Five years of hip impingement pain: sorting causes from compensation

You're listening to the Restoring Human Movement podcast, where movement experts discuss the latest evidence-based practices to help you and your clients move with mastery. Hey everybody, it's your co-host Sebastian with the Restoring Human Movement podcast. Thanks for joining the show. Today I wanted to do an email about lower back pain and trail running, somebody seeking some guidance. So what I decided to do rather than affect anybody's privacy is I actually asked AI to create an email about what they have found in the internet to be common questions and concerns associated to this problem.

So I'm going to answer AI today and let it know what I think it should possibly do. So I'm writing to you in hopes that you can offer some insight into persistent problems on my right hip. For about five years now, I've had impingement feelings during squats, even bodyweight ones. This is escalating, it's been escalating for the past six to 12 months to the point where I'm having to give up a lot of activities that I love. I really, it's really impacted my lifestyle here. I'm finding it hard for us to go on runs, play pickup basketball, and even hike in the mountains, which is a real bummer since I love being outdoors.

And to be honest, it's affecting certain intimate moments as well. Plus, I'm having to skip out on surfing and skiing, which is a huge part of my life. Left hip is totally fine, but the right one feels like it's tight, sore, and generally off, almost like something's not aligned. It's not sharp, it's dull, that kicks in later, usually in my hip and groin region. It used to radiate further, but I've been working on my adductors, which have been super tight, and that's helped a lot. It used to radiate into the testicle region. I still get discomfort in my SI joint and lower abs, and this hip snap.

And the hip snaps, when I move a certain way, sitting for long periods, like at work or driving up in the mountains, really sets it off. It's a complex area, and honestly, not sure what's going on. I'm hoping it's just tight muscles, maybe tight psoas or abductors, but I'm worried it could be a labral tear or something serious. Any advice you give would be helpful. Okay, so let's just suggest a couple things down here. Number one is, it's hard to tell exactly what's going on unless we do a physical exam on this person, but we do get a lot of information from a good detailed history. And so, taking a history and asking secondary questions for this person can be helpful, like, does the popping hurt?

When it feels like the hip clicks, does that also hurt or does it feel better? Usually, labral tears or labral pathology is associated to not just clicking and popping, painful clicking and popping. And if it duplicates the symptoms that we're talking about, then it could be a big part of it. But labral tears oftentimes have a lot of either a longer history of hip problems, like this person, like, they've had it for a long time, so maybe they are correct with a non-traumatic labrum. And usually, hip impingement could, they say, could lead to labral tears, just from, like, wear on the cartilage.

If you guys don't know what a labral tear is, a labrum is the cartilaginous gasket in the hip, which helps to center the hip, they say. And it could have some tears or frays in it. Interestingly, though, I don't know if you guys know, that hip labral tears don't always hurt. There was a great study that they did on some NHL hockey players a few years back, and they took asymptomatic people, so people who did not have any pain, imaged them, and saw that I think the number was, like, two-thirds of the hockey players, so over half, had labral tears found in an MRI. So, it begs the question, more than half of them, it didn't hurt, there's a labral tear there, does it relate, you know?

Now, the person later can have pain, and then you'd see the labral tear, and they'd say, ah, it's a labral tear. But, again, painful clicking and popping. Just because the person is using their hip a lot, and they have impingement, doesn't mean they're always going to have pain either. And we've had plenty of people who have been told they're going to need a hip replacement by the age of 30, and especially the dancing population, because they have dysplasia and stuff like that, and it's pretty wrong. A lot of them end up getting a lot better once we figure out how to rehab and change their lifestyle a little bit.

So, I can tell you, though, from this person, like, they have, usually what we look for is a pattern. We look to see, is there something which is common or similar amongst the activities they can't do, or at least as a general theme. So, usually with hip impingement cases, it's squatting patterns. So, if the person can squat all the way down and be in a passive, kind of non-loaded, non-effortful, deep squat position, like if you were going to go down and just, like, play around on the ground with some toys, then that would be a non-loaded squat position. If this hurts still, yeah, hip impingement, labral tears, things like that would be kind of on the list.

