Hip Pain with Squats? Stop Blaming the Hip Flexors

Hip pain with squats?  Stop blaming the hip flexors and assuming they are tight as soon as someone complains of pain or pinching in the front of the hip.  While I understand that clients expect to work when they come into the gym, quick fixes are not profitable in the long run.  Ensuring a client has solid technique on all of the basic lifts is the best way to ensure you can work them, and as such, you should constantly be assessing and re-assessing how they move.

I see a big problem with associating movement issues with specific fixes, or causes, without even assessing.  Have someone squat.  Butt wink?  Stretch the hamstrings.  Feet turn out?  Stretch the calves.  Pinching in the front of the hip?  Stretch the hip flexors.  This is NOT assessing!

 

Way too many people are excessively stretching their hip flexors because they make the assumption that they are tight

 

and that that’s what’s causing a pinch in the front of their hip during squats.  Or, this is what they have been told.  Even worse, it’s the information they have seen circulating on social media.  But pain and pinching on the anterior aspect of the hip can come from many different causes.  As they say, ASSESS DON’T GUESS.

If you are dealing with a client who is experiencing pinching in the front of the hip during squats, it is a good idea to assess the many factors that could be contributing to this, including assessing their squat.

INTEGRATING THE FEET

I have discussed the importance of the feet in previous articles and will discuss it again in an upcoming article.  By now you know that the feet play an important role in pretty much everything you do.

The squat, more than the deadlift, has a rotational component to it.  I see the squat as a mix of frontal and transverse plane movement.  The external rotation torque at the hip, typically cued using “knees out”, begins at the feet.  This is why cues like “spread the floor” and “screw the feet” are also often used to cue the squat.

Level 2 online course banner

At a basic level, look for feet that are properly grounded.  Weight should be evenly distributed within the foot tripod.  Your foot tripod is triangle formed between the head of the fifth metatarsal, the head of the first metatarsal and the heel.  Your center of gravity should remain centered within that tripod at all times.  As well, the toes should remain in contact with the ground, pushing down into the ground in order to grip it for stability.  If the toes lose contact with the ground, or if the weight is shifted to the heels, the center of gravity is no longer centered in that tripod.  In order not to fall backwards, the hip flexors will work hard to essentially pull the torso forward.  This will usually result in a feeling of tightness or pinching in the front of the hip.

Watch your client squat from a sagital view.  If they look like they are folding forward, this should cue you to come down to the feet to pursue your assessment.

MODIFIED THOMAS TEST

If you do suspect tight hip flexors, or want to rule that out, using the Modified Thomas test can be helpful.  If you do not have a therapy table, you can use two boxes lined up together and that usually does the trick.  Have the client sit at the very edge of the table, grab one knee, then let themselves fall back on the table, holding that knee towards the chest such that the low back and sacrum are flat on the table.  Have the client relax the other leg.  Normal length of the hip flexors would result in the thigh touching the table or hanging slightly below it.  This is equivalent to approximately 10 degrees of hip extension.  The knee should flex to 80 degrees.  If the knee remains extended, this indicates tightness of the rectus femoris.  To see how to perform the test, make sure to watch the video above!

Often, people will have tightness in the rectus femoris but not in the psoas.  In this case, you can stretch the rectus and not the psoas by focusing on knee flexion at 0 degrees of extension to avoid over-stretching the psoas and projecting the head of the femur forward in the acetabulum.

SQUAT STANCE AND HIP SCOUR

You would be surprised at the number of people who are using a squat stance that has been imposed to them.  For example, they have been told to squat with feet shoulder width apart.  Granted, many people may intuitively gravitate towards a stance that is more comfortable for their hips and/or allows them more hip flexion.  However, when a client complains of anterior hip pinching or pain in squats and they have a very narrow stance, I always verify whether that is actually appropriate for their hip structure.  For most people, a very narrow stance (and one with the feet quite parallel), will result in the proximal femur running into the acetabulum early.  This may result in a feeling of pinching in the anterior hip, commonly mistaken for hip flexor tightness (or addressed by stretching the hip flexors).

You can use the hip scour test for the squat to get an idea of an individual’s hip structure and capacity for a narrow, deep squat.  If you move them into flexion and they feel a pinch in the front of the hip and moving them into abduction makes that pinch go away, you can be pretty sure stance had at least something to do with it.  If moving the hip into abduction increases the range of flexion, you will also avoid other issues that can come from squatting at an inappropriate width.

