The Hipsters guide on the management of Hip “Tightness”
“What’s the best stretch for tight hip flexors?”
“How do I target my glutes tightness?”
“No matter what I do I can’t get rid of the tightness in my groin”
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Tightness around the hip has been misunderstood for a long time now, including by me.
A report from patients of “tightness” is often mistaken for a soft-tissue of some sort (e.g. muscle) that is short (i.e. tight) and needs a lengthening intervention (e.g. stretching). This is particularly common in young active people who are involved in repetitive hip bent and twisty (flexion +/- rotation) activities such as football (soccer, AFL etc), tennis, hockey and other similar sports, usually around 16–25 years of age.
For the 40+ population experiencing tightness in their lateral (side) hip, this blogpost/article doesn’t apply, those will need to be screened for Gluteal Tendinopathy (aka Greater Trochanteric Pain Syndrome) as well as what is discussed below.
The below picture demonstrates some areas of common areas of tightness reported by patients, areas that are in the vicinity of: Hip flexors, glutes, ITB/TFL, Adductors, Quads.
I have seen many patients who have been prescribed stretches, foam rolling, trigger pointing and numerous other exercises or interventions that are soft-tissue focused, with the aim of “improving flexibility” or targeting “trigger points” to “release” these soft-tissues (e.g. hip flexors, glute, piriformis etc.)
I have also seen many patients given “mobility” exercises to force extra mobility into their hip joints based, usually, on the advice of a well-meaning fitness trainer who is trying to get them to squat deeper. Instagram and social media is full of “increase your hip mobility” exercises.
All of these interventions, whilst providing short-term relief, have failed to help these patients with their “tightness”, some have made them worse. Yet patients will continue to do them even though they are just ‘scratching an itch’, putting a stimulus into an area that temporarily overrides a ‘feeling’ (tightness), and the problem with ‘scratching the itch’ is that the ‘itch’ will require a bigger and bigger stimulus over time to achieve the same short-term effect.
Having previously (several years ago) seen no improvement by targeting the “tightness” with ‘lengthening’ interventions (massage, stretching, trigger point, active release etc.) I had a closer look at the hip flexors and proposed that the iliopsoas tendon at the front of the hip may have been getting stirred up by being stretched (compressing into the hip joint) and compressed into flexion as well. I borrowed the Tendinopathy model from other tendons to explain that the the hip flexors probably won’t like stretching due to compressive forces and the best way to reduce the “tightness” feeling would be an ‘optimal load’. Little did I know that the patients at the time were experiencing the same short-term relief (scratching the itch) that all other modalities provide, but it was not a long-term solution.
I was wrong. Yep, I disagree with my past self, whilst patting my past self on the back for trying and sharing his clinical thoughts and experiences.
After seeing other areas of chronic ‘tightness’ across the body that were not caused by soft-tissues but were a “sensation that was referred from a nearby structure” (Upper traps from Cervical Spine, Distal Quads from Patellofemoral Joint, Quadratus Lumborum from Lumbar Spine) I have realised that many of these “tight” hips, groins and buttocks were in fact:
The Hip Joint.
The Femoroacetabular Joint (The Hip Joint)
It’s difficult to summarise the complex hip joint, however it can be simplified as following:
- It’s a ball (femoral head) and socket (acetabulum) joint
(Latin: Acetum=Vinegar, -abulum =Container…therefore acetabulum = little vinegar cup)
- It is a much more stable joint than the shoulder (another ball and socket joint) due to the depth of the socket (acetabulum). The more “coverage” there is by the acetabulum the more stable it is, but the trade off is there is less mobility.
- There is articular cartilage on the femoral head and there is a Labrum in the acetabulum. Like the labrum in the shoulder (and similar to the meniscus in the knee) the hip labrum further helps deepen the joint and provide stability as well as dampen/distribute forces from the femur into the pelvis.
The thing about the hip joint, that makes it different to the other joints is that it’s what I call a “quiet, slow cooker”. Whereas other joints can be stirred up quickly (and settle down quickly) hip joints can take months and years to overload/stir up and get ‘cooked’ (discomfort, “tight”, pain), and likewise take months/years to settle down (if at all).
