What Causes Hip Tightness and Pain?
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I hear it all the time…my gymnast is having hip flexor pain. I even had a national team coach tell me once that the national team is suffering from hip flexor weakness and that is why a majority of them are having pain. Really? A gymnast has weak hip flexors…then she went on to tell me they’re strengthening the gymnast’s hip flexors. That might be one of the craziest things anyone has ever told me. I tried politely to let them know it’s not a hip flexor issue, but they didn’t listen.
If you’re a gymnast and you’re having hip tightness after having been flexible in the past, you’re having hip pain now, or you’re looking for better ways to control your hips, then this is your post.
Remember, that if you’re having pain, you need to get your hip or low back examined by a qualified provider…don’t go it alone!
What We’ve Always Thought
We’ve always thought that the hip was a stable joint that maintained mobility even though the hip was stressed (landing, jumping, splits, etc). The hip acetabulum (the socket of the hip) is deep in comparison to the shoulder, and the head of the femur (the ball part of the joint) sits deep into this socket. There are also incredibly strong ligaments that surround the hip that stabilize it and keep the head of the femur from dislocating or subluxating. Stability is maintained.
Or so we thought.
It is stable in that it is very difficult to dislocate a hip and the hip musculature is great at splinting the hip when injured. The trouble starts to occur when the hip senses stress, or it gets taken to range of motion it wasn’t necessarily intended to go to.
Ouch…It Can Do WHAT?!?
In gymnastics, the hip can be taken to such a range of motion that the neck of the femur can pivot on the acetabulum, or even worse, the femur can pivot on a portion of the pelvis, and create subluxation of the femoral head outside of its protective acetabulum or socket. We consider this repetitive subluxation and abnormal movement of the hip microinstability and it can even start to stretch out the ligaments and injur the labrum (the labrum is a protective ring that helps maintain proper alignment of the hip and distributes the forces equally across the hip joint).
The official name for pinching the soft tissue in the hip and causing pain from abnormal hip motion is called Femoral Acetabular Impingement (FAI). FAI can lead to further damage of the hip called a labral tear. Once the labrum is injured, it can cause even more microinstability.
Other things can also cause microinstability in the hip include dangerous landing positions and too much stress on the hip, which is fairly common in gymnastics.
Ridiculous Stretching Causes Injury
One of the ways that the hip is stressed in gymnastics is through stretching splits. Many times you’ll see in the gym a coach pushing down on a girl, trying to help her attain greater depth in the split position.
THIS IS DANGEROUS. STOP DOING IT NOW!
Most of the times, this coach has stopped stretching muscles and has started stretching the ligaments and capsules of the joint.
It also does not align with current research on muscle flexibility (Guissard et al, ACSM). Muscle flexibility is not actually an elongation of the musculature. It’s the central nervous system (CNS) allowing the muscles to relax more over time but only when stretching done properly and we help the body to stabilize itself with the new range of motion.
Many times, when we stretch passively, we’re putting enormous load on the ligaments, capsule and labrum of the hip, and this causes more microinstability (and eventually, true soft tissue injury)
The other component that I’ve seen is using soft tissue mobility work to quickly increase range of motion in the hips. I personally think that this creates 2 problems.
- The body cannot control the new range of motion in the hips causing the potential for increased injury there
- Most of range of motion that is increased is usually not hips at all, but rather lower back flexibility
The later can be even more dangerous than the first point because most gymnasts are not prepared to accept the new low back range of motion because their core control is not up to the level needed.
These techniques, in my opinion, are all dangerous if not married with control. Using passive overstitching and pushing on a gymnast in splits is just plain stupid. Using the soft tissue is a much better idea, but you have to make sure your gymnast can accept the load…keep reading to get more information on this.
Back to Microinstability
The CNS, the controller of our whole body (think brain and spinal cord), does not appreciate microinstability in joints, and reacts to this instability by splinting the hip joint, and the CNS uses the large muscles around the joint to do this. These muscles include the iliopsoas (hip flexor), gluteus medius/minimus, tensor fascia latta, and adductor group (groin muscles).
Think of it this way, the big muscles jerk the femoral head up into the socket limiting its movement so as to protect it from the subluxation and micro instability that the CNS deems as dangerous.
Now, we’ve created tightness that was not previously there.
