But there’s more to the story. The core is where we generate, absorb, and transfer forces to and from our extremities, which means we need to focus on stabilizing the connection between extremity and core. Enter the hip.

In this article, I shared knowledge that came from years of seminars, textbooks, mentorships, and trouble-shooting all kinds of injuries. I revealed that hip instability is the common thread of so many problems – from back pain to shin splints – and sub-par hip performance is far more common than you might think. But unless you’re in a serious state of denial, admitting that your hip isn’t working so well is not the hard part – fixing it is. So, let’s make this simple. I’m going to break fixing your hips down into five steps:

Step #1: Deep Tissue Mobility

I know, you expected strength and stability drills, but before you ask your muscles to work, you should probably make sure they are able to work. Foam rolling and lacrosse ball mobility drills have become all the rage, but while “everyone’s doing it” is a good enough reason to get most people on the bandwagon, understanding the purpose and value of these drills will help prioritize when and where you should spend time suffering through deep tissue mobility work.

When a muscle is tight, range of motion can be compromised. Lack of range of motion causes changes in movement patterns that limit quality of performance and ultimately create injury risk. A tight muscle is a weak muscle. An overstretched or long muscle is also a weak muscle. This conundrum is known as the length-tension relationship. In short, this rule says that a muscle must be at mid-length (or on a slight stretch, to be exact) to generate optimal force. If a muscle contracts by shortening, how can the muscle generate force if it is already shortened? This concept applies not only to overall length of muscles, but to isolated units within a muscle.

We know that several muscles play an intricate role in supporting the hip joint, but I’m going to play favorites and pick on the gluteus medius. Not just because it is notoriously tight, but because this is the most common source of breakdown I come across in the clinic. And the glut med is no job for a foam roller – too close for missiles, Mav, better switch to guns. Due to its smaller surface area, the lacrosse ball is the perfect tool to dig into the lateral hip and provide enough pressure to release the fibers. Spend a few minutes on each side, and consider your glutes ready for action.

Step #2: Isolated Strengthening

Turns out, there is a purpose for those wimpy isolation exercises that have been shunned by the fitness world in lieu of functional training. (Don’t worry – we’ll get to that, too.) After step one, you’ve smashed, mashed, and rolled your hip fibers into prime shape for work, and while they can now create a stronger contraction, they are clearly still weak. This second step is not a quick fix and requires some good old-fashioned hard work. Cue: targeted, remedial strengthening.

Before I step into the lion’s den by singling out some exercises, let’s get a few things straight. First, I have read many studies examining the best way to elicit hip muscle activity and there are a lot of conflicting results. Regardless of the exercise, a major factor in the effectiveness of targeting a specific muscle is cuing and awareness. In other words, if a person tries to squeeze their glutes during an activity, then the glutes are more active. Second, if a person has weak glutes, then pretty much any method of targeting glute strength will do, as anything is better than nothing. Lastly, anything is better than nothing also applies to compliance. If an athlete isn’t going to do the exercise then it’s not very effective, is it? So let’s keep it simple and easy to perform.

While this overview of hip strengthening methods is far from comprehensive, no list of lateral hip exercises would be complete without side-lying abduction. After all, this is the primary “action” of the glute med when the muscle fibers concentrically contract. Additionally, side planking is an excellent way to isometrically fire the glute med as the lateral hip muscles keep you off of the ground. Want to get fancy? Hold a side plank and perform abduction with the non-weight bearing leg.

Step #3: Functional Strengthening

Moving right along! Your glute med is now willing and able to work, so the important focus now becomes retraining this muscle to work functionally. In weight bearing, the glute med must fire to stabilize the pelvis, mainly in unilateral stance. Therefore, I recommend targeting the glute med in weight bearing with focus on double- and single-limb stance.

A simple way to ensure the glute med is firing as you weight bear is to use a resistance band around the ankles or knees while walking. Forward, backwards, laterally – whatever method suits your mood. Lateral step-ups and single-leg Romanian deadlifts also work well to functionally train the glute med. 

