Running with hip impingement: what it is and how to rehab it

You're listening to the Restoring Human Movement podcast. Thanks for joining the movement, movement. I'm Sebastian Gonzales, show curator and head clinician at Performance Play Sports Care in Southern California. This show's for active people, those who refuse to let pain and injury get in the way of their life and how they want to live it. Trails and trips, fields and courts, whatever moves you. Each episode features rotating host, expert guest, and real clinical conversations that help you move better and trust your body again. Here we go. Today we're covering hip impingement, and this is a condition that a lot of our runners, hikers, outdoor enthusiasts suffer from, and they have groin pain in the front crease of the hip.

I'm going to be covering what it is today, different facts about it. I think there's a lot of misinformation out there about it, unfortunately, so I'll try to clean some of that up for you. And I'm going to cover three of the questions that we see commonly from some of the clients that we work with here at Performance Place. So I'll start first by saying hip impingement is something that definitely you could improve from. You don't have to suffer from it. You don't have to get a surgery from it most of the time. But a lot of the misinformation out there will lead you into being inactive and also thinking that you'll need surgery for this.

What it is is basically an impingement point. There's a condition similar in the shoulder called shoulder impingement. It's where this one in the hip is where two areas are said to impinge and impact on each other, creating like a punch point in the front part of the hip, in the crease of the hip. Special note that if you have pain in the back of the hip or in the side of the hip, like where your hip pocket is, most of the time this is not hip impingement, but there can be aspects of it which are affecting those areas too. But for the most part, it's usually front crease of hip, sometimes extended a little bit down into the thigh as it starts to refer.

It certainly doesn't go into the back, although the back issues can be associated to this since poor functioning of the hip can lead to back issues and knee ones as well. The most common one that we see here is called cam deformity. A cam deformity is where the ball of the hip joint is no longer a ball, it's an egg shape. This is something that people tend to develop when they're active younger individuals, like when they're active when they're 15 years old and they're still celiacially maturing, which kind of leads us into begging the question of if you've had it since you're 15 and you're 40 or 50 years old now, why is this a problem now?

You know, I'm a believer that you can survive with an oblong shaped femoral head. I don't think you need to necessarily go down and shave that part down. Now, if you have a large amount of bony obstruction due to advanced osteoarthritis, this is a whole different conversation and a whole different podcast. But if it's just bony obstruction or, sorry, I don't want to say bony obstruction this because it's not completely accurate. If you have an oblong shaped femur and you have a cam deformity, do not worry. Usually rehabilitation and knowing exactly what to do can get you out of the weeds with this thing.

The other type that we see is called pincer. Pincer is where the socket of the hip now has some overgrowth, which is called the pincer. And even if you have a normal shaped femur head, this obstruction on top, the pincer deformity then can create some impingement into the front part of the hip as well. And then there's mix. Some people have a little bit of both. Now, it's thought that impingement will lead to arthritic change or labral tears. I don't know if there's 100% association to that, so I don't want to say that's necessarily true. But I can see how there is ongoing pain in a hip either due to hip impingement or even things like overactive hip flexors or bursitis, et cetera, that can lead the person into deconditioning the hip, changing its mechanics, having compensated movement, and then that would then lead to those other things that I just mentioned.

But it's not 100% accurate to say that one will lead to another. I don't believe at this point. I don't think that's what the literature is leading us to believe. Now, a lot of people with this will have pain into the front crease of the hip. It'll get worse with usually rolling around in bed, getting in and out of cars, sit-ups, crunches tend to bother it, deep squats with or without weight, sometimes sitting on a toilet. Walking can sometimes be painful. Jogging can be as well. Sprinting sometimes is. But as you notice, I'm saying sometimes because everybody is quite a bit different with how much they have problems with one activity versus another.

But it seems like one thing that is a very big commonality is the deep squatting position. Whether you're deep squatting with support, with your hands on a table, if you're doing a goblet squat, if you're back squatting, or if you're even doing that knee-to-chest stretch that some people do for their back, those are pretty big commonalities that bother people, especially as the knee, knee of the hip that's involved, comes up towards the face and goes across the nose line, which is cross-body type of position. This actually simulates some of our positive orthopedic tests that we do called Fadir's test and Scour's test.

These tests are ones that are most of the time pretty painful and positive on people with hip impingement. Sitting time is something that tends to increase the probability of somebody having it. So imagine somebody who is a tech worker, they work a nine-to-five or they do 40-50 hours a week and then they like to go run or jog on the weekend. Like this person is probably doing, in my opinion, they're doing a lot of sitting and so maybe a simple thing to do is them just doing the opposite of what their sitting position does to their hip. So they could just do hip stretches, like hip extension stretches.

Now, will this work for everybody? Probably not. But just exposing the hip to some movements other than the things that it has been doing can be very valuable. And it can be a simple way to pump the joint and make it so its mechanics are working a little bit better in the early stages of recovery. All those stretches where people are doing where they're crossing their hip across their face and stretching their piriformis and so on. I observed that that basically duplicates the mechanism that bothers them. It duplicates a lot of the positive testing, like Fadir's test and scours. So I would usually have them not do that for a short period of time.

Now for a quick pause before we keep going. Hey everybody, it's Sebastian. If what we've been describing in the show so far sounds very familiar and you've been dealing with some ache, pain, or stiffness that keeps coming back no matter what you do and no matter what you try. We're offering a free discovery call today where we brainstorm with you what has been working for you, what hasn't been working, and we also try to unravel what is a critical part of the puzzle that you've actually been missing that's keeping you from full recovery and getting back to full activity. The link's in the description.

