Lifestyle, Pain Relief, physical therapy

Hip flexor pain: What causes it and how can I fix it?

A common issue I see quite a bit with my clients is pain/tightness in their hip flexors. I see it in all types of clients, all sports, and all work professions. Stretching can provide temporarily relief, but if you are still having issues, then listen up! We are going to take a little more in depth look at the biomechanics of the hip flexor and some treatments for improving them!

Figure 1: The hip flexor complex
Figure 2: Anterior Pelvic Tilt

The hip flexor is made of the psoas and the iliacus. The main job is to flex the hip, but if you look at the attachment points, you can see that they have a much bigger impact. The iliacus attaches along the inside of the pelvis. The psoas is attached the lumbar spine. Doing activities that create load on the hip flexors (we will get into this later) will create tension on the pelvis and create a forward rotating pelvis (see figure 2). This pulls your spine into too much extension and creates issues related such as tight back muscles, tight hip flexors, and tight quads. This poor pelvis position will also pull the hamstrings taut, making you feel like your hamstrings are tight all the time. They really aren’t, the pelvis position just continues to put constant tension on them, making them feel like they are tight.

Oh, but there is more! There is one more SUPER important muscle and connection that is not being show on figure one. While the figure shows the hip flexor attachments, it doesn’t show a very important muscle that it is also attached to – the diaphragm. Which brings me to figure 3. Check out that diaphragm! Notice the right looks different from the left in not only shape, size, but also attachment to the spine. Cadavers have proved that the diaphragm is fused with the psoas. This has proved biomechanically to be a MAJOR connection between the trunk and lower body. The diaphragm is also a major player in controlling ribcage mobility, lumbar stability, and spinal flexion.

Hip flexor pain, or tendinitis/bursitis is created with activities that are repetitive. This can be walking, running, or the non-activity repetition such as prolonged sitting and standing. If you sit for work for 6-8 hours a day and then go out for a run, you haven’t given your hip flexors a break at all, regardless of the change in activity. Also, lack of awareness in pelvic position while sitting, standing, or strength training is also a cause in lack of improvement in tightness. In order to get true hip flexor relief, you have to be aware of your position.

Here’s some examples of some common exercises that help improve position, but also come with a load compensatory patterns.

  1. Hip lifts/bridging: Don’t get me wrong, I LOVE BRIDGING! The posterior chain is super important for altering an anterior tilt. But, when you are bridging, however that may be, are your feeling strain in your back? If you are, even if you still feel hamstrings too, you aren’t doing it completely correct and your hip flexors are still tight. When you perform a hip lift, you should feel your hamstrings, then abdominals, and then at the top your glutes: IN. THAT. ORDER. You should feel nothing in your back, hip flexors, or quads. How do you fix it? Lower your bridge height, reduce the progression until you feel the correct muscles and so that you can do a basic hip lift correctly and then add progressions back in.
  2. Lunges: When you lunge, you should have equal weight between both feet, and you should come up by pushing through your front foot, straight through the arch. So if you are doing a lunge with your left foot back and your right foot forward, you should lower straight down keeping your ribs tucked in and your tailbone tucked under, and then push through your right heel to rise feeling your right hamstring and your left glute. Feeling too much quad is a clear sign that you are very anteriorly tilted.
  3. Planks/push ups: This one involves more attention to the psoas attachment at the diaphragm. Prone positions are even more difficult to maintain a neutral tilt, because you having to now fight gravity. When you are in a plank-type position, the ribcage should be tucked under and you should feel your diaphragm active. Your tailbone should also be tucked under and your glutes should be active. A glute WILL NOT activate if you are not to at least a neutral pelvis!

So what happens if you work on all of these things and you still can’t get into the right position? Depending on how long your hip flexors have been tight and the activity level that you do, this pattern may be ingrained pretty deep. There are a few options for you:

Physical therapy: You knew this one was going to be first! Literally 2-3 visits with a specialized PT can clean up these patterns. You could have an underlying pelvis restriction preventing you from moving. Once the restriction is manually fixed, your hamstrings and glute will start firing and you will be able to continue on your own. You can learn more about a really awesome one in Charleston here. 😉

Personal training: Another great option. You don’t have to go to one forever, but if you are serious about working out, a few weeks with one isn’t a bad idea. They will teach you the body awareness you need to ensure you are exercising correctly. There’s a great spot here.

Pilates: Pilates is all about learning a neutral spine. They are excellent at breaking down exercises to the foundations and teaching you how to maintain proper positions. Plus, it’s really hard and challenging! It could be just enough to teach you the awareness you need.

References: Siccardi, Marco & valle, Cristina. (2018). ANATOMY: PSOAS MAJOR MUSCLE.

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