shells” to help strengthen these areas, but according to Dr. August, there are other effective exercises that recruit a greater percentage of both the gluteus medius and the gluteous maximus.
For his patients, Dr. August prescribes:
Side Plank Abduction with the Dominant Leg Down- Slowly lift and lower the top leg while focusing on the glute muscles. Be sure to stay in position rather than “rolling back” and out of a neutral alignment. Repeat 10 times.
Front Plank Hip Extension- Assume a plank position, bend one knee ninety degrees. Then, squeeze the glutes and extend the hip past the neutral position towards the ceiling. Repeat 10 times.
Band Walks- Place band just above the knees at the bottom of the quads. Maintain the position of knees out wide, never letting them cave in while taking steps sideways. Start position is hip width apart, step is shoulder width, and then back to hip width. Repeat for 20 steps.
He explains that they are the “gold standard exercises but I wouldn’t necessarily have a patient do this day one. For instance, an athlete who is quad dominant might need to work on neuromuscular activation first so that they would know how to contract these muscles.” Without the understanding of how to recruit the hip external rotators, hip extensors, and hip abductors, athletes will compensate by using other muscle groups to perform the exercise and it becomes ineffective.
To address this, August subscribes to the philosophy of Christopher M. Powers, founder and owner of the Movement Performance Institute in Los Angeles who believes that muscle recruitment must be taught by doing static holds first. August agrees explaining that his “patients start with sustained holds of exercises for two minutes first. This is because static holds takes more concentration and control to maintain good form which increases cortical-motor activity.”
A good physical therapist might start with the basic clam shell in order to teach muscle recruitment and would utilize increasingly difficult bands around the legs to acclimate the patient over a period of a few weeks before moving on to the “gold standard” exercises. Those would begin as non-weight bearing activities, but bands and weights can be added over time as improvement in strength and mobility is seen.
Also, until pain subsides, patients should avoid deep squats, internal rotation of the hips, and hip adduction.
Once the muscles surrounding the hip regain strength and the pelvis is in alignment, a person with FAI will typically find that they are able to return to sport.
If this sounds like what you or your athlete is experiencing, find a physical therapist who can diagnose your symptoms and start you on a plan that will help you to return to athletics.