Attention: CrossFit Athletes with Hip Pain! When Mobility goes Wrong!
Attention CrossFit athletes dealing with hip pain, DO YOURSELF A FAVOR AND READ!
So you have hip pain when you squat? The pain is in the front of the hip or groin. Must be a tight or strained hip flexor. Not so fast my friend.
Hip pain or “tightness” in the front of the hip is a relatively common complaint amongst CrossFit athletes, but it shouldn’t represent a big set back for the athlete. What I’ve observed at boxes across the country, with patients in my clinic, and with social media threads discussing hip pain, is the tendency for the athlete’s pain to be quickly labelled as a “hip flexor”. Once that label gets stuck on to the athlete, it’s like a parasite has entered the host, and a predictable sequence ensues.
The athlete now labeled with a hip flexor, begins a stretching and mobility routine. Relief is short lived and the intensity must be stepped up in order to get the same relief. However, aggressively stretching the hip flexor serves no benefit past a momentary sensation of relief. You would be much better served spending your time desensitizing the area, working on joint centration, strengthening of the muscle, and modifying your movement in a way that no longer compresses the front of your hip (this is where a movement based medical provider can help) Stretching the hell out of your anterior hip structures at best is irrelevant, but at worst will contribute to increased sensitization of the area and the development of a chronic hip problem.
But if feels good?
Welcome to the dark side of self myofascial release, the negative feedback loop that is stretching. If the worst thing you could do for an injury is stretch, then it would still feel better after you did it. Even if it is making it worse! Your body will lie to you! You may start with a couch stretch, and before you know it you’re progressing to intense posterior to anterior, banded distraction stretches. These may feel good, but only serve to continue to stress the tissues in the front of the hip, and perhaps even create laxity. This could allow the femur to translate forward at the bottom of the squat, creating an even more compressive pinch, and the cycle continues.
Athletes will find themselves with an ever increasing sensation of “tightness” or pain. They will begin having pain with more and more movements that were previously not problematic. They will seek out a stronger ‘fix’, such as a massage therapists to give them deep tissue massage and smash their guts out with a “psoas” release. They feel better for an hour, so they assume it helped………., but then it comes back. They think, “WOW, there must really be something wrong with me”. Then they seek out the trusty orthopedic doctor that is more than happy to order an unnecessary MRI. The MRI will likely come back with some sort of structural issue as they almost always will (even in a normal, uninjured person). The athlete, eager to get back to 100%, has the surgery. The surgeon, eager to be the unquestionable protagonist of this tragedy, tells the patient some version of this statement on their follow up visit: “Be glad you went through with the surgery, when I opened you up there was a lot more damage in there than I even saw on the MRI”. The patient leaves the surgeons office convinced of his rightful place on top of the throne of American medicine, and relieved to be “fixed” by his worthy hands and infinite wisdom. (slight sarcasm for dramatic effect)
Patient then goes through a generic, post surgical physical therapy program, likely designed for a sedentary person, and not an active athlete. They are released upon completion of an unchallenging course of rehab. They are never taken through a fully developed, return to play program that would adequately prepare them for life at the gym. Due to their time away however, the anterior hip has been given a chance to desensitize and cool down a bit. They enjoy a nice little honeymoon phase of light exercise, as they pick up with their fitness journey. As they begin to progress their intensity however, the old familiar pain begins to rear it’s ugly head. The once heroic athlete has now been transformed in to a tragic figure, having done “everything” that the medical world has to offer, is now left to deal with there bad hip for the rest of there life. They take ownership of it. They treat it like a pet dog. They take it everywhere with them. It will never leave there side. It’s now there companion for life. Happily. Ever. After.
BUT IT DOESN'T HAVE TO BE THAT WAY!
If it’s not my hip flexor than what is it, and what do I do about it?
As stated earlier, most of the CrossFit patients that I have seen that have been diagnosed with hip flexor strains by friends, the internet, or a medical provider are actually dealing with a sensitized anterior hip. If you wanted to give it a pathoanatomical label then call if femoroacetabular impingement, however in reality your hip is just tired of being anteriorly compressed. How to know the difference? A simple screen is this, do you have pain at the bottom of the squat, or does it hurt if you lie on your back and pull your knee towards the opposite shoulder? If so, you are likely dealing with an anterior hip that has gotten highly sensitized (extremely common for CrossFit athletes) Common lifting faults such as starting a squat in an overly extended lumbar or anteriorly tilted position can contribute to the sensitization. Or maybe the athlete is bouncing out of the bottom during the squat, and creating a highly forceful pinch before driving out of the hole. Also it could simply be due to increased amount of volume. These are just a few potential reasons that your hip could begin to get sensitized.
So if I’m not stretching, what should I do? Here's what you really want to be doing!
STEP 1. DESENSITIZATION- The unequivocal, unavoidable, righteous first step!