Here’s the deal, when you notice that your gymnasts hip flexors, groin muscles, and gluteus muscles become tight, your gymnast is splinting their hips to protect them.
So when we force a stretch, we’re trying to overwhelm the protection mechanism of the body, and this usually just creates further injury.
The hip is THE pivotal structure of the lower half of the body. It’s movement can be key to protecting the lower back and lower extremities (like the knees), but when the muscles start to splint the hip, and we push through we start to instigate the CNS even more, and we start creating a cycle of splinting and protection that limits movement.
The low back and the hip are intimately related (BFF’s) because of their proximity. The hip, according to SFMA theory, is a mobile joint, and it likes to move. The lumbar spine should be relatively stable. The lumbar spine range of motion is limited in comparison to the thoracic spine and hip, but it does likes to move under compete control. Finding out more about core control is important for your gymnast, so click here to read more.
The hip becomes stable again when the muscles splint it, movement can be forced, but something else besides the hip has to make up for the motion and it is usually the joints above and below. This can be one of the main instigating factors in lower back stress fractures and knee overuse injury.
There can also be another side effect from this splinting…limited range of motion. Your gymnast and athletes become tight.
Why Do Muscles Get Tight?
Remember that muscles become tight for two reasons. Muscles get tight to either move stuff or protect stuff.
And usually when a gymnast becomes tight after having been flexible in the past, they are most likely trying to protect something.
So Let’s Protect The Hip
The great news is that if the hip is just in protection mode. We can help build reflexive stability in the hip and protect the hip against microinstability. We can build control in the hip!
Because in gymnastics, and plenty of other sports, we create an environment of instability in the hip, we have to continually go back to reseting the hip out of splint mode and into movement mode. We have to make sure the smaller muscles of the hip (low threshold muscles) are turned on and ready to support the head of the femur in the acetabulum prior to large muscle movement (high threshold movement).
Physical therapists call this joint centration or joint kinematics, but calling it “optimal position of the joint prior to movement” better describes what is going on.
In the hip, there are small, deeper muscles like the piriformis, gemellus, obturator,and quadratus femoris muscles. Their main job is to optimally position the head of the femur in the acetabulum just prior to the large muscles of the hip taking action to move the lower extremity. The head of the femur is stabilized and protected in the joint when these muscles do their job first.
Control First, Power Second
So how do we create control in a young athletes hip?
We do this by encouraging low threshold, optimal position muscle activation. The first two should be done every day. Here’s our progression:
- Core control and breathing
- Hip dynamic stability drill on back (must watch and implement every day!)
- Cross Crawl/dead bug/starting bear crawls
- Tall kneeling stress
- Chops and lifts
- Sport specific drills with bands (we have to build control at higher ranges of motion and more stress) Check out this post from Dr. Dave Tilley with more sport specific drills for gymnast’s hips.
DON’T DO THE ADVANCED, SPORT SPECIFIC DRILLS IF YOU HAVEN’T WORKED THROUGH POINTS 1-6!
This is also how we prevent hip injury in the future. We have to continually build control, and return to control in the future. We recommend adding core control and hip stability to every warm up and every cool down.
Doing the exercises often helps your gymnast’s bodies to know it’s OK to move and they don’t have to splint in order to protect.
We can also gently stretch the structures around the hip, and doing gentle soft tissue is also a way to increase mobility in the hip…BUT REMEMBER,
Stretching is a process NOT an event!
Part of the process is not taking muscles and joints past the point of anatomical limitations. We also have to go slow and let the body adapt to the new range of motion.
To stretch your hip, start of with some gentle foam rolling and then stretch. Never stretch to pain. Pain starts the splinting cycle that we talked about earlier and isn’t effective for long term performance. Here’s a video on how to do it.
We also need to create stability in the hip once we stretch or do soft tissue. We give ourselves a window to increase stability and control with mobility work. Get back to the hip control exercises to make sure we give the body the best possible potential to keep the gains we make with stretching and soft tissue.
So there it is. Keeping the hip under control is a vital part of protecting our athletes from injury now, but also it helps to build really cool habits that last a lifetime (the Gymnast Care motto). These are activities your gymnasts can do no matter what sport they do in the future and they can be protected from hip DJD, back pain, and injury as an adult…so keep at these.
If you have a question, make sure you leave it in the comments below.