Bringing the knee to the chest, even when supine or face-up, can be a hind list as well. But if it's not painful to do, it usually is not going to be one of those two things. Now, I've had a lot of questions over the years about hip impingement. And we can't really talk about labral tears unless we talk about hip impingement, because the mechanics are typically the same and less traumatic. But the hip impingement is usually associated, it's mechanical. It's mechanical in most scenarios. Yeah, it can be structural. So, there's cam and pincer and mixed ones and so on. But also, the mechanics of your pelvis have a lot to do with it.

There's been radiology studies over the years that show that actually a posterior tilt increases the amount of hip flexion or range of motion you have, even in internal rotation, when you allow a posterior tilt as opposed to an anterior tilt. The anterior tilt reduces the amount of range that it has. So, if you have an anterior tilt or a lumbar spine that kind of sway back in your squat position like you're super attentive, it tends to hurt. Now, if you do an unloaded one and it doesn't hurt, yeah, you can still have hip impingement. But now we have a posterior tilted spine, or sorry, posterior tilted pelvis, a rounded spine, which allows for more room in the hip socket.

It didn't change your anatomy. You still have cam or pincer. But in this case, it becomes non-symptomatic just by how we're changing loading patterns. Now, this person has pain during squatting, even body weight ones. But again, we need to identify, is the range passively, is it painful or not? So, they've had it for a long time, though. They've had eight years of it. Now, I tend to tell people, realistic expectations-wise, like, if you've had pain in a region in the past, you're going to have it again. And that's not to scare anybody, and it's not to make them feel defeated. It's actually to empower them.

So, if you've had hip pain in the past, and you knew the warning signs of what it was going to look like when it starts to maybe come about, and you can do something about it, yet still keep active, does that make you feel defeated, or does it make you feel empowered? For me, if I knew the signs of about to rain, I looked outside, I saw clouds starting to form, I would kind of want to know that so I can just get my rain jacket. No big deal. It's raining today. My hip hurts a little bit, but I can do something about it. And so, if you're more educated about it and see warning signs, like your time spent in a rest phase when you have the injury or being scared of movement really goes down.

But it doesn't stop the re-onset. The onset is associated mainly to risk factors. Are they picking the correct exercises? Are they only squatting? Are they only lunging and squatting, and they're not doing any hip-dominant exercises? Are they sitting a lot at work? Do they sit 80 hours a week? Those are all factors that could really play into this. I saw someone recently that we talked about his hip impingement, and we found that in a squat assessment, we could see that he was putting body weight into his left hip, which was the symptom hip. It created a pinching feeling. And we talked about, does it make any logical sense?

If you have pain on that hip, why is your body putting more weight onto it? And he's like, I don't know. And then we start talking about his other leg. And his other ankle, his right ankle, his opposite ankle, had a long, long history, a big highlight reel of injuries, which was never fully rehabbed. And we found out that it actually had movement limitations, which pushed him onto the symptomatic side when that right ankle terminated range, and he couldn't get any lower or use it, so he pushed over to the other side. So in that case, his injury is a manifestation of an older injury, which is dictating how he moves.

So for all we know, this person has an eight-year history because of something even older, like something on the opposite limb, which is a part of it. Now, what we can do in a scenario like that is we can address these risk factors. Can we decrease the amount of loading into that right side by decreasing the amount of, I guess it was left side, let's say opposite side. Can we decrease the amount of loading onto the symptomatic hip by increasing the amount of range in the other ankle? Maybe the other ankle is weak, and the range of motion is not really limited, but it's weak and it's not bearing its weight, it's not doing its job.

In that case, maybe we strengthen that ankle or foot. Maybe he has stiffness in other areas of the body that we can address that aren't really painful. So those are ways that we can address risk factors is finding an area that doesn't hurt, it doesn't move, or it doesn't work well, and restoring function to those, if possible, to take the workload off of the area so it stops returning over the course of all these years and years. Now, we can also look at, again, exercise selection. Are they doing an exercise over and over again, which is provoking the issue? If they're married to the idea of squatting, then that may increase it.

