In this blog we are going to talk about hip pain and running. I am going to assume that most of you here are runners, does anybody actively have hip pain? I chose to do this topic because it’s probably one of the most common things I see in my practice and presents us with a lot of issues. I’m going to give you some framework that can help you identify these issues and take you through my lens as to how we treat running pain.
Here are some of the key ingredients that result in pain free running. These don’t necessarily apply only to the hip; it mainly applies to running in general and sports performance. So, there are 3 things that you absolutely need - mobility, stability, and strength. The couple key areas we mainly need mobility in is the hip, the ankle, and the big toe. For the hip, when looking at mobility, you must be able to get the hip back and behind you to push yourself forward. When looking at stability, you need to be stable mediolaterally using your glutes so there isn’t any pelvic drop while running. I'll talk to you about a couple tests that we do to identify those key areas. When talking to runners in the past, we have dealt with numerous ongoing issues in the hip, such it's bursitis, tendonitis, piriformis syndrome, etc. The main thing runners say is they feel weak in the hips. When talking about hip pain, there are many different diagnoses that people get categorized with but what I think the most important thing is, is understanding the mechanical faults that are behind it. Often this is just a diagnosis and doesn’t tell you what you need to address to get it fixed. That’s where you need to go back to the key function and identify where this person is lacking in their mobility, strength, and stability. Usually, it’s not as black and white, considering that everyone could have different anatomical structures and training routines. The hip is a ball and socket joint that is stabilized by the muscles around it. The main driver of hip extension and stability is the glute maximus and the secondary is the glute Medius, which adds stability to the pelvis. We also have a lot of small muscles imbedded within and help to control rotation within the hip. When assessing people, it’s important to isolate these muscles and structures around the joint to determine what the issue is.
How does the hip function with running? Hip extension is a huge factor in mobility, and depending on the type of runner, will depend on how much hip extension required. The main muscle group that restricts flexibility and range of motion in the hip is the psoas muscle and the hip flexor. The glute Medius comes into play when we are looking at stability. I wanted to give you a test that you can do at home to determine the tightness and mobility in your hip flexors. If your hip flexor is tight then it will not allow for your hip to fully extend backwards. Hip extensions can also sometimes be inhibited by tight quads. One way to test this is by lying flat on your back and pulling one of your knees to your chest. If your opposite knee lifts off the ground, that is an indicator of tight hip flexors. The other thing that the hip needs to be able to do is rotate. You can test this by crossing one leg over the other to create the number 4, and then seeing how far down your bent knee drops. If your knee doesn’t drop down very far then you will have a very hard time rotating your hips and pelvis.
Have you ever heard of a hip drop sign? If I am running and my right hip drops when my foot strikes the ground then that indicates that my left glute Medius is weak, which is a very common thing we see in runners. It’s as simple as being able to see if a runner can independently contract one glute from the other. This is a great indicator of glute strength and force generation. I wanted to give a couple tests that you can do to test the strength in the hip. The easiest one to do is a side plank with bent knees. Once you get up into the plank position you will lift the top knee up, like a clam. What we are looking for here is shakiness or inability to hold your hips up high off the ground for 20 seconds; this would indicate glute Medius weakness. If the athlete looks comfortable and isn’t having trouble with the clam, they can straighten the top leg and hold it out for 20 seconds, making it a little more difficult. For runners it is important to have different levels that isolate these muscles because increasing the difficulty makes it more applicable to all athletes when finding those slight imbalances. The other test for the glute max, the main driver, is the bridge test. You will lay on your back, straighten out one leg and use your other leg to lift yourself off the ground trying to hold it for 20 seconds. What you are looking for is shakiness in the hips, not being able to hold the position, or a drop in one of the hips. If you are doing the single leg glute bridge with your left leg, and your right hip drops, that indicates glute max weakness.
The next tests we incorporate will address hip stability. For this test we will be using a step-up to perform a lateral step down, any type of step will work for this exercise. You will start by standing horizontally on the step, keeping one leg on the step, and lower yourself down until the other foot touches the floor. For this test you want to look for a hip drop when trying to lower your foot to the floor. The hip drop indicates there is not enough stability and strength in the hip. Another thing to look for is if your knee is coming past your toes as you lower yourself and squat down. That’s not necessarily a bad thing but it indicates that there is more quad dominance than glute dominance. Research shows that if people do that on this test, they will do the same thing when they run. Rather than using your glute and hamstrings when you run, your body will recruit her quad. Ideally for this test, when you are squatting down your hips will remain level and your knee will stay behind your toes. This is a great exercise to try and challenge your glutes as a runner. There is also one more thing we can do to test this, which is just performing a squat. When thinking about hip pain, we are thinking about whether someone is quad dominant or not. Someone who is very quad dominant will get their knees too far over their toes when they squat. This pertains to hip pain because loading up the quads rather than the glutes or hamstrings will lead to developing a dysfunction such as tendonitis or piriformis syndrome.
