Nick D’Amelio Exercise Physiologist
We all know someone who has experienced pain through their hips at some stage throughout their life. Whether it be from playing sports as a child, through pregnancy for some women or maybe pain has come on from sitting at a desk for too long over the years! Many may often ask the question, what is it that is actually causing my pain? Is it my muscles? Is it my bones? What can I do to decrease the pain? Don’t worry, in this blog we’ll explore two common types of hip pain that we see in the clinic and give some ideas on how an exercise-based approach can be used as a part of an overall management plan to help treat it.
Lateral hip pain
Pain and tenderness at the outside of the hip, often noticed during side-sleeping and weight-bearing activities such as walking, climbing stairs or getting out of a car, may be indicative of gluteus medius tendinopathy or lateral hip pain. Trochanteric bursitis (or inflammation of the hip bursa) is another commonly cited culprit for lateral hip pain however this has only been shown in a small percentage of patients to be causative and is often secondary to glute med tendinopathy.
The gluteal tendons attach the glute muscle to the thigh bone and aid in transferring load through the hip joint when we move our legs. Repetitive load during running and walking, or any sudden change in activity or biomechanics (think new footwear) can cause these tissues to become compromised resulting in irritation and pain. This can be especially apparent in positions where the tendon is compressed such as in a side-lying, cross-legged or in a seated position for prolonged periods. However, this pain doesn’t mean that those postures are bad but rather just that the tissues are unhappy and irritated in that position.
The aim of doing exercise to treat painful hips is to recondition the joint and surrounding structures to be able to progressively tolerate load in a more manageable way so that an adaptation occurs and normal activities can be resumed in a pain-free manner.
A good place to start your rehab for this condition is with isometric exercises that load the glute tendon or side of your hip. 3-5 sets of 20sec hold: 20sec rest is a good protocol to use and pain tolerance for these exercises should not exceed 2-3/10.
- Side lying straight single leg hover
- Standing single leg balance with theraband resisting abduction (your thigh being pulled inwards)
- Standing ‘running man’ stance with swiss ball between lateral hip and wall
- Double leg bridge with a band around the outside of the knees
These isometric exercises or holds are helpful in reducing pain and sensitivity to then be able to do more dynamic work that further challenge the hip.
As a progression, the above exercises can be done for repetitions of 15-20 as well as doing things like clams, step-up variations, lunges, side-lying footwork, side skaters and scooters on the reformer or slider.
Progressing further from these dynamic movements, we use exercises that integrate the whole kinetic chain such as the incorporating weights and bands with upper body movements into the previously mentioned exercises. E.g. a step up with a dumbbell bicep curl and press on the opposite arm or balancing on one leg doing a medicine ball wall throw.
Anterior hip pain/tightness
Hip flexor strains and hip flexor tightness or tension are commonly seen in the clinic and can benefit from exercises that appropriately load the hip flexors as we’ll see below.
The two major hip flexors; the Iliacus and Psoas, can be grouped together as the Illiopsoas and work to flex the hip which is important in most sports – particularly in running and cycling.
The tension or perceived tightness of these muscles is often blamed for causing anterior hip pain and associated dysfunction to the position of the pelvis. Hence everyone is told their hip flexors are too tight or overworked and that haven’t been doing enough stretching.
Whilst range of motion in the hips is important, continually stretching, releasing and needling these muscles in isolation is unlikely to provide any long term benefits to hip pain or tightness. Mobility exercises as a part of a general warm-up would in fact be better than static stretching to achieve requisite range of motion through the hips. Stretching and mobilising may provide some temporary relief or give a short-term improvement in pain that allows you to do more in your training but exercise rehab for this condition shouldn’t stop there.
Sports Physiotherapist Randall Cooper describes in his article ‘Exercises for Tight Hip Flexors’ how he uses the following to train the hip flexors instead of stretching them citing that “weak muscles get tight”. By improving the condition of these muscles with training they are less likely to pull up tight and sore or be prone to strain when they are required to work in training and everyday life.
Reverse Nordics (called Thigh Stretch in pilates) – in a kneeling position slowly lean backwards from the knees keeping your trunk in line with your thighs until you feel the quads and hip flexor region activating. This is a nice way to work the area in a lengthened position. In progressing difficulty try:
- 3 x 20sec holds
- 3 x 12 repetitions
- 3 x 12 holding a weight plate at the chest
Powerband hip flexion pull – lying on your back with arms to your side, have a power band around your ankle and on the other end fixed against a post, draw your ankle towards your chest so that you create tension on the band and in the front of your hip. To progress this exercise have the opposite foot on a swiss ball so that you use one leg in a straight leg bridge to work the opposite glute (like we do in cycling and running) whilst the other leg bends towards you to pull the band. Try 3×8 repetitions each side varying the hand position to increase or decrease the stability.
Additionally, pilates exercises such as dead bugs, which require good control of the lumbo-pelvic-hip complex are a great way to work the abdominals appropriately with the hip flexors. Another exercise we like to use for clients with this issue is a reverse lunge to knee drive assisted on a TRX or, as a progression, with the front foot on a small step.
In summary, the active strategies to treat hip pain are to:
- restore requisite range of motion;
- reduce pain and sensitivity using isometric exercises;
- address strength deficits in specific areas/muscle groups with dynamic exercise;
- integrate exercise that challenge the hip with the rest of the body i.e. kinetic chain;
- and, gradually get back to doing normal things i.e. MOVE THROUGH LIFE!