Anterior hip pain is a common complaint in athletes as the hip is commonly placed into positions of significant impingement in many sports.
You have more than likely dealt with an athlete complaining of pain in the anterior crease of the hip or in the groin. In fact, the terms hip pain and groin pain are fairly common, while the accurate clinical diagnosis of hip and groin pain remains a significant challenge in sports medicine.
Understanding what is causing the pain is a great place to start, coupled with an understanding of the potential mechanisms and movement impairments that contribute to pain.
This will allow you to implement an informed and individualised management exercise strategy. Above and beyond manual therapy, being able to provide a structured rehab program to both protect your clients from further injury and expose them to sufficient stress to help with recovery is the actual key to rehab.
The two important questions I will answer in this article are:
- Where is the pain coming from and how should I direct my intervention?
- What are the impairments that are contributing to pain and how can I effectively address them?
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WHERE IS HIP PAIN COMING FROM?
I think this first question is important to answer, whether you are coming at this from a therapist perspective, or as a movement specialist or trainer. Many of the people I see with anterior hip pain, typically located deep in the inguinal area, have received treatment for adductor-related groin pain.
And while the adductors are an important component of managing anterior hip pain, they are not the only suspect we should be chasing.
A one-day agreement meeting, The First World Conference on Groin Pain in Athletes, was held in Doha, Qatar on November 4th, 2014. A unanimous agreement was reached on the terminology and classification system of groin pain in athletes (1).
When an athlete presents with anterior hip pain (or groin pain), this pain can be adductor-related, inguinal-related, iliopsoas related, pubic-related or hip-related. As well, there can be other causes of hip pain like hernias, nerve entrapments, referred pain, etc.
While the terminology and classifications are based on both clinical examination and an extensive history of the athlete, the main point I want to highlight here is that
classifying where the pain is coming from helps direct the intervention more appropriately
ANTERIOR HIP PAIN
Anterior hip pain typically presents as pain deep in the front of the hip and can refer to the mid-buttock and lateral hip. Individuals with long-standing hip pain usually have dull, achy pain but will get a sharp pain with quick, unexpected movements or specific positions.
Reproduction of pain on flexion, adduction and internal rotation (FADIR) is suggestive of hip impingement. Here’s how it’s done:
Patrick’s test can be useful for differentiating hip pain from sacroiliac joint dysfunction:
Pain localized to the SI joint when pressure is applied simultaneously on the knee of the abducted hip and the opposite anterior superior iliac spine suggests sacroiliac pathology, while groin pain, spasm, or limitation of movement is suggestive of hip pathology.
MAKE SURE TO WATCH THE MAIN VIDEO OF THIS ARTICLE FOR MORE DETAILS ON THIS TEST
Of course, hip-related pain has its own challenges and can come from many different sources as well: labral tears, ligaments sprains, femoroacetabular impingement (FAI), hip joint instability or capsular laxity, among others.
HIP MOVEMENT IMPAIRMENTS
Despite the many potential sources of anterior hip pain, many athletes present with characteristic, modifiable impairments like decreased hip muscle strength, decreased trunk muscle function, decreased control in hip adduction/knee valgus on single-leg tasks and decreased dynamic balance (2).
For example, on a single-leg squat, you might see increased hip adduction, knee valgus, lateral trunk flexion or trunk rotation on the side of complaint. Here is a video of an Olympic lifting athlete who came to me with right anterior hip pain. Notice the difference on his single-leg squat on the right leg versus the left:
And according to Sahrmann’s Movement Impairment Syndromes,
abnormal or excessive force on the anterior hip joint may cause anterior hip pain and subtle hip instability that perpetuates the cycle of pain
A study from Lewis, Sahrmann and Moran (3) found that “decreased force contribution from the gluteal muscles during hip extension and the iliopsoas muscle during hipflexion resulted in an increase in the anterior hip joint force”.
What does this all mean from a practical standpoint?
It means that there are many contributing, compensatory, modifiable movement impairments that we can improve to manage anterior hip pain despite the many potential diagnostic causes of pain.
