Don’t jump the gun…
If you’ve ever spent time around athletes, you’ve come across those that have asked to get their hips stretched, right? Or have you ever had athletes that complain about hip tightness and wanted it to be loosened up? Perhaps even have others complain about it being locked up with the inability to open up?
If you haven’t yet, don’t worry … you will, and when you do … don’t jump the gun! Stop that urge to immediately treat the area thinking that it’s a hip flexor issue! There may actually be something underlying that may be the cause of their continued grief.
There’s a common condition that it could actually be besides hip flexor tightness. Rather than thinking superficially at the musculatures, dive deeper into the hip joint itself. One of the more common diagnoses found at the hip is femoroacetabular impingement (FAI). The treatment for this condition varies from its assumed counterpart. One issue takes soft tissue management into consideration, while the other focuses on maintaining structural integrity. If you’re at stump on how to differentiate between these two conditions, or need a crash course refresher then you’re in luck!
Yes, you can do Thomas’ Test to check for hip flexor tightness, or palpate the area of chief complaint to confirm your suspicion, but if you think about it, FAI can also be positive with these findings. To combat any ambiguity, just shift your attention to the joint and assess for FAI instead.
These are a few orthopedic tests that I tend to gravitate towards:
Flexion-Internal Rotation (FIR) Test
Start with complete flexion of femoroacetabular joint
Then, add complete femoral internal rotation
(+) = recreation of anterior hip symptoms noted
Flexion-Adduction- Internal Rotation (FADIR) Test
Start with complete flexion of femoroacetabular joint
Then, add complete femoral adduction
Finally, add femoral internal rotation
(+) = recreation of anterior hip symptoms noted
Flexion-Abduction-External Rotation (FABER) Test
Start with complete flexion of femoroacetabular joint
Then, add complete femoral abduction
Finally add femoral external rotation, resting ankle on contralateral thigh
(+) = recreation of anterior hip symptoms noted
Circumduction Test
This is a bonus test since it blends in nicely between tests
Start in the FADIR position and move it into FABER
(+) = recreation of anterior hip symptoms when going from FADIR to FABER
A combination of positive findings within these tests (or others of your preference) solidifies the possibility that FAI exists. Now that it’s suspected, you can appreciate the possible restrictions and limitations associate with it, treat it accordingly, and refer out if necessary.
If you’ve ever worked on loosening up the hip flexors only to find that it’s not working as you’d originally thought, then reconsider your working diagnosis.
Instead of focusing attention on the anterior chain musculatures of the hip, redirect your attention to the posterior aspect, most specifically the ischiofemoral ligament. Empirically, I’ve found that once this ligament is lengthened, it allows the femoral head to sit more congruently within the acetabulum.
Information extracted from: https://teachmeanatomy.info/lower-limb/joints/hip-joint/
It’s cool because it presents itself clinically with an immediate increase in internal rotation and some relief in the FIR and FADIR tests! How exciting huh?
So the last question you’re probably wondering - how the heck do you lengthen out the ischiofemoral (posterior femoroacetabular) ligament anyways?! You’re in luck again!
Here’s an easy way I like to perform this:
Athlete/patient lays supine with their legs flat on the laying platform
Cross the ipsilateral foot over the other knee (forming a “Figure 4” with the legs) so that the plantar aspect faces downward (if possible)
Add axial load on the femoral shaft (this load will shift and separate the femoral head from the acetabular rim causing the ligament to lengthen)
Hold for at least 30 secs
To the naked eye, this treatment looks like you’re stretching out the hips rotators (aka. piriformis stretch), but in actuality, your aim is deeper on the ligaments. Give that a shot and see how it feels for the athlete. Don't forget to reassess the ROM (especially IR) after performing this move. I can't tell you how much this is “money.” You’ll literally see immediate changes when done properly!
Check back and let me know how it works out! I’m excited to hear your progress!
Thanks for being curious and taking the time to read this! Hope it added value to your life and equips you to become better than you were yesterday!
Dr. Joe Jaime, DC, DACBSP®, ATC, CSCS®, FRC®ms, CES