Why does my hip hurt when I squat? Femoroacetabular impingement considerations.
There are many clinical situations where restricted movement at the hip is apparent. Arthritis, joint prosthetics (ie. you’ve had a hip replacement!), traumatic damage like a capsular or labral tear, joint necrosis… the list goes on, you get the idea.
A common condition that you may have heard of, femoroacetabular impingement (FAI) is a contributing factor in some cases. FAI is a hip situation whereby the structure of the ball and socket joint creates a restriction to the range of motion (an “impingement”) in flexion, which is the movement created when you lift your knee, or in forward bending.
Fig 1 below shows 2 common types of these structural changes that create impingement. In the “cam” type restriction in a) on the left, the head of the humerus is excessively bony in such a way as to restrict the rolling around of the ball in the socket. In the “pincer” type restriction in b) on the right the acetabulum (socket) is excessively bony in such a way as to restrict movement in a similar manner. People with FAI may have types a or b, or both!
Fig. 1 an example of hip joint structural differences commonly seen in people with FAI. Cam (on the left) and pincer (on the right) type changes are shown.
This might manifest as pain or stiffness in activities like deep squatting, ascending stairs, running or even walking! Or, conversely, It might not manifest with any symptoms at all...
Some sources place the prevalence of FAI at 20% or more in the general population, but interestingly many people who have observable FAI on medical imaging are asymptomatic (meaning they have no hip complaints at all!). This is neat, or at least I think it’s neat! It goes to show that as with many injuries, we can have often have a few structural problems without any real impact on our physical functioning. The human body is pretty resilient!
Still, there are many folks for whom FAI does indeed contribute to pain or dysfunction. As mentioned, the presentation in such cases typically consists of pain and restricted range on deep squatting, lunging, pivoting actions, using the stairs, or running amongst others, everyone's unique situation looks a little different.
So if this is your situation, what should you consider doing to manage it. Well happily there are a few easy considerations you might make. Consider the following.
Activity modification: One of my favorite moments in movie history comes from the timeless classic The Karate Kid 2. In that film, the wise old Mr. Miyagi advises Daniel San, his protege, that the “best way to block punch is no be there”. In other words, if you want to avoid pain, don’t do painful things, like getting face punched in that particular case.
In our case we can switch out getting punched in the face with a few key movements that are known aggravators for FAI related pain. The movements that will aggravate FAI pain are deep hip flexion, adduction (crossing the leg over the midline), and internal rotation.
Functionally, this means that you should stay out of deep (end of range) squatting positions. This doesn’t mean that you can’t squat, just stay out of full depth positions.
Other things to avoid include valgus positions (think knock knee positions) and crossing your legs when seated.
Speaking of being seated, when things are particularly flared up you may also choose to spend some time in a reclined position, or even avoid prolonged sitting altogether by using a standing desk. The reason for this is that seated positions can drive your hip into aggravating levels of flexion, especially if you are angled forward at the trunk. Splitting your time between seated, reclined and standing positions (cycling through 20 minutes at a time for each) can be very helpful.
- Stretching: Stretch your psoas muscle! This is a muscle that when tight can pull the femur forward exacerbating the impingement action that is so problematic in FAI. There are a few methods for doing this. A lunge style stretch works wonderfully and is demonstrated at 4:10 in on an old old video of mine here. But you could also simply lay on your stomach for 5 minutes with a pillow under your knee to lift the hip, you pick your favorite!
- Strength training around the hip: Strength training the hip extensor muscles especially the glutes, as well as the hip lateral rotator muscles will help to keep the hip out of impinged positions and reduce you frequency of moving into impinged positions.
- Core control and strength training: Is there anything that core strengthening doesn’t help? The reason that core strength is helpful in managing FAI symptoms is that a rock solid core helps you to prevent moving into an anteriorly tilted pelvis position (See fig 2 below). This crummy position increases your angle of hip flexion and therefore puts the hip into an impingement position. It’s important to note that control is as important as strength. Mindful attention to your postures is just as important as the brute force that your core can generate. So practice the skill of beautiful movement! Practice controlling good postures. See the video above for more details on this.
Fig 2. Anterior pelvis tilt position shown on the left in (1), versus neutral position in (2) on the right.
Gait modification: While There is mixed evidence around how aggravating walking and running is for people with FAI, if you are a runner it may be beneficial to have a proper video based analysis and correction of your run gait to manage any maladaptive learned gait patterns. In general consider it a good idea to (during rehab) avoid hill running and to reduce the size of your stride, which most people with FAI will do by default anyway. On walking, avoid walking in along a narrow line (model style walking, or running a narrow trail).
Manual therapy: Manual therapy including hip tractioning of belted distraction techniques can help to reduce pain when FAI symptoms flare up. Obviously this is something that you would do most commonly with your physiotherapist, but there is a simple home traction trick that you can try on your own (see the video) that may be useful.
So there you have it, a few simple home tricks that you can use to manage your FAI symptoms. There is no magic wand, but a combination of approaches including exercise, avoiding aggravating activity and manual therapy can help.
FAI is a multifaceted condition and no two people have exactly the same presentation. You can ask your physiotherapist for guidance specific to your situation. Still, in general, most people dealing with this condition will benefit from the suggestions presented here and in the video above. Try this stuff out and see how it works for you!
Further reading (if you really want to impress your friends)
Diamond, L. E., Wrigley, T. V., Bennell, K. L., Hinman, R. S., O’Donnell, J., & Hodges, P. W. (2016). Hip joint biomechanics during gait in people with and without symptomatic femoroacetabular impingement. Gait & posture, 43, 198-203.
Cheatham, S. W., Stull, K. R., Fantigrassi, M., & Montel, I. (2018). Hip musculoskeletal cvonditions and associated factors that influence squat performance: a systematic review. Journal of sport rehabilitation, 27(3), 263-273.
Emara, K., Samir, W., Motasem, E. H., & Ghafar, K. A. E. (2011). Conservative treatment for mild femoroacetabular impingement. Journal of Orthopaedic Surgery, 19(1), 41-45.
Wall, P. D., Dickenson, E. J., Robinson, D., Hughes, I., Realpe, A., Hobson, R., ... & Foster, N. E. (2016). Personalised Hip Therapy: development of a non-operative protocol to treat femoroacetabular impingement syndrome in the FASHIoN randomised controlled trial. Br J Sports Med, 50(19), 1217-1223.
Wright, A. A., Hegedus, E. J., Taylor, J. B., Dischiavi, S. L., & Stubbs, A. J. (2016). Non-operative management of femoroacetabular impingement: a prospective, randomized controlled clinical trial pilot study. Journal of science and medicine in sport, 19(9), 716-721.