Physics...Physiology...Physical Therapy

Lateral hip pain due to lower ab weakness

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This week’s superstar is Amber. She has had lateral left hip pain off and on recently. No injuries, just progressive onset during the winter. Maybe we can blame it on the weather or lousy roads. Either way, this is what she looks like running at a normal speed.

And this is what she looks like running at a faster/tempo pace.

From behind in both videos, her left hip doesn’t appear to load as efficiently as the right. During walking or running, there should be a loading phase during which the glutes lengthen to accept the body weight, which then allows the glutes to have more power potential for push-off. Initially, her left hip seems to avoid the loading, which is where her pain is coming from.

From the side, we see limited knee drive as well as high arm swing. Both of these are often found with weakness in the lower abs, as her upper body will attempt to compensate by pulling the hips into flexion.

So we need to get her hip loading more efficiently and get her lower abs fired up. Firstly, a stretch for the glutes. We also did manual treatments for gaining hip flexibility, but this is what she will be working on at home.

We also did a lower ab dynamic strengthening exercise using an exercise ball. I think she really enjoyed this one!

After gaining flexibility in the hip and firing up her abs, this is what her running looked like.

Notice more symmetry and efficiency with loading of the hips from behind. Notice also the improved knee drive and more relaxed arm swing in the video from the side. Again, when muscles are loaded properly, they are able to work more efficiently. With Amber, consistent attention to hip flexibility and lower ab strength will help keep her running faster and faster. Great job Amber!

Abdominal strain due to thoracic restrictions

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This week’s spotlight is on Owen. He is a rockstar runner experiencing right upper abdominal muscular pain. No specific injury, but rather slow onset with running, unless he lied to me and does cage fighting at night! Let’s see what his run looks like.

Notice the asymmetry in his shoulders and arm swing. The right shoulder carries lower than the left and there is increased swing in the left arm.

The joint mechanics of the thoracic spine and rib cage are what we call ‘coupled’, which means that there are always combinations of rotation and side bending going on. For Owen, his thoracic spine did not left sidebend or right rotate as efficiently or as far as the opposite directions.

We also did another assessment for hip flexor tightness.

It’s subtle, but he is slightly more limited on the right side, as indicated by his upper body not bending backward as far with left foot forward, compared to the right. Tightness in the psoas is a very common issue and can limit hip extension, as well as trunk extension and rotation.

Before doing exercises, he spent time on the treatment table to loosen up his hip flexors and diaphragm. Upon palpation, the right side of his diaphragm was tight and reproduced his upper abdominal pain. This leads me to believe that his limited psoas flexibility, as well as asymmetric thoracic motion is causing poor flexibility of the right side of his diaphragm.

So here’s what we did about it. First a thoracic mobility exercise.

Next a core/hip flexor stability exercise using arms to drive motion through the thoracic spine and rib cage.

We also threw in a thoracic/hamstring stretch, again to get his thoracic spine moving as cleanly as possible.

After these exercises and manual treatment, here is the new and improved Owen.

Notice more symmetry with arm swing, indicating rotation of his core is more even, and the shoulder height discrepancy is decreased. Activities to keep progressing his balance and symmetry of movement will be essential for him to get rid of the pain and become a more efficient runner. Keep up the great work Owen!

Hip extension: is it due to hip flexor tightness?

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This week’s spotlight is on Kaylie. She is a collegiate runner and softball player. A real common combination right? Only a superstar could pull it off. She presented with history of hip and knee issues without significant injury, but also wondering if being in a catcher’s stance was affecting her running gait. Her coach has been working with her on improving her hip extension, mostly with stretching the hip flexors and strengthening her hip extensors. Indeed, this is a very common place to start, but we’ll see how it plays out. Here are videos of her running initially.

The most obvious thing in the side view is the lack of hip extension, indeed her hips never really reach neutral. This is certainly not ideal. But again, is it due to tight hip flexors? behind it is difficult to discern much in the sagittal plane (forward/backward), but there are some inefficiencies with how her upper body moves.  Upon exam, her hip flexors were moderately tight