They are “quiet” because they are deep and we just don’t get the clear nociception input (peripheral nervous system detection of painful stimuli) that we get from the other joints. What we do get is often a vague and widely distributed feeling of “tightness” and “achiness”.
The below diagram demonstrates where the hip joint refers when it is ‘cooked’:
You’ll notice that the common areas of the sensation of “tightness” referred by the hip joint mimic the common areas of “tightness” that have been traditionally labelled as “(Muscle here) Tightness”, especially Glutes and Hip Flexors, and sometimes ITB/TFL and Quads (interestingly much less often hamstring/calves).
So what is “Tightness” then?
When a patient reports they feel “tightness” this is their translation of a nervous system input. In this case it is their report of a sensation that feels like “tightness” but often does not have anything to do with ‘shortening of a soft-tissue’.
This is an important distinction to be made which I have written about previously (see Cervical Spine Pain and Upper Traps Tightness) and I think it applies across the body. I have seen “tightness” that is not soft-tissue related but is a joint-referred sensation in the:
- “Upper Traps” referred from Cervical Spine
- “QL” or “Glutes” referred from Lumbar Spine
- “Glutes”, “Hip Flexors/Groin”, “ITB/TFL”, “Quads” referred from Hip joints
- “Quads” referred from the Patellofemoral Joint
All of which have traditionally been managed with stretching and massage and other soft-tissue interventions.
The Metaphor that works the best for me and my patients is
“The referred sensation of ‘tightness’ is like an ice-cream headache or a brain-freeze. A stimulus (cold at back of the mouth) is producing a sensation (pain) somewhere else (in the brain). The stimulus and the sensation don’t match here, you don’t feel “cold” in the brain, you feel “pain”.”
Likewise several structures in the body commonly refer a sensation of “tightness” somewhere completely different due to a stimulus (nociception). No patient with patellofemoral pain points at their kneecap and says “my joint hurts”, they come in and report a vague tightness or pain everywhere around the kneecap, this is the joint-referral pattern for that particular joint. Likewise, no neck pain patient comes in and jams their finger into their neck onto their spine and says “I have neck pain”, no…. they vaguely rub their surrounding upper traps area or up in to their head. As you can see from the below picture, the same can be said for lumbar spine, no patient sticks a finger into their right L5/S1 facet joint and says “that hurts”, no….they rub a vague area in their QL/Glute and sometimes beyond.
The problem with targeting the “tightness” (which isn’t soft-tissue related) with modalities such as massage guns, trigger pointing, stretching is essentially you’re throwing a stimulus at a sensation to ‘drown it out’, pretty much like “scratching an itch”. The problem then is, over time, a patient will require a bigger and bigger stimulus to ‘scratch the itch’ and get ‘temporary relief’. Too many times I have seen patients excessively stretching hip flexors and/or glutes or purchasing more and more soft-tissue toys such as trigger point balls or expensive massage guns just to ‘scratch that itch’ when all they are doing is 1) ignoring what the hip joint is trying to tell them by drowning it out and 2) further stirring up the joint underneath… leading to more “tightness”.
Well how do I know if I have soft-tissue-length-issue or just a referred sensation of “tightness”?
Simple. Get assessed.
Qualified and registered healthcare professionals are (should be, not always) well trained enough to test your soft-tissues and then your joints and then differentiate the patients feelings from that assessment.
If a patient reports “hip flexor tightness” and points to their groin a Clinician should do a ‘Thomas Test’, if there is no significant difference between the legs dropping off the edge of a treatment bed/plinth/table, and the hips have extension this should suggest there’s no issues with quads/hip flexors soft-tissue length.
Flexing the knee helps give you an idea of rectus femoris vs vastus-group tissue length differences. However, if the suspected hip joint is cranky, there may be some muscle guarding or increased muscle tone in the hip flexors that restricts hip extension. This becomes then becomes a chicken-or-the-egg scenario, is the hip flexors causing a joint issue or is a joint issue causing a hip flexors issue? In my experience, many soft-tissue “tightness” issues around joints are joint-driven issues.