It only takes a few minutes to fill out the form. Okay, back to the show. The third thing is that should they, is there anything to do, what should they be doing if they've tried everything? I would really take a look in the mirror and see if you could narrow down the things that you've tried honestly. Some people, I need to have a really good heart-to-heart talk about if they've really given certain things a good chance. I've talked to so many people with this condition and we've seen so many people with our telehealth services as well that they say, oh, I've tried everything and say, well, what have you tried?

And they said, well, I looked on YouTube and I did some stretches and that didn't help. And then so, I ended up going to a doctor and they told me to rest and I did about three weeks and that didn't help. And so then, I went to go to a professional massage therapist and we tried about three sessions and that didn't help. And so, what I've noticed is that a lot of these people will, they won't necessarily do the correct dosage of some of the things. Like, for example, like, I'm not promoting massage therapy for this by any means, but I'm just giving an example. So, if somebody had been suggested the massage therapy to improve their condition or their pain, at least with pain management, and they were told to try it for about three weeks, did they actually do it those three weeks or did they just do a couple times?

I know in our industry, strength training is a very helpful thing with hip impingement. And if you only did resistance training and no other form of real pain management with it, like no stretching, no tissue work, anything else like that or no mobilizations of different parts of the body, it would probably take about six weeks or so to really have a good benefit with it. And some people say, oh, I tried that. Well, so what did you try? I tried strength training. Well, how long did you give it? I gave it like two weeks and then, yeah, I just, I stopped. Well, you didn't really try everything. Like, you tried, you tried some things to an inadequate dosage and other things you've tried are just passive in nature.

When you look in the mirror, you write things down, I want you to think about what each of these things, these treatments that you've tried, what they do for you and if they solve a, what we call a needs analysis. And so a needs analysis is where we've identified a possible risk factor. So there's risk factors that will increase your probability of having a condition and then there's habits that you can do that will decrease your probability of having that condition. So for example, if I took up smoking, my probability or my risk profile of getting lung cancer is higher, but I also know that there's habits that I can partake in that won't really increase my risk of having lung cancer and in fact, it may actually decrease it, but it's just a good habit like eating well, going on walks, sleeping well.

Like these are all things that can help with longevity, decrease in chance of morbidities or cause of the death and so on. And then so we can do similar things with problems like hip impingement. So we know that people with hip impingement who are sedentary tend to have a higher risk profile. So did you try a spurt of walking? Are you hitting 10,000 steps a day? So if you're trying quote everything, but they're just passive in nature, like someone's rubbing on your hip or someone's stretching you or you're stretching yourself and you're taking rest like, but you're not really hitting your 10,000 steps in a day, like you're, you're missing easy wins there.

Also, resistance training is a great thing to decrease your probability too. Resistance training and that can be, strength training is number one priority with it and how you do the resistance training matters. It can matter quite a bit, especially in the later stages of things. In the beginning, you just kind of go out and you try things that aren't painful to do but are hard. This decreases your risk profile of many different musculoskeletal disorders, including hip impingement. So when you are looking at the things that you've tried, say an injection, say soft tissue work, medications, stretching, and so on, are these things solving that risk profile issue?

So if you have not tried things to decrease your risk profile, you need to make sure you've done some passive care, which is going to be some of your things that I just mentioned. Something to help you manage pain to make you feel comfortable that you're going to get better because it can be a mental battle. I understand that. And number two is you need to do something to support the area. It has a longer term payoff, such as resistance training, taking 10,000 steps a day, getting some of your cardio in by any means possible. These are things that are going to be unique to the person in front of me.

And if that person already has met those needs, I don't need to suggest that they do more of it. And I hope you guys understand that, that, again, each person's problem is slightly different. Their risk profile is different. Their needs analysis is different. And for that reason, the assessment that tells us the lack of activity they're doing gives us better insight of what to suggest to them. I know, for example, people who say they've tried physical therapy, they say, ah, I've tried that already. I did three months of it, which is actually, I'm surprised a lot of people actually do comply with the physical therapy recommendations for at least frequency.

They go, I went two to three times a week. What'd you do? Well, I got stretched out a little bit and I did some clamshells and then I got this sheet of paper and the sheet of paper told me to do clamshells and mini band walks and hip stretches and box squats and all these things, flutter kicks, dead bugs, boat pose, et cetera. And when I'm looking at that sheet, I see that all of these are not really high resistance training exercises. Like they're, they've done what they believe is, physical therapy, but actually in my opinion, good physical therapy becomes good resistance training protocols.

Like a clamshell essentially becomes a single leg hinge pattern because we know that a clamshell, it starts to get the glute medius muscle on, which helps out to some degree, but eventually that, that's an entry level exercise and then we need the glute max to work well. The glute max will help posteriorly tilt the pelvis and decrease the contact on the rims. Also, the ab wall is important in this too because it also kind of rolls the pelvis into a posterior pelvic tilt. The way we would do this is probably single leg deadlifts. That is the upper echelon of that physical therapy exercise. You should not be in this floor-based regress exercise purgatory forever.

If you feel like you've tried everything you possibly haven't. Most people that I meet have not really tried everything but they've tried everything to the best of their knowledge. There's a gap in their understanding and they're getting frustrated because they don't want to go do the same things again. They feel like they've tried them and they feel like there's no hope for them but it's because they haven't been presented these alternative options.