Step #4: Dynamic Stabilizing

Continuing along this progression, it is now time to make sure we can supply hip stability in the right amount, at the right times (just like oxygen). Plyometric work such as speed skaters and single leg work in the form of broad jumps or box jumps require the glute med to stabilize the pelvis during more dynamic activity. This is challenging, but struggling with this stage is necessary in order to carry over good movement patterns established in simple, controlled activities to more unpredictable situations.

Step #5: Skill

Here’s the fun part. How you choose to use and challenge your shiny new hip stability is up to you. Your sport will guide the next steps in training your hip to ensure your stability is up to par for the specific demands you place on your body. Remember, breaking down complex skills into their smaller parts is crucial to successful performance. Perfect practice makes perfect.

That’s it. A systematic approach to tackle movement dysfunction. Using this logic, now you can apply your own tried and true techniques. (Spoiler alert: this also works pretty well for our other core-extremity connector, the shoulder.)

The post It’s All in the Hip: 5 Steps to Fixing Movement Dysfunction appeared first on Breaking Muscle.

Since I know your secret, I’m going to let you in on one of mine. I want to tell you the one thing I see over and over again. The one difference between good performance and maximizing performance potential. The one thing that can be the difference between staying healthy and getting injured. And because you are so smart, you ask, “Why should I listen to you?”

Here’s what you need to know: I am a physical therapist who works almost exclusively with athletes. From lacrosse players to CrossFit, from recreational to the very elite, these are the individuals with whom I work day in and day out. I left the humdrum world of ultrasounds, icepacks, and ankle-cuff weights to work with the most motivated clients and best teachers – athletes. All day every day I work one-on-one with athletes watching them move and problem solve their way (back) to 100%. And over and over again I see a common thread limiting my athletes, their Achilles heel – the hip.

Almost all of the cases I treat stem from lack of core stability – specifically, from the lateral hip musculature (and yes, I group hip muscles into the core). Certainly you could see how this may be true if I were to only specialize in lower extremity treatment, but since I am telling you one of the secrets to my success, you should know that hip dysfunction also explains almost all of my waist-up cases (the technical term). As we go about our day-to-day lives moving from point A to point B, much of our activity requires us to move forward, or in the sagittal plane. Marathon runners, swimmers, point guards, and quarterbacks all have their eyes on the prize, in front of them. In order to produce any movement in this front-to-back plane, we must be able to use our lateral stabilizers, or anti-rotators, in the right amount, at the right time. Piece of cake, right? Now stabilize your core and control functional, diagonal, movements. Bob and weave, pivot and cut, juke your guy out of his cleats. Better have hips that would make Shakira drool.

The hip muscles – the glutes, the deep rotators, and yes those adductors that seem like they only exist to cause problems – are collectively charged with the daunting task of stabilizing everything above and below the hip. For example, as we walk, when we stride forward the standing hip must provide the force needed to prevent our torsos from dropping side to side and hold the hip and pelvis stationary (relatively speaking) to allow the knee to perform the simple hinge action for which it was designed. With such a large role, you can easily see how individuals of all abilities would have difficulty successfully controlling this multi-planar joint and the real trouble begins when compensations set in.

Let’s start with the Trendelenburg gait. This is a dysfunctional movement pattern we physical therapists are taught ad nauseam and love to point out during gait analysis. “Ooh, ooh! His pelvis dropped to the contralateral side, Trendelenburg!” This gait pattern occurs due to weakness of primarily the gluteus medius. We learn that this hallmark sign of lateral hip weakness can be spotted when the non-weight bearing hip drops lower than the level of the standing hip. Since we go to school for a really long time, we also learn that some individuals will compensate for this weakness by leaning their torso toward the side of weakness. You can assess this by watching someone walk, or stand on one leg. In our advanced classes, we learn that the glute med (we are older and cooler, so we abbreviate now) is also a rotator and when it is weak, the knee caves into an ugly valgus position (pictured right) because the hip dropped into internal rotation, straining the medial aspect of the knee.