To quickly assess the hip joint, if the Clinician finds that there is pain or reproduction of “tightness” past 90degrees of hip flexion and/or with a hip Scour test or FADIR test (Flexion+Adduction+Internal Rotation), that would suggest that it is the hip-joint referring a sensation of “tightness” rather than the hip flexors being tight.
These tests are somewhat reliable to be sensitive although not specific, what is not reliable is poking the hip flexors and asking the patient “does that hurt” or “does that feel tight”. Grab a bunch of pain-free people off the street, without any history of injury/pain around the hips, and poke their hip flexors and you’ll probably find a good handful will be painful. Do the same experiment with hip joint testing and you’ll find it is much less and those that are painful will end up reporting that they have in fact had vague symptoms intermittently most of their life.
Hip flexors (funnily enough, just like the long-head bices tendon… more shoulder similarities) do not like being poked and are (more often than not) painful to poke, especially in those with long-standing hip pain, as will be further elaborated below.
So what is stirring up the Hip Joint?
The hip joint, in the absence of trauma or an accident, gradually starts getting stirred up over weeks, usually months and years (slow cooker), typically with activities that involve one or a combination of the following:
- Loaded deep hip flexion (eg: deep squats)
2. Loaded hip flexion with rotation, especially internal rotation
Sometimes the hip joint pain occurs as a result of a condition called FAI (FemoroAcetabular (..hip) Impingement).
FAI/Hip Impingement
Some people have developed ‘extra bony anatomy’ in their hips. More bone results in more stability in a joint, however there is a mobility cost. The difference between mobility (joint range of motion) and flexibility (soft-tissue length) is often forgotten in the general public and some healthcare professionals and definitely many Social Media fitness and health gurus.
If the extra bone grows on the femoral head (the ball) it’s called a ‘Cam Lesion’ which is more common, if it’s on the acetabulum (the socket) it’s called a ‘Pincer Lesion’, which is less common and if it’s both (on the ball and socket) it’s called a ‘Mixed Lesion’.
This extra bit of bone reduces the available range of motion in the joint as the two joint surfaces contact each other sooner.
When a patient:
1. Reports Hip Joint Pain with hip bent/twisty activities
2. Has pain on Hip Joint Assessment
3. Has a Cam, Pincer or Mixed Lesion on Xray
They are diagnosed as having Femoroacetabular Impingement or FAI (femoral + acetabulum = hip… so basically Hip Impingement) (Griffin, Dickenson et al. 2016).
It’s unclear whether there is a genetic predisposition (aka “born with it”) or whether these hips develop over time, however the current consensus suggests that it may develop as a response to cumulative and repetitive heavy loads on the hips during peak growth phases in early adolescence. Specifically with very active kids participating in many hours/week of hip bent (flexion) and twisty (rotation) sports.
A Cam Lesion is much more common, there is still debate and discussion about all of this but perhaps it is the lesion that develops during adolescence in active kids doing hip bent and twisty sports. Acetabulum Pincer lesions (similar to acromium slope/shape…another shoulder similarity) seem to be less often, or in my experience appear to only be involved in causing FAI when there is also a Cam Lesion (mixed lesion). Perhaps Pincers are quite common out there in the population (similar to the acromium slopes in the shoulder) and perhaps are more asymptomatic (no issues) in the absence of a cam lesion. Who knows..?🤷
Bent (Flexion) and twisty (rotation) sports that FAI incidence is higher include Soccer (Football), Hockey and Tennis, or specific athletes in sports such as Baseball Pitchers (front leg), particularly in kids who participate in many hour/week in that sport, and FAI is especially more common in “big kids”, kids who are large (large body mass, but not necessarily obese) for their age.
Bone simply grows where bone is needed and it grows in response to the external inputs place on it therefore it’s my opinion that active kids with a high hip stability requirement due to their sport grow extra bone in their hip to assist with their stability (at the expense of mobility).
There is a saying in Veterinary Science which we have stolen for Human Medicine:
Don’t run big dogs too soon.
In other words, big mammals (dogs, humans….elephants) who are still developing skeletally (early adolescence) shouldn’t have extreme or high levels of mechanical load through their joints. Joint cartilage takes time to ‘condition’ (like a callous forming on a hand with repetitive load, instead of a blister) based on the load put on it over time.
