Exercises for Hip Impingement. What TO do and what NOT to do.

Hip Impingement. A frustrating diagnosis that can leave you more confused than before. Doctors tell you that surgery is the only true “cure” to fix this boney pathology. But try physical therapy first you’re told...

So you try physical therapy. Correction: you try physical therapists. Doesn’t work. You go to a chiropractor. Doesn’t work. Yoga. Nope. Pilates. Nothing. So what’s the deal? Is exercise useless for hip impingement? And is surgery the only treatment?

No. Exercise can be incredibly powerful in alleviating hip impingement symptoms. But the way in which we exercise is the key to seeing results.

We must have the right strategy in place. A strategy that builds a foundation for strength and flexibility in our hips. A path that builds resilience in you instead of reliance on someone else.

In this article, I’ll help you create that strategy for yourself.  

My Hip Impingement Story 

In 2014, I wanted an answer to my chronic hip pain. I went to a highly-respected Manhattan orthopedic surgeon and got the infamous X-Ray and MRI. I was told I had femoral acetabular impingement (“FAI”) aka hip impingement.

I got all the tests. The cortisone shot in the hip socket. The FADIR test. I was apparently a good candidate for surgery. So I scheduled the surgery a few weeks out. I was sick of this pain and ready to move on with my life.

But leading up to surgery, something didn’t sit right with me. I did some research online and quickly realized I was rushing into surgery. Did I really do everything I can to avoid surgery? Am I just looking for a “quick fix” to a more complicated problem?

I was only 25 years old. Were my hips really so damaged I needed them shaved? There were too many doubts so I decided to cancel the surgery. I needed to take a step back and truly understand why I was in pain. The bone-on-bone explanation did not make sense to me and it was time to enter the world of corrective exercise.

This was one of the best decisions of my life. Not only am I no longer in hip pain but I’ve learned more about my body than I ever imagined. I understand what muscle weakness is and what it does to our bodies. I understand the value of mindfulness and how critical our relationship to pain is.

I’ve experienced the physical and mental challenges of training out of chronic hip pain associated with hip impingement. I share this story before we dig deeper into hip impingement so you understand my background.

I’ve been where you are. I understand what you’re feeling. And there is a better future for your hips. But the path may not be what you expected.

What is hip impingement?

Most people reading this know the medical definition of hip impingement aka FAI. I won’t spend too much time on this but for sake of due diligence, here is a definition from the reputable Cleveland Clinic:

“FAI is an unusually shaped hip joint that causes two bones in the hip to rub together. The pressure causes friction between the top of the femur (thighbone) and acetabulum (part of the pelvis). FAI can limit motion and cause pain. Without treatment, FAI can damage the cartilage that provides cushioning in the hip. This damage can lead to arthritis, or painful joint deterioration.” Quoted from the Cleveland Clinic's review of FAI.

Scary stuff. But also misleading. The key word in this definition is CAN. It shows up three times but is crucial to emphasize. FAI can limit motion and cause pain but it also might NOT. FAI can damage the cartilage but it might NOT. And cartilage damage can lead to arthritis but it also MIGHT NOT.

Many people are walking around with hip impingements without any pain. Numerous studies demonstrate that there is no connection between hip pain and hip impingement. Here are a couple of my favorite:

• Out of 244 young men with no history of hip pain, 67 or approximately 25% of them had signs of hip impingement. Reichenbach et al.
• Out of 1184 men, 17% had signs of hip impingement. There was no association between hip pain and hip impingement. Gosvig et al.

So what is hip impingement? A common anatomical feature of the human hip bone that may or may not be associated with hip pain. Let me ask you this: if you were not in pain, would you care that you have hip impingement?

What does hip impingement feel like?

Hip impingement symptoms vary depending on the individual. This is unusual as most medical conditions have a consistent pain-pattern. According to reputable sources, the pain is:

• “[I]nsidious and activity-related..[and] predominantly in the groin.” Clohisy et al.
• “[P]ain or stiffness in the groin or front of the thigh... made worse with bending up of the hip or at the waist, such as when riding a bike, tying shoes or sitting for long periods of time.” John Hopkins review of Hip Impingement.
• “Pain in the hip, groin, or lower back that can occur at rest as well as during activity.” Washington University Orthopedics Hip Impingement Review.
• “During or after flexing the hip, as when running, jumping.” Mayo Clinic review of Hip Impingement.

So the pain can be in the hip, groin, front of thigh and lower back. The pain occurs during activities like riding a bike, tying shoes, running and jumping. But pain can also occur while at rest and sitting for long periods of time.

There are hundreds, if not thousands, of different pain patterns one can experience when diagnosed with hip impingement. The question is how do we know the pain is coming from hip impingement and not something else? How do we know it’s not coming from muscle weakness? Or extremely limited hip internal rotation? Or limited hip extension? Or an overactive nervous system?

We don’t know. And many orthopedic surgeons or hip impingement “experts” don't know either. There are too many variables outside of our control. Chronic hip pain is complex. And although we want a reason for our hip pain, we cannot force one.

The FADIR Test

In addition to an MRI, most doctors will administer the FADIR test. If you’re reading this and were diagnosed with hip impingement, you probably received it. If there is pain in this diagnostic test, this confirms a hip impingement diagnosis.