But other types of squats, goblet squats, split squats, reverse lunges, barbell squats, sissy squats, all these ones are different ones where you can challenge different parts of the quad in a squat pattern, but also not provoke the hip. So it really depends. Now, again, we're looking for this pattern here. So we see that hip flexion bothers them because it's a squat pattern, body weight or not, body weight or more, rather. And we see that running, that's an extension pattern, hip extension pattern, but also hip flexion, pickleball, or sorry, pickup basketball, that's the extension pattern, hiking extension pattern.

Usually intimacy is extension pattern, especially based upon the positioning trend. But if it's man on bottom, it could be more reflection pattern, but it's usually more of an extension pattern, like, like, so it's like thrusting, right? Surfing extension pattern. So there's a lot of extension patterns here, which make me believe that this may be more of an issue with pelvic position than just only, just only the, the cam or the pincer. So to me, this looks more like a hip impingement case, but how to, to, to manage it is to be determined. But I think a common question comes up here is that there's a lot of other things going on.

There's the adductor, there's the tightness of the adductor, there's the tightness of the hip flexors, there's the TFL, there's the SI joint hurts, the back hurts a little bit. So all these things are, they're all in a relationship. They're all the same thing. I'm not going to say that we have to treat and diagnose each and every one, but each one of them is trying to pick up slack for what's going on. Like, how can you really expect a hip flexor to be happy in a scenario where the hip is stiff? How can you expect the SI joint of the pelvis to work well if there's poor strength in the hip? So all this low back, pelvis, hip, and even down into the knee, foot, ankle, like that's all in a relationship.

We call it interplay. And so they have coupled movements based upon each other. Like if you extend the hip, like if you're going to run and it doesn't extend, it'll just extend your low back and anterior tilt, your pelvis. So that is all coupled movement. And you have to make sure that all of it is restored if there's any deficiencies. So what I would look at is I would assess the low back, I would assess the pelvis, the hip, and I would assess your ability to do like a single leg pattern, like a lunge or like just even a balance test. I would look to see, are they able to hip hinge well with and without weight?

I'd like to see what their squatting is and see if they're doing any odd movement patterns in the squat. In that case, I'll just coach them out of that. And I'd like to see what their core routine looks like. So I think there, but realistic expectations again with this is it'll probably return, but I usually think that good management really comes down to sending the person up for success and able to manage it on their own and knowing that they can do things like running and hiking and stuff like this. If they have a good base, they need to make sure they haven't been out for like six months and all of a sudden jump in and play five basketball games.

Like there's an ordered process and a strategy to reintegrate back into running and basketball and all these types of things without having re-injury in other areas or aggravating that one area again and then being frustrated about it, keep coming back. So we call this pushing the functional envelope. A lot of strength trainers know it. A lot of physical therapists know it, but we're basically setting the person up for success by strategically loading them and making sure they have the assets they need to actually accomplish the sport in the amount of volume or times a week that they want to do it, but well, so, but I would not get distracted by this SI joint, lower abs, adductors, all the type of stuff.

Like if you get a good exam done, like it'll, it'll show you what the main cause is and all the other stuff is just, is compensation collateral. Like you don't need to get all these different things worked on and diagnosed most of the time. It's super common for people with hip stuff to feel their SI joint and lower abs and adductors. And the testicle thing is typically something associated to some nerve involvement. So we know that there's some nerve involvement possibly in here, or we've met people who have actually have inguinal hernias who have sometimes have the testicular involvement. But you need to be examined for that as well.

Like usually there's a mass involved and stuff like that. So again, this is not intended to be medical advice for you guys. So I want you to be checked out and just know that you'll, you'll, you'll save a lot of time money if you just get checked out. Like essentially a good healthcare provider on your team for a lifetime is worth your weight in gold. And they're basically a cheat code to getting to where you want to go faster than self-help or YouTube videos and stuff like that. So be responsible, make sure to take care, to take care of yourself. And if you guys are looking for the webinar that we did on this, I think it's a good starting point to understand like what hips are like in certain categories.

It'll expand on some of the things that I talked about today. Also too, we have something called a discovery session, which is a very reasonably priced consultation that we do. We have telehealth and or virtual options. We also have in person and we're licensed in different states. So you'd be surprised the amount of people that we, we can see medically in different states as well. So give us a ring and all of our contact is in the description for the podcast. See you next time.