There is also a ‘red flag’ (must be screened for) condition that is unrelated to this topic of “tightness” that affects 8–15yo kids that can also be impacted by active and large kids called Slipped Capital Femoral Epiphysis. I won’t go into detail about what it is however it is a tricky bugger to catch early and it is yet another reason (along with Perthes Disease in younger kids) why parents/coaches/carers/guardians need to get their kids in to see a Registered Healthcare Professional (Orthopaedic Specialist, Sports Physician, Physiotherapist) for assessment and management.
Back to cranky, tight hips….. what’s also interesting is we often see this hip pain in the acute stages during adolescence, but because active kids who are doing many hours/week of their sport are often hurting everywhere (growing pains), more often than not we catch these hips when these kids are active adults in their 20s and 30s as demonstrated in the below graph.
Watch out for “Mechanical Symptoms”
When patients report a “clunking” and/or a feeling of immediate instability (less common in atraumatic cases) or when there is a clear blocking-type restriction on hip ROM assessment limiting hip flexion to <90deg, and especially if there is a history of trauma, the Labrum must be investigated.
Often on plain MRI (non-arthrogram) where there is a gradual wearing down of the labrum (in the absence of trauma) or any articular surface cartilage you may see sub-chondral (under cartilage) bony oedema.
Metaphor time: Articular Surface Cartilage is similar to the thick fondant icing on a wedding cake. It protects the lovely spongy cake underneath from the rest of the world. If there’s a big enough issue with the Icing (the cartilage) the cake underneath will be impacted (the sub-chondral bone).
One of my experienced Physio (and life) Mentors plays with fancy cars in his spare time, his analogy is: “Articular cartilage and bone is like the paint on a car. The pain has the paint-protector on it that protects the pain and the metal underneath from further deterioration. However if that paint-protector wears out (either over time or with extra help) the pain below and the metal can deteriorate too”.
When the articular cartilage is not doing its job well enough this will appear on MRI as a signal in the bone (water) which indicates bony oedema.
However, when there is clear “mechanical symptoms” (clunk, ROM restriction, instability) and especially a history of trauma (acute or overload), an MRA (MRI + arthrogram) might be indicated to better contrast the joint surfaces and rule out significant and unstable labral tears which may require arthroscopic (surgical) intervention.
Can I get hip joint referred pain without FAI?
You betcha!
Case Study 1 — Cam Lesion in the other hip
Consent given by patient.
I recently had a 40yo male who trains in Jiu Jitsu and Judo get hip-joint referred pain, he had a big restriction in his hip flexion (90deg and pain) and internal rotation added to that made it worse. His other hip was not symptomatic (not causing tightness/pain) at the time but had similar but less restriction in these ranges. At 40 he is very disciplined with his stretching to maintain his flexibility so he can compete in what are both very hip bent and twisty sports.
A Bilateral Hip Xray was ordered and we found the painful hip was clear, and the hip what was fine had a cam lesion…. which is an example of how:
1) The radiology (Cam Lesion) does not always match the Clinical Symptoms (pain-free)
2) XR imaging doesn’t always show what’s going on but can rule out what isn’t.
In his case, his hip joint simply couldn’t tolerate the hip bent and twisty loads that were being put through it in Judo and Jiu Jitsu and he developed symptoms referring from the hip joint.
He asked how he could still “stretch” his glutes, I asked him where he’s been feeling it when he does “stretch” his glutes (he pointed to his groin, indicating his hip joint). I had to educate him that it’s unlikely he can get his glutes on stretch with his hip anatomy (long-term hip flexion restriction of 90–100deg) and if he would have to target the glutes directly with soft-tissue toys like trigger point balls or foam rollers if he wanted to.
What exactly is causing the pain or ‘feelings of tightness’
You’ll notice I’m yet to mention “what structures are causing the pain” because this is a brain-tickler. Even with an MRI it is often difficult to nail down what exactly is causing pain in many joints. The term “non-specific (region) pain” is popping up recently in research and it is a way for Clinicians to say “we know the issue is in that (region) but we can’t say for sure what is causing the pain, but it won’t change the management, you should get better so we aren’t concerned about the specifics and we may never know what the specifics are”. The most common area for this term currently is for low back pain, ‘Non-Specific Low Back Pain’ (NS-LBP), and there’s also ‘Rotator Cuff Related Shoulder Pain’ (RCRSP) for the shoulder too.