After these assessments, there are a few things you can do to address the dysfunctions occurring in the hip. Before doing any strengthening exercises, it is important to stretch to ensure better range of motion. First, we will start with stretching our hip flexor. We will use a heavy band and attach it to something such as a squat rack and then you will secure the other end of the band directly under one of your glutes. You will get into a lounge position, and the leg with the band is the one that is kneeling on the floor, that will also be the hip that you are wanting to stretch. From here you will contract the glute on the leg that is kneeling on the floor and shift your weight forward which will result in the stretching of the hip flexor. If you want to increase this stretch, you can lift the arm from the side you are stretching and reach it over your head. A lot of times where people go wrong with this is they don’t hold it long enough. I usually start people by holding this stretch for a minute to help build tolerance. This exercise incorporates the stretch component and by contracting the glute you are also gaining muscle control and allowing your brain to isolate muscles independently. Another good hip stabilization you can do is the side plank clam with an added band. You will put a band around your legs, which increases the difficulty in trying to separate your legs and puts more load on the hips. When you are starting off with any of these isolated exercises, the prescription with how you do it is important. When you first start off, you want to try and hold it for about 20-30 seconds. During the first two weeks your brain is working on reestablishing the connection to that muscle, so holding it longer will make it easier for your brain to isolate and recruit that muscle. After about 2-3 weeks of holding the exercise, you can begin doing reps where you move the top leg up and down with the band. You can start doing 3 sets of 15. The same thing applies for the singe leg bridge. You will keep the band on your knees and when you go up into your single leg bridge you will tension the band a little bit, which will isolate the glute. If you try this at home and are struggling to isolate the glute then you can regress it into doing a double leg glute bridge. The same thing applies here, you want to start off by just holding the position so that your brain can recruit those signals to your glute. Then you can begin doing reps of this exercise once you have good glute recruitment and stabilization.
Next, we will move again to the lateral step down, there are different levels to this that you can do at home that can help you increase stabilization and strength. We will start by getting a TheraBand and placing it around your hips and then attaching it to a stationary object that can hold the band. This will cause the band to pull your body in. The goal is to use your hip to keep yourself stable and push out against that band as you do your step down. This works a lot on glute stabilization. Different studies on muscle recruitment have shown that the lateral stepdown is the exercise that recruits the most fibers in the glute Medius. Once you have mastered the exercise with the band pulling you away from the step, you can add a kettle bell. You will put the kettle bell in the arm on the same side as the leg that is stepping down onto the floor. This will increase more force away from your hip, causing you to recruit more stability and strength. When it comes to the number of reps we are doing, you want to do about 2 or 3 sets of 10. We will also touch on a single leg RDL that can also build strength in the glutes. With this exercise, a good place to start is with a 10–15-pound weight. You will hold the weight in the opposite side that you are doing the exercise on. You want to get a slight bend in the knee, stand on one leg while sending the other leg back, and come back forward through the hips. Make sure when you come up that you are focusing on contracting that glute to bring you forward. This is an exercise, assuming you don’t have back pain and can control the motion well, I like for clients to go a little bit heavier on. Usually, I want them to do 6-8 reps and feel like they need to take a break afterwards due to the difficulty. Those are my top exercises that I feel you can get a lot from if you are dealing with hip pain, there are various levels and can work well for any athlete. I also recommend almost all of them to be barefoot.
Another big thing for me is the framework in which I work with patients who are having this kind of pain. First, I like to eliminate any pain the patient is having in their day to day before introducing any training specific exercises. Next, I move to checking their run form before moving forward so that I can make sure they are running correctly and safely. There are a couple things you can think of from a queuing standpoint to address your hip issues. One is to think about running inside a box, so working on not over striding. When you overstride, it causes the knee to become locked out which does not allow for much absorption and puts a lot of stress on the knee and hip. Another thing to think about is having active glutes while you run. Every time you push off the ground you want to try and isolate that muscle so that you are constantly activating that glute. The last thing to think about is keeping your hips underneath you. For example, when you are running up hill you want to focus on keeping your hips underneath you to drive you forward, rather than letting your hips set behind you. How I like to set up the program for getting people back to running pain free is by first taking people through the assessments that we did today to identify the cause behind the diagnosis. Next, we create a progressive exercise prescription plan. A lot of times people get into trouble when they start with certain exercises and continue to do them from week 1 to week 3. With the progressive exercise plan, it allows you to slowly build muscle, stability, and strength, rather than keeping your muscle in the same place. When looking at how you prescribe the exercises with sets, weight, difficulty, all of those must be prescribed personally to each athlete otherwise you won’t see those results. Once people are feeling better in their day to day then we will begin ramping up run volume. As they begin increasing their mileage without any issues, we will perform a run analysis to measure force between the hips. This will eventually lead to getting back to their normal training program and running without any hip pain. The way that patients typically get started with us is by setting up a new patient evaluation. With this we will talk for about 20-30 minutes about what they have going on and seeing if its something we can help them with. Depending on the runner and what they have going on we can help to fix them in 4 visits, sometimes it takes 6 visits, and we usually meet with patients once a week so to help them address their issues.
If you don’t have hip pain and want to add in some of these things to your day to day, adding in a couple of these exercises 2-3 times a week can also just help with tightness and mobility. Lastly, just to touch on a couple of our different services, we do offer standard physical therapy and we also have a run analysis program. The Run Analysis program includes some assessments, like we went over today, and they are geared towards the entire running aspect, not just the hip. We will get you on a treadmill and use some of our software to address key measurements such as pelvic movement, cadence, force absorption in the left versus right leg, and muscle recruitment in the left versus right leg. From that we will give you queuing to help improve your run form to eliminate any current pain you are having.