Hip Pain: What Helps, What Hurts
Hip pain. Clients of all shapes, sizes and ages complain about it. Hip issues can be as simple or as complex as each individual, and a good personal trainer knows how to assess for mobility and function and when to refer out to a physician or physical therapist. Recently there has been a lot of buzz in physical therapy and sports medicine circles about a “new” dysfunction of the hip called femoroacetabular impingement (FAI).
FAI is a pathomechanical process in which abnormal-contact stresses between the ball and socket cause joint damage around the hip, predisposing the client to osteoarthritis and labral degeneration. FAI-related pain may be felt in the groin, in the low back, around the hip and sometimes in the thigh. How do personal trainers properly assess this dysfunction in clients and know when to take certain measures? What type of programming is recommended when a doctor prescribes conservative treatment?
Programming Guidelines for FAI
As with programming for any client, it’s vital to take an individualized approach when working with a client who has FAI. To avoid “irritating” the client and to help her achieve her goals, emphasize quality, not quantity. The first step is to understand what type of FAI the client has (cam or pincer). It is crucial that you understand the pathology and communicate with the physical therapist and rehabilitation team, especially postoperatively if that is the case. For optimal outcomes, always consult the client’s physician and/or physical therapist.
Here are some points to consider when designing a training program for a client with FAI:
- What are the results of the fitness/movement assessment? Use the data to create a safe baseline.
- Factor in the client’s age, lifestyle, prior/present exercise habits and medical history.
- Explore how the data affect anatomical, biomechanical, physiological and neurophysiogical demands on the body.
General programming. Focus on lengthening tight musculature and then stabilizing weaker phasic musculature (glutes, hamstring and core). Combine this approach with aquatic therapy and cardiovascular exercise to train the client holistically.
Initially, teach single-plane exercises, such as horizontal leg press. You may progress to inverted leg press (avoiding end range), leg curls and hip extension (for example). This will create a foundation for more advanced exercises. When ready, progress the client to biplanar axis exercises, such as diagonal reverse lunge and diagonal forward lunge, to challenge the nervous system. This dynamic movement also recruits muscle stability while targeting the weaker sagittal stabilizers (gluteus medius and minimus) needed in everyday movement. Progress further to compound exercises, such as minisquat with mid row, reverse lunge with overhead medicine ball chop, and forward lunge with trunk rotation holding a medicine ball.
There are several exercises that should be avoided when training a client with FAI:
- deep squats
- exercises that involve excessive hip flexion with internal rotation or hip flexion with external rotation
- plyometrics, particularly box jumps
- any exercises that cause the client pain
Cardiovascular conditioning. A comfortable cardiovascular component is another essential piece of the programming puzzle. Have the client use machines such as the elliptical trainer, which will provide physiological benefits to the cardiovascular system but also increase circulation.
Strength training. Focus strength training on weaker phasic muscles such as the gluteus maximus, gluteus medius/minimus and hamstrings over the quadriceps. Exercise choice and type of equipment will depend on the client’s experience with exercise, his body type, his goals and whether or not the client has had surgery.
Flexibility. Concentrate the stretching protocol on tight hip flexors, quadriceps and the IT band. Introduce stretches in a controlled manner, and offer home practice options, such as a modified lunge.
Core training. Core stabilization is an important aspect of the overall program. Focus on the external obliques, quadratus lumborum and multifidi. Ideal exercises include bridging with a stability ball and standing diagonal trunk rotation with a cable or medicine ball held at chest level. Progress the latter move to a partial lunge with trunk rotation.
As the client improves, integrate more challenging exercises, such as wood chop with reverse lunge. Pilates and yoga can be good cross-training options, not only for their flexibility and breathing benefits but also for the core strengthening that occurs from moving in multiple directions. Of special note, swimming complements training, owing to the buoyancy principle and the relaxation effect. Most important, when working with any client, if there is uncertainty as to whether or not an exercise will cause pain or damage, ask a physical therapist or physician or do not perform the exercise.
While working with a client who has FAI may initially be challenging, a professional and well-thought-out plan of action that includes the client’s allied health professional team will garner results and appreciation.
For more in-depth coverage of FAI, please see the complete CEC/CEU article, “Exploring Hip Pain: Femoral Acetabular Impingement,” in the online IDEA Library or in February 2012 IDEA Fitness Journal.
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