Watch the video below to see how to perform the hip scour:

ANKLE MOBILITY

If you did have an individual with the hip structure for a narrow, deep squat, that capacity would still be dependent upon optimal ankle mobility.  If dorsiflexion is limited, the hips need to move back more, which affects that ability to deep squat.  Again, the torso will need to come forward to counterbalance the larger moment arm at the hip, and if the feet are too narrow (and the feet aren’t stable…), the hip flexors will perform that task, again resulting in a sensation of tightness or pinching at the front of the hip.  This still has nothing to do with the hip flexors being tight or needing stretching.  On the knee-to-wall test, if the distance required between the wall and the big toe to touch the knee to the wall is less than 9-10cm, there is a restriction significant enough to affect the squat.

You can test for ankle mobility using the knee-to-wall test as seen in the video below:

FEMOROACETABULAR IMPINGEMENT

Femoroacetabular impingement (FAI) is a clinical disorder of the hip that results in premature and/or excessive contact between the proximal femur and the acetabulum.  It can come from variations in the structure or morphology of the femur or the acetabulum (or both).

Cam morphology is a flattening or a bump or ridge at the junction between the femoral head and neck.  Pincer morphology represents a deeper acetabulum with excessive coverage of the femoral head.

Cam and Pincer morphology of hip

FAI is considered multi-factorial, namely because Cam and Pincer morphologies can be found in asymptomatic individuals.  As such, just the presence of a Cam or Pincer morphology alone is not enough to diagnose FAI.  This means that even if there was a structural component, many other factors that contribute to impingement are still worth assessing and addressing as they can help decrease symptoms and improve function.  Some studies have found strength deficits in hip flexion and adduction associated with FAI, so again, caution must be taken to avoid over-stretching the hip flexors, as this could further exacerbate dysfunction.

Those who do have FAI typically report stiffness and pain in the hip joint that is always present and can be exacerbated by certain movements or posture, namely squats.  Of course, when in doubt, you should always refer out to a qualified professional and work collaboratively to manage FAI.

MANAGING IMPINGEMENT

If there was a bony femoroacetabular impingement, or an associated injury such as a labral tear, you would have to expect to make some permanent changes to an individual’s training regimen.  As such, if you suspect this, refer out and work collaboratively as mentioned previously.

If there is pain, pinching, tension or discomfort in the hip related to specific activities or movements, these should be temporarily minimized or modified to remove this trigger.  This may include altering squat variations, avoiding stretching the hip flexors and re-assessing other factors that could be contributing to pinching and tightness in the front of the hip.

XPN World banner

Another important factor to address is weakness of the deep hip muscles (the hip rotator cuff).  This can compromise the stability of the hip, but it can also overload the larger muscles of the hip and lead to increased anterior glide of the femoral head in the acetabulum.  It can also compress the joint.  All things that result in anterior hip pain, pinching and/or tightness.

Addressing impingement should include working the deep stabilizers of the hip.  Here is a video article I wrote on the subject: How to Build Resilient Hips.

ASSESS DON’T GUESS

As a coach or trainer, our job is to solve problems.  This means digging deeper into potential reasons why there is pain or someone is not moving properly.  If we stop assessing and just associate Problem A with Fix 1, we stop doing our job.

We need to stop blaming the hip flexors whenever we hear a complaint of pinching in the front of the hip.  Many factors can contribute to pain and pinching in the front of the hip, and often times, stretching the hip flexors is not only unnecessary, but can be detrimental.

Instead, when you hear “pain” or “pinch” in the front of the hip, use that opportunity to pull out your assessment tools and use your analytical mind to help your clients.

Enjoyed this article?  Click the link on the top right-hand corner of the video to share it, we sure do appreciate it!

 


 


Mai-Linh Dovan M.SC., CAT(C)
Certified Athletic Therapist
Founder of Rehab-U

 

 

Be part of the conversation

Get access to your free 20-min video
The Movement Optimization Strategy

  • This field is for validation purposes and should be left unchanged.
+
+
+

FREE full body workout sample

  • This field is for validation purposes and should be left unchanged.
+

Post-clinical
Rehab

+

Movement
optimization

+