But this is a challenging movement for anyone. It combines deep hip flexion with adduction and internal rotation. It’s not surprising that people who are already in chronic hip pain will feel even more pain in this position. What if we had someone with chronic low back pain do a back bridge. Probably would not feel great either.

With proper training, these movement patterns can be improved. Slowly someone can improve their ability to get into hip flexion. Then they can improve their range of motion in adduction and internal rotation. By respecting the pain and not fearing it, the body slowly opens up. Eventually, the FADIR position becomes easier and less painful to access.

My hip pain was always in the outside hip region. For some of my clients, it’s in the groin. For others, it’s in the hip crease. And for others, it’s more in the low back or high glute area. And all of us had a hip impingement diagnosis.

The diagnosis simply does not matter. Maybe we all had hip impingement. But this did not dictate our movement training. Instead we each focused on our individual hip limitations. We worked with our individual pain patterns. And through this practice, the pain slowly but surely starts to dissipate.

Physical Therapy and Hip Impingement 

I have nothing against physical therapy. In many situations, physical therapy helps people recover from some debilitating injuries. But just like any field, it has its limitations. And in my experience, one of those limitations is helping people in chronic hip and other joint pain.

Physical therapy is integrated in the medical and insurance industries. In these industries, there are recognized gold standards for treatment. In respect to hip impingement, the gold standard for treatment is surgery. Although there is an effort made to treat hip impingement through conservative care, these efforts are limited and inefficient.

What a physical therapist once told me in his office sums it up perfectly: “Oh you have hip impingement. You gotta just get surgery for that, man.” This seems to be the general attitude in physical therapy offices. They’ll do what they can but surgery is the only cure for hip impingement.

This is not true for all physical therapists. It was true for the three physical therapists I saw for my hip pain a decade ago. But now that I'm in this field professionally, I come across many physical therapists that have different methodologies. Those that understood the limitations in their field and decided to keep searching for the truth.

And I think this is true for any professional in the pain and movement space. Do they just accept the status quo in their field even if they see it’s not working? Or do they keep digging for the truth to help people? Any movement professional can potentially help people in hip pain if they are truth-seekers and not loyal servants to the dogma of their field.

How to Exercise for Hip Impingement 

Just like there are hundreds of reasons for why someone is experiencing hip pain, there are just as many exercises to train hips out of pain. The critical element here is that we are not trying to fix hip impingement.

Instead, we are building stronger and more flexible hips. Because strong and flexible hips don’t hurt as much as weak and stiff hips. Any effective training program will focus on a trainee’s specific individual hip limitations.

Obviously, there is no way for me to know every reader’s specific hip limitations. So what I’ll do instead is provide 2 exercises that will improve your FADIR test position. As I explained earlier, this is a test performed by doctors to confirm a hip impingement diagnosis.

My position is that it’s not the hip impingement that is causing pain but an inability to access these positions with function.

FADIR stands for Flexion, Adduction and Internal Rotation.  For the purposes of this article and to demonstrate my point, I'll share 2 exercises targeting only flexion.  This means that the two other positions of this test - adduction and internal rotation - will not be included. 

There are hundreds of exercises that target these movements and hundreds of combinations of each. My goal here is to simply show you that none of these movements are fixed. 

You can make the FADIR position more comfortable.  Just like you can make any other position that is currently causing you pain more comfortable. 

Some people will need more stretching while others will need more strengthening.  If you struggle with hip flexion, give these 2 exercises a try and then test your FADIR position. If adduction or internal rotation give you more problems, go to my blog homepage and search for these movements to find exercises that target these movements. 

Are there any exercises to avoid if you have hip impingement? 

A common question I get is whether there are exercises or activities to avoid if you have hip impingement. I get this question often and it’s a commonly searched question on search engines so this is clearly a topic of interest. 

The major theme of this article is that a hip impingement diagnosis is irrelevant. You can have hip impingement and have no pain. Conversely, you can have hip pain but no hip impingement. So the way I would restructure this question is whether there are any activities or exercises to avoid if you have chronic hip pain.

In other words, the question would be something like the following: “Should I avoid running if I have hip pain?” instead of “Should I avoid running if I have hip impingement?” This shift alone makes it easier for people to answer the question.

Another helpful strategy is to perform the exercise but do so mindfully. If the pain gets above a 6 or 7 during the activity or exercise, then slow it down and see if you can reduce the intensity.

The reason for this encouragement is because avoidance is a slippery slope. I see many people in a pattern of avoidance and fear which can make the pain even worse. This reinforces a feeling that you are broken or damaged because of hip impingement. And nothing can be further from the truth. 

Conclusion 

My advice for those starting their movement journey is to focus on the things you can control. You cannot “fix" hip impingement. And you don’t need to. The goal is to get out of hip pain right? Does having hip impingement matter if you’re not in hip pain?

What are the things you can control? How good are your hips at accessing internal rotation? Or flexion? Or any other major hip movement?  Shift your intention to improving movement and not pain. 

Keep it simple. Find your limitations and program exercises that target those weaknesses. This is the path out of chronic hip pain.