Whether or not patients should be given a “non-specific” diagnosis directly is debateable, personally I’d never tell a patient “You have non-specific back pain” … it’s not nice to get a ‘label’ like that in my opinion, it’s probably better to save the ‘non-specific’ terminology for research and for chat amongst fellow clinicians.
But rule out other stuff — Differential Diagnosis
A Clinician should always rule out everything else around the hip including lower back and pelvis causes of discomfort. Lumbar spine and SIJ conditions are usually difficult to rule in but easier to rule out, so ruling these out can be quite simple.
The day after I first published this I had a long-term intermittent “buttock pain” patient, during assessment whilst trying to differentiate SIJ vs Hip I asked her to hop but she was very hesitant but was able to do it to her own surprise. There was no pain on other SIJ testing (shear, thigh thrust etc.) so in this case I was happy to rule out SIJ. In her case, end of range hip flexion and 90deg flexion + internal rotation of the hip reproduced pain.
What is the best way to manage a cranky hip?
Glad you asked…..
Education and Activity Modification
I educate the patients on all what stirs up the hip through the day or during their sport and we dial everything back where possible, basically avoid or greatly limit things that stir the hips up.
This includes loaded bent and twisty hip stuff (sports), and prolonged positions (sitting with legs crossed, hip flexion).
If needed I recommend they make changes to their sitting, if really cranky I might recommend a high-density foam wedge to sit on, to open the hip joint up (reduce hip flexion).
Oral NSAIDS
If the patients hip is particularly cranky and causing night time pain, I will recommend they see their GP or a SEM Physician and discuss whether oral NSAIDS (eg: Meloxicam) are indicated and can help over 2–4 weeks. There’s a time and a place for oral NSAIDS, I’m always careful to screen patients for contra-indications for nsaids use and will use my GP colleagues to help me do this as there are many adverse reactions that can occur (Davis and Robson 2016).
Strengthening
Across the body, where there is significant pain there is weakness nearby (ie: ouchy ouchy = weaky weaky), we see this in the quads with knee pain, rotator cuff with shoulder pain, glutes with hip pain, trunk or “core” with back pain etc.
Regardless of whether it’s chicken or the egg I will prescribe strength exercises for the hip, lower limbs and sometimes the trunk for hip patients.
Many traditional glute exercises involve deep hip flexion (eg squat) so sometimes hip strength exercises may include things like monster walks, hip hydrants, clams (here come the hip clam internet nazis), side lying leg lifts etc.
If the patient is a high-level athlete I will also screen strength around their hip (flexion, extension, abduction, adduction, internal and external rotation) with hand-held dynamometry to get an idea for any areas that require attention and then prescribe exercises accordingly.
Mobility
Hip Mobility exercises? I don’t give these out anymore for patients who have hip joint referred pain, I educate the patient that “you should respect the mobility that you have”. Often hip mobility increases as hip disability/pain decreases. By the time patients hear this from me they are often relieved as they have tried every possible “hip mobility fix” they have googled or seen on Instagram.
For those who don’t have hip joint referred pain lacking mobility, sure, I’ll give them a bunch of mobility exercises. Here’s a nice page of mobility exercises by Mike Reinold: https://mikereinold.com/6-hip-mobility-drills-everyone-should-perform/
Long-term restriction in hip mobility often is coupled with a lumbar spine mobility restriction, particularly in lumbar spine extension and rotation. I will often prescribe spinal mobility exercises such as knee rocks, cat-cows/camels, open the book, thread the needle etc. to keep their lower back happy.
Static Stretches
The hip joint isn’t tolerating hip flexion, so if they feel “glutes tightness” which is a hip joint referral and the hip is cranky in flexion and internal rotation is it really a good idea to give a glute stretch? This might seem like a silly and loaded question, however it is a commonly prescribed exercise and does nothing but causes further irritation in the hip joint (and therefore further “tightness”…so … just needs more stretching right?.. wrong.)