HOW DO WE IMPROVE HIP MOVEMENT IMPAIRMENTS
Avoiding excessive impingement is about improving the distribution of joint loads and dynamic positioning. When dynamic control is the goal, there are always many elements to consider. I discuss pelvis-femur dissociation and pelvic stability in my article: Hip Pain – A 3-part Exercise Strategy to Get Rid of It.
I can’t stress the importance of the strategy enough. For example, if you did find that pain was adductor-related, the exercises you choose in the Activation sequence would be different than what you would choose for hip-related pain. Speaking of the adductors, if that is something you are dealing with, then you also must read my article on adductor function and strength.
And because poor hip range of motion results in poor outcomes for managing anterior hip pain, you also must read this article, which deals with what hip mobility really is!
Since I’ve dealt with many other elements in the previous articles linked above, let’s focus on trunk and hip muscle strength and function for dynamic control.
MAKE SURE TO WATCH THE MAIN VIDEO OF THIS ARTICLE TO SEE MORE EXERCISES
The distribution of load through the hip requires the ability of the hip to control rotation forces. Typically, a lot of time is spent working on hip mobility and creating rotation through the hips. Less time is spent on controlling rotational torque. Simple exercises like Pallof presses are classic “core” exercises that actually require hip rotation control:
These can be progressed to pitchfork raises:
And while you want to continue to load the hip, you will initially need to avoid placing the athletes into positions of impingement and focus on adduction, abduction and extension strength. Lateral step-ups are a great addition to the Integration sequence, as are lateral resisted lateral squats which work on hip abduction with extension:
LOW HANGING FRUIT
Knowing where pain is coming from is an important aspect in managing anterior hip pain. Although there may be different causes for anterior hip pain, there are many characteristic movement impairments that can and need to be addressed to get athletes out of pain.
In the clinic, we like to call these the low hanging fruit. They should be the focus of your program and they will guide the choice of exercises for your rehab plan.
Rehab, like training, requires that we consistently select work that allows for maximal stress while still protecting injury. This is why you need an understanding of how individuals move and a structure to create learning-driven changes in the way they move.
This is why #rehabistraining!
- Weir, Adam & Brukner, Peter & Delahunt, Eamonn & Ekstrand, Jan & Griffin, Damian & Khan, Karim & Lovell, Greg & Meyers, William & Muschaweck, Ulrike & Orchard, John & Paajanen, Hannu & Philippon, Marc & Reboul, Gilles & Robinson, Philip & Schache, Anthony & Schilders, Ernest & Serner, Andreas & Silvers, Holly & Thorborg, Kristian & Holmich, Per. (2015). Doha agreement meeting on terminology and definitions in groin pain in athletes. British journal of sports medicine. 49. 768-74. 10.1136/bjsports-2015-094869.
- Kemp, J. L., Risberg, M. A., Schache, A. G., Makdissi, M., Pritchard, M. G., & Crossley, K. M. (2016). Patients With Chondrolabral Pathology Have Bilateral Functional Impairments 12 to 24 Months After Unilateral Hip Arthroscopy: A Cross-sectional Study. The Journal of orthopaedic and sports physical therapy, 46(11), 947–956. https://doi.org/10.2519/jospt.2016.6577
- Lewis, C. L., Sahrmann, S. A., & Moran, D. W. (2007). Anterior hip joint force increases with hip extension, decreased gluteal force, or decreased iliopsoas force. Journal of biomechanics, 40(16), 3725–3731. https://doi.org/10.1016/j.jbiomech.2007.06.024
- Grant, C., & Pajaczkowski, J. (2018). Conservative management of femoral anterior glide syndrome: a case series. The Journal of the Canadian Chiropractic Association, 62(3), 182–192.
- Shindle, M. K., Ranawat, A. S., & Kelly, B. T. (2006). Diagnosis and management of traumatic and atraumatic hip instability in the athletic patient. Clinics in sports medicine, 25(2), 309–x. https://doi.org/10.1016/j.csm.2005.12.003