Do your hips feel tight or like you have a pinching sensation when you squat or during other activities that demand deep hip flexion?
This is a very common complaint we hear on a regular basis. Whether due to demands of a sport like Crossfit, weightlifting, cycling or from an increased amount of sitting in a different work setup (thanks, 2020!), it can be frustrating when many of the normal stretches don’t seem to offer any real relief.
This is a common issue that responds really well to conservative management including activity modification, restoring motion, improving muscle strength, movement mechanics, and motor patterns. This should be encouraging news! By following a specific plan you will be able to calm down irritated tissues and get back to doing activities you enjoy.
Step 1
The first step will be to remove or modify painful activities – this is a TEMPORARY adjustment to your daily and sports activities to decrease the irritation on already sensitive tissue. Continuing to assume pain-provoking positions can slow healing down, and our job is to create a healing environment through activity modification.
Through modification, you can continue to train and exercise by prioritizing movements that don’t exacerbate symptoms early in the treatment/recovery stages.
There are several ways to approach this part of the process:
1. Range of motion
2. Intensity (or Speed)
3. Loading
Changing Your Range of Motion
Using variations of squat form can help change the amount of hip flexion required and decrease stress on irritated tissues but allow you to continue training. Less hip flexion and more upright posture is a better choice if you are dealing with anterior hip pinching/pain with squatting.
Goblet Squats and Front Squats are good variations to start with because your torso is more upright and they require less hip flexion compared to the back squat.
Modifying Squat Depth and Improving Motor Control
Another consideration is the modification of squat depth and improving motor control in the bottom of the squat. Using “hover squats” - squatting to a surface just above where symptoms start and holding that position isometrically (muscles are working, but not moving) can help improve control in a position that is typically most difficult for those with front of hip pain. Holding the non-painful position (usually five sets of 15 – 45 seconds) can allow work on positioning while creating a pain-modulating effect on irritated tissues.
Step 2
Stop stretching the hip flexors. When you have pinching in the front of the hip, more often than not it has more to do with the position of the femur as it relates to the pelvis/hip socket.
You might feel pressure and tightness in the front of the hip leading you to think that stretching the hip flexor will help – when it can actually make things worse.
With front of hip pain, the hip flexors and especially the psoas, are often weak and overstretched while some of the muscles responsible for hip extension – hamstrings and adductors, are short, weak, and underutilized. Other hip extension muscles like the glute max, deep hip external rotators and posterior glute med are not working as well as they should. Since these muscles attach to the head of the femur and are responsible for pulling it backward – if they aren’t as engaged as they should be, the head of the femur can glide too far forward – leading to the tendency to feel the pinching sensation in the front of the hip.
A tight feeling muscle isn't necessarily a short muscle. Strengthening the hip flexors and improving strength and activation of the glutes and deep external rotators can help with better pelvic and femur position as they relate to one another.
Try the following to work on improving the posterior capsule to create more space in the hip joint:
Posterior Capsule Stretch: A great drill to improve squat depth and decrease pinching in the front of the hip is the posterior capsule mobilization. Most athletes will try to stretch the hip by using the pigeon stretch but after trying this one will be able to isolate the backside of the hip to allow for better movement of the hip into flexion. Spend 2 – 3 minutes on each side, 3x/week.
Step 3
A third consideration is ankle range of motion and access to ankle dorsiflexion. Improving access to dorsiflexion will allow better access to pushing knees forward over the toes in a squat pattern, decreasing the hip flexion demand in the movement. A quick way to see if this will be helpful is to try squatting with and without a heel lift (heels elevated on a change plate). If pinching in the hip is decreased when you are using the heel lift, then you would benefit from working on ankle mobility.
Step 4
Finally, try out different squat forms to find one that works best with your anatomy. Trying to squat a certain way because you saw someone else do it might not be optimal based on your skeletal structure. Some athletes need to squat with a wide stance, others will be best served with a narrow stance. Some athletes squat with their toes straight forward while others will require a slight turn outward.
More important than assuming a “correct” stance based on an arbitrary "ideal" is that the mechanics of the movement are clean and pain-free. A good squat involves whole foot contact with the ground, knees tracking over the toes, and a good understanding and control of spine extension.
*** Too many times we have seen athletes come into the clinic with hip pain from squatting as a result of being coached into squatting in a position that is too wide or narrow. Or they have been instructed to keep toes forward to create maximal torque. These positions are not ideal for everyone and you can still create the same torque with a toe out and wider stance position – especially when cued and educated on how to perform a squat correctly.
If you have spent time working on improving your mobility and strength and are still having pain or pinching with squatting, don’t just stop moving. Seek out help from a healthcare professional who understands the mechanics of squatting and wants to keep you moving and working out.
Having a plan to follow that is specific to you and your body mechanics and current sensitivity level will help move the dial forward and get you back to squatting pain-free.
Recovering from injury and irritation with squatting can be frustrating and annoying – find a provider who will be a partner in your journey.
The physical therapists here at 901PT are all athletes and have extensive experience working with athletes of all levels to get them back to one of the most fundamental fitness and functional movements.
If you have questions about what's going on with your hip and would like to see if you're a good fit for what we do, book a discovery call!
***Disclaimer: None of the above should be considered medical advice and should not be substituted for care from a licensed medical professional. Use the above as information for discussion and dialogue with your medical team.***