Hip flexors? Sure, if they can tolerate hip extension then go for it. However, there is still a possibility that iliopsoas getting internally irritated being compressed against the front of the hip joint so as long as that’s been ruled out go ahead and ‘scratch that itch’, if it feels good, do it.
Rub their butt?
Why?
Needle their glutes? Double-why?
Their glute “tightness” or hip flexor “tightness” is a feeling. Sure…. Rub something hard enough, or stab it with a horse needle and you won’t feel the other feeling (scratch the itch)… but for a short-time only.
If a patient wants to poke pointy things in their hips (massage guns, trigger point release) I’m more than happy for them to do that if it helps them “feel it less” for a short time, I’m a big advocate of “if it feels good, do it… but in your own time” unless it’s something like a glute stretch which may “feel good” but has potential to do harm (stir up the joint…. or the gluteal tendon in gluteal tendinopathy…or stir up a sensitised sciatic nerve…).
Would I still do it if a patient asks me? Absolutely, always happy to provide some short-term relief from pain or discomfort as long as I gain informed consent (the ‘informed’ bit is telling them that it’s just one stimulus drowning out another for a short time and won’t fix or cure them or accelerate their recovery). If a patient doesn’t ask for it? Nope. It’s funny how the less I offer it to more patients don’t accept it especially once they understand the locus of the ‘tightness’ they feel, they’re happy to discuss and practice their rehab program.
If I am doing any form of hands-on work and a patient asks “can you feel that tightness?” I always say the same thing (based on my honest opinion, experience and the available evidence) “no I can’t feel that, but you can”, their ‘tightness’ is their sensory input.
Gradual return to activity
Once the patients pain-free range of motion increases and they are reporting less symptoms I’ll plan with the patient a gradual return to appropriate activities.
As mentioned earlier in this post, hips are a “quiet, slow cooker”, they take a while to stir up, they take a while to get better, even once the symptoms subside the joint may not be ‘conditioned’ and will take many months (sometimes years) to get back to previous high levels of activity.
‘Resurfacing’ a medical-sports-documentary on Andy Murray (former world number 1 tennis player) (https://www.imdb.com/title/tt11243364/ ) is an intriguing watch and there are many lessons in there on managing a very complex hip.
The key messages to come out of this doco for me were: “Always give a cranky hip extra time than you think when returning to high-levels of sport” and “Don’t compare your cranky hip to another persons cranky hip”, in the doco Andy was calling Lleyton Hewitt (who had a pretty quick turnaround after hip surgery) to get an idea of how long he’d take (spoiler: Andy should have taken longer but he rushed it).
Case Studies
These patients have also kindly provided consent for me to share their de-identified cases with you.
Case Study 1 — Tight hips in a middle aged man
A mid-40s tall male saw me for left groin pain and “hip flexor tightness” which he’d had for 20 years, normally comes and goes within a week but this time was sticking around for a few weeks.
He was getting hip tightness walking the dog, discomfort and difficulty lifting his leg up whilst seated (hip flexion) and getting in and out of a car.
He reports recently (last few months) he has been sitting more for longer periods due to occupational reasons (and covid).
He reported no lower back issues, but I probed a little further with his history and found out:
- He was a big boy early (10–14years old) and he played many hours/week of AFL (Aussie Rules Football)
- A month ago he had been doing A LOT of paving (repetitive bending over and twisting at the hips +/- lunge and twisty squat movements).
On assessment:
- R=L Thomas Test (no difference in “hip flexor/quad length”)
- Groin pain with Hip Fl >90 — Made worse with FADIR test
We discussed the likelihood of him having “stiff hips”, perhaps due to his anatomy which developed either at birth, during adolescence or at birth. Suggested it might be due to something like a Cam lesion but imaging isn’t necessary as it should settle down with activity modification and imaging won’t change management.
He was given activity modification advice, what to activities (loaded hip bent/twisty) and resting hip positions (prolonged hip bent/twisty) to avoid.
He was encouraged to continue to run/jog, as this shouldn’t’ stir it up further and to get the car seat tilted down.
He came back in a month and was much better and said “it’s strange, it is better but I didn’t’ do anything to make it better, I just avoided things that made it worse”.
Yep, another case of Activity Modification being a great management tool.