(PLEASE DO NOT confuse desensitization with REST, rest is the strange uncle of desensitization, he’s got some of the same traits as dad, but something just isn’t right about him, and you definitely don’t want to spend a couple of weeks with him, if you do then you’ll be worse off for it)
What you need to do next is take a quick inventory of all of the movements that you are doing to create anterior compression, and try to get a subjective quantification of this stress? For instance, how much squatting are you doing, how much time are you spending in the bottom of a squatted position, are you stressing it further with excessive stretching, are you sitting all day in an anteriorly compressed position, are you driving in an anteriorly compressed position, are you climbing tons of stairs, are you running hills or an inclined treadmill, etc. etc. Write all of these things down, to get a good idea of how much of the day you are actually spending in a position that is feeding the problem. Now start cutting as much of these out of your life as you can. Example of how to do this without losing much physiology or fitness:
1. Significantly cut back or eliminate your mobility routine, eliminate banded distraction, couch stretching, no more pulling your knee to your chest to stretch, no more bouncing in to a toe touch, etc.
2. Some athletes may still be able to get away with olympic lifts, BUT I would still recommend cutting the volume back around 50%, maybe more, during the desensitization phase. If you're still feeling the discomfort Oly lifting, then be honest with yourself and regress the movement (for example you may just need to pull from the blocks or off of the rack during this phase to minimize anterior compression) You will maintain a large percentage of your pulling strength while still accomplishing desensitization
3. Modify your sitting and driving position to decompress the anterior hip
4. Work on pelvic positioning, and foot/femur positioning during squats to reduce compression
5. Modify other aggravating behaviors based upon the inventory you took earlier (again, this is where a movement based medical provider is clutch) ex. take the elevator rather than climbing the stairs, don't sit with your legs crossed, etc.
STEP 2- Specific, movement based, return to gym program
I get it , this is the point in the article where I should give you “3 simple strategies to completely eliminate hip pain”, but, that would be malarkey.
Why won't I just vomit out some exercises to you?
Because the magic is not in the exercise and it NEVER will be, the magic is in the specificity of the exercise and it’s relevance to the patient in front of you.
Are you stuck in an anterior tilted pelvic position due to weakness? Are you stuck in an overly extended, athletic posture with high tone lumbar erectors? Do you have overly lax, unstable hip? Do you have dysfunction at the ankle or thoracic spine, driving you in to a forward torso lean, and creating compression? Can you even control pelvic tilting, in an unloaded position, before we progress to improving your lifting form? Do you have a left/right strength imbalance to where you preferentially load and drive off of one side more? If so, is it do to a prior injury of the opposite side lower extremity? Tell me about your pelvic floor? What about breathing strategies? Can you properly breath diaphragmatically unloaded? Do you have a left, anterior innominate? Tell me about the bony morphology of your hip joint? Do you have a hooded acetabulum on the impinged side? What about your set up position in terms of femoral rotation and foot width, has that been optimized? Do you have a hip architecture that allows for a wide range of movement variability? If so, are you taking advantage of that available variability, and changing your squat positioning to move the load around? On and on and on we go………..
Are all of these different variants that I describe above bad? NO!
Are they predictors of injury? NO!
These are simply just traits and characteristics, that in an uninjured athlete, just make them who they are. They ARE however relevant in the hip pain patient simply because they can increase or decrease the compression forces in the joint. A good clinician will perform a detailed enough of an assessment to know exactly which of these variables can be manipulated favorably in order to tip the balance away from further sensitization and towards healing. In other words, in the hands of an expert medical provider, each of these variables might shift the treatment strategy. It may be a subtle shift or may be seismic, but the point is, they are important. The level of specificity that an expert clinician will bring to your treatment can literally be the difference in quick resolution or the development of a chronic problem. If you take one thing from this article it should be this:
Smarter not Harder, Simplicity through Specificity
So why is stretching so bad?
It’s not that stretching is bad, and it certainly can be a useful piece of the mobility puzzle. However, in the ‘injured’ athlete it’s probably not the best thing you could be doing. It probably will not resolve your issue, and in certain types of injury it can feed the problem. In the sensitized hip, the aggressive stretching simply becomes another stressor that further sensitizes the tissue.
Well when do I need mobility?
The truthful answer is that you need mobility when you need mobility. Have you been assessed? Do you know what you mobility weak links are? Is your mobility issue driven by lack of stability somewhere else, is it due to bony morphology, is it protective tone created by the brain, or maybe it’s just the result of poor joint centration.
I acknowledge that this is not a sexy blog post, but sometimes facts aren’t as fun as malarkey! The good news is that surgery can be avoided in the vast majority of cases. If you are a patient that is thinking, “I’ve been to a physical therapist, chiropractor, or other provider, and it lead no where, just know that I get it, and I understand completely your frustration. The medical system has failed you. It’s failing a lot of people. Cookbook exercise, popping joints, and steroids are the standard of care, and it's a shame.
However, there are good guys! Experts with your best intentions in mind. My best advice is to seek out a movement based medical provider from a resource like Clinical Athlete or Movement Providers. They should be able to walk you through the above steps, while properly modifying your training. If it works, put them on speed dial, lean on them as a resource for any other future issues, thank your lucky stars that you have a trusted team member on your side, and then tell all of your friends, so that the good guys can win!
Dr. Davis is now seeing patients in Dubai and can be found at DubaiPainFree.