Anterior hip impingement

I'm writing about this because a recent patient came in with pain at the front of the hip which was worse for crossing the thigh across the midline and felt mostly in the crease of the thigh at the groin level. They had come from another therapist who instructed lunge stretches.

Exercise for the hip region is also an area of further interest for me. I've trained further in exercise rehab in cases of osteo-arthritis, internal cartilage damage, psoas tendinopathy, hyper-mobility, and "CAM" lesions. So I immediately thought"Aha! I know what needs to be done here".

Anterior hip impingement can happen in younger and older people, generally for different reasons though. But both groups need to avoid stretching the psoas muscle, such as lunge stretches. Sometimes it feels relieving for an hour after a stretch but comes back again asking for another stretch. Or, as it often does, it gets worse for this stretch. That is really telling you something useful. This can be frustrating, why is it getting worse for stretching?

Basically the tissue at the front of the hip joint is already over-stretched, compressed, damaged or inflamed. It needs resting from stretching, compression and overloading for six weeks or so. Anti-inflammatory medications sometimes have benefit, usually small in my experience. The over the counter anti-inflammatories also have the interesting property of interfering with new tissue growth. There are herbs that in my experience can have a place here.

This is a very complex region. It can pay to have imaging done because bony deformations in the hip ball joint, which can be there from birth, or slowly aquired really impact on the management and expectations for the patient. The patient history and nature of the complaint and their age guides this decision.

In anterior hip impingements, there are however safe and useful methods for loading the hip musculature and recreating good movement patterns at the level of the deep hip muscles which are essentially usually below the level of awareness control, but often need waking up.

Simple postural awareness in standing or sitting make a big difference. For example, don't cross the legs - it may not compress the tissue but it does help tighten the back hip capsule that drives the hip bone forward into the tender tissue later on. Sitting with the feet on the floor, knees slightly wider than the inside hip line is best. Sitting with the weight on the sit bones with neither a slouch nor a tilt to soften the TFL muscle can really help. The TFL muscles activity must be "downtrained".

Your posture in sitting, standing and walking is in itself a form of 24/7 treatment. I spend time helping patients become aware of how to do this. For example, helping patients take command of their knees using imagery to soften them, and where to place their weight in their feet is useful to off load the front hip structures.

Lately I've been finding methods of hip-joint traction with active movement to be an additional method to speed movement pattern rehab up and some of these can be prescribed for home-treatment. It can be a very positive experience for a patient with this issue to find a way to painlessly and immediately go beyond their restrictive barriers, if it can be achieved. It's not in every case, and the tissue of concerned doesn't get immediately healed - but its recovery or its management does improve.

For athletes like cyclists and runners six weeks needs to be spent wisely, you de-condition in two weeks. A supported, graded exercise progression can make all the difference. And of course, realising that when the lunge stretch is making things worse, you've just been given some really useful information!