Case Study 2 — Painful hip in a Tennis Player
A female 16yo state and national level right handed tennis player presented with left anterolateral (front and outside) groin/hip pain during peak training in the lead-up to multiple representative events. She was particularly working on her serve recently and serves/week, training sessions and matches gradually dialled up to high levels over the previous couple of months.
Pain was all of the time and started a few months earlier on follow-through during the serve whilst landing on her left leg (hip flexion and internal rotation). This young lady was large for her age from early adolescence.
She had a past history of lumbar spine pain and ROM restriction however this was clear on assessment.
She had hip pain past 90deg Flexion which was made worse by FADIR test.
She was keen to keep training if at all possible due to upcoming rep events.
Initial management included:
- Lumbar spine mobility
- Restriction/dialling back deep hip flexion activities (squats, rowing machine, glute stretches)
- Restriction/dialling back low priority serve loads (not at training, save it for matches)
- Dialled back all other training groundstroke loads
- Education/activity modification for resting hip positions involving hip flexion and rotation
- Hip/Trunk strength
Two weeks later she was back and there was no change.
We ceased tennis completely and to back me up with that call (stopping her participation) I also referred her to a SEM Physician, with a referral for bilateral hip xray on the way to her review with the SEM Physician, which did find a left hip cam lesion, indicating Femoroacetabular Impingement (FAI diagnosis requires 1) patient reporting symptoms, 2) clinician reproducing symptoms on assessment and 3) confirmation via xray).
It’s great to work with the local SEM Physicians when managing high-level athletes to back up tough calls and fine tune management of complex musculoskeletal conditions, whilst also covering the medical side of musculoskeletal conditions.
The SEM Physician agreed on the FAI diagnosis, backed up my call to cease sport, and prescribed oral NSAIDS. Furthermore, by the time the patient saw the SEM Physician she had a blocking-type restriction of her hip flexion and the SEM Physician discussed whether there was a need for a 3T MRI vs MRA to rule out a significant labral injury. The MRA of the hip would also involve a local anaesthetic which can help confirm the hip as a the pain generating source, and a corticosteroid injection could also be administered at the same time as the MRA.
In this case, the patient only needed 2 weeks on oral NSAIDS and complete cessation of her sport to settle her hip down, over that time we also kept her entertained with her lumbar spine mobility, upper limb/trunk/lower limb strength program, hydrotherapy and walk/light jog intervals.
We returned to tennis training (no serves) for two weeks and then gradually built up her serve load, monitoring her hip flexion and her symptoms over that time. Gradually the pain receded but the “tightness” stuck around to varying degrees and we used her reported levels of “tightness” as a guide as to how hard to push over her season.
Summary
Well there you go, those are my current thoughts on “tightness” around hips and why Clinicians must consider ruling out the joint first before targeting soft-tissue causes of “tightness”. I felt the sudden urge to write all of this out because I needed to update my previous blogpost (out of disgust with myself….) but I’m keeping that one published (for now) because it asks some good questions at the time and demonstrates how what we know today may be completely different tomorrow (I’m fully aware that this may be the case in 5 years after this blogpost).
Hips are complex, this was a big post and was simply on a common cause of tightness with the hip joint as the driver.
There are many other hip conditions that I didn’t touch on that need to be considered in active young people such as Hip Dysplasia, Traction Apophysitis, Lumbar spine referred pain etc., and also a crossover in the 40–60yo demographic such as Gluteal Tendinopathy (aka Lateral Hip Pain/Greater Trochanteric Pain Syndrome **shudder**… I hate the word ‘syndrome’)…..Gluteal Tendinopathy…. oh boy…. another commonly mismanaged condition.
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References
Davis, A. and J. Robson (2016). The dangers of NSAIDs: look both ways, British Journal of General Practice. 66: 172–173.
Di Silvestro, K., et al. (2020). “A Clinician’s Guide to Femoroacetabular Impingement in Athletes.” Rhode Island Medical Journal 103(7): 41–48.
Griffin, D., et al. (2016). “The Warwick Agreement on femoroacetabular impingement syndrome (FAI syndrome): an international consensus statement.” British journal of sports medicine 50(19): 1169–1176.
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