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