When you zoom the microscope out, you can see that hip weakness looks like a lot of things, not just the Trendelenburg sign. Often, there are no deviations in sight and more importantly, the negative effects have far greater reach than just pain at the hip or the knee. My athletes have shown me time and time again that when one movement strategy fails, they have an arsenal of second and third-string muscles ready to take over. Being able to substitute muscles in a time of need makes for a great short term strategy, however if such compensations are sustained over time, you will eventually see a plateau in performance and breakdown of muscles that are doing someone else’s job in addition to their own. Have you ever had to pitch in a little extra to make up for a colleague or teammate? Sooner or later being taken advantage of will get old.

• Instead of demonstrating “down and in” collapse at the knee and ankle, the posterior tibialis at the inner shin can do a great job of lifting the arch and reducing the knee valgus. The posterior tib also excels in causing debilitating shin splints when used to do more work than it is supposed to.
• The sartorius is an abductor and external rotator of the hip and with connections at the anterior hip and the medial knee, like the posterior tib, this long strappy muscle can pull the knee up and out when it contracts. Makes a good substitute for the glute med, right? Absolutely, with hip and knee pain to boot.
• If the glute max slacks off and lets your torso lean too far forward, the ankle plantarflexors are ready and willing and help hold you up. How much weight do you think your calf muscles can squat? You get the point. 

The secret should be pretty clear by now – by mastering hip control in all planes, you can control whatever kind of movement you would like your body to create. You can be as static or dynamic as the hip allows. When the body works how it is designed, it is a powerful machine capable of both force and finesse. Big muscles do the heavy lifting while small muscles make minor adjustments. This results in efficient (read: strong and safe) movements. Control your hip, and you control your body.

Don’t miss part 2 in the series: It’s All in the Hip: 5 Steps to Fixing Movement Dysfunction.

Photos courtesy of Shutterstock.

Valgus knee graphic by LadyofHats, Jecowa, Stündle (File:Human skeleton front en.svg) [CC0], via Wikimedia Commons.

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What Causes Groin Injury and Pain?

Groin pain is often due to overuse or repetitive specific use of the lower abdominals and proximal thigh. But there is a broad spectrum of differential diagnosis in groin injuries. While most often the pain stems from soft tissue dysfunction, such as a muscle strain, tendonitis, or contusion, occasionally groin pain may be referred from the lumbar spine, osteitis pubis, neural entrapment, “sports hernia,” and true hip pathology, to name a few.

RELATED: It’s All in the Hip: 5 Steps to Fixing Movement Dysfunction

Acute groin pain is common in sports that involve kicking, running, or rapid changes in direction, such as soccer, football, and martial arts. Athletes will associate pain with a specific movement and may feel or hear a pop in their groin. Physical examination might reveal tenderness, bruising, and muscle swelling. Usually, these resolve with rest and physical therapy in four to six weeks. If there is tenderness along the inguinal ring, hip joint, or lumbar spine, the matter will warrant further investigation.

What About Chronic Groin Pain?

Chronic groin pain presents a more elusive challenge in diagnosis. This condition may be due to an ignored acute injury that continues to be irritated by activity. An original injury that doesn’t go away points to a more severe pathology.

Stress Fractures

Stress fractures are an injury at any bony site in the body and arise due to repetitive load and overuse. The most common stress fracture sites that refer pain to the groin are those of the pubic ramus (#4b in the illustration to the right) and femoral neck (the femur, just below the hip joint). A stress fracture presents as gradually worsening pain, intensified with weight bearing and usually decreases with rest.

RELATED: Female Athletes More At Risk For Stress Fractures

Avulsion Fractures

Avulsion fractures occur when load is so strong that the muscular attachment tears away from the bone. These injuries are associated with a forceful muscular contraction, and a palpable defect at the insertion of the muscles on the pubic rami may be felt.

Osteitis Pubis

Osteitis pubis is a chronic inflammation of the pubic symphysis (#5 in the above illustration) and adjacent bony structures as a result of repetitive stress of the muscular attachments during running. It is characterized by groin pain, tenderness at the pubic tubercle (#4d and also illustrated to the right), and pain with running, sit ups, and squats.

Sports Hernia

Athletic pubalgia, or “sports hernia,” presents similarly to an acute groin injury with sharp pain during rapid change in direction or forceful kick. It usually does not resolve completely with rest, and, while there is no palpable bulge like with an inguinal hernia, the opportunity exists to allow some of the abdominal organs to press against the weakened tissue.

LEARN MORE: Sports Hernias May Be Caused By a Hip Disorder

Hip Pathology

Two conditions of the hip that may cause hip pain and most certainly should not be ignored are Legg-Calve-Perthes disease (LCP) and slipped capital femoral epiphysis (SCFE):

LCP is avascular necrosis of the proximal femoral epiphysis, occurring in boys between the ages of eight and thirteen. Avascular death means that bone tissue dies off due to a lack of blood supply. As youth are becoming more active in unconventional sports (i.e., Harrison Maurus in weightlifting), as parents and coaches, it is our responsibility to figure out when our children are experiencing simple soreness and when something really wrong. A kid with LCP will complain of gradually worsening groin pain that refers to the abdomen or thigh. Over time, they may also develop a decrease in mobility and pain with movement.

SCFE occurs in boys ages ten to seventeen, who are tall, lanky, and thin, or morbidly obese. Groin pain in these athletes will either come on quickly with an acute incident, or gradually due to repetitive stress. As the condition progresses, the athlete will have pain referring into the hip and medial knee, as well as a limp.

Both LCP and SCFE warrant further investigation by an orthopedist and possible surgical intervention.

When to Seek Treatment

As with all injuries, anything that continues to persist beyond a few days or does not go away with rest requires medical evaluation. Groin injuries related to soft tissue, while annoying, have the ability to progress into a more sinister pathology due to the altered movement and mechanics that ensue to protect the area.

In acute cases, rest, ice, and anti-inflammatory medications are a good place to start. As always, if it doesn’t resolve, find someone you trust who knows more than you and get it checked out. An injured athlete isn’t an athlete; they’re just an injured person.

Photo 1 by Wiechers at nl.wikipedia (Transfered from nl.wikipedia) [GFDL, CC-BY-SA-3.0 or CC-BY-SA-2.5], from Wikimedia Commons.

Photo 3 by BruceBlaus (Own work) [CC-BY-3.0], via Wikimedia Commons

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A common complaint for many elite athletes is hip issues, such as pain and instability (hypoplastic or labrum tear). Hypoplastic simply means incomplete or underdeveloped, and labral tears are often the result of a traumatic injury, such as dislocation. The labrum follows the outside rim of the socket of the hip joint, and acts like a socket to hold the ball at the top of your thighbone in place. Unfortunately, athletes who participate in sports such as hockey, soccer, football, golf, and ballet are more susceptible to developing a hip labral tear.¹ These conditions be quite substantial to those who are affected, but now thanks to a new and improved surgery, athletes may be able to have it repaired to a “like new” condition.²

Research was performed on 21 male, elite athletes who had hip pain and instability issues. These athletes were professionals and participated in soccer, hockey, football, skiing, baseball, basketball, and ice skating. 17 of the 21 patients were followed for more than 32 months. Upon receiving an arthroscopic reconstruction technique, 81% of the participants returned to action at a level similar as before they were injured. All but two of the patients had shown improvement on various mobility indexes.³

“The proper function of the labrum in the hip is a critical component of mobility for any athlete. When this area gets hurt, repair can be difficult. Our review study highlights that a majority of athletes can return to a solid level of play utilizing the ipsilateral iliotibal band autograft and physical therapy. While additional research needs to be performed on the technique, we are hopeful that its increased use will allow more athletes the ability to return to the sports they love,” said Marc J. Philippon, M.D., of the Steadman Philippon Research Institute in Vail, Colorado.⁴

The results of this study are promising – technological advances are allowing for conditions often considered difficult or impossible to repair to be reconstructed to a similar level as before the trauma incurred. Many athletes in various sports suffer hip injuries each year, and may never return to action at the same level as before. Fortunately, this new procedure gives new hope to those who suffer from various hip conditions.

Photo courtesy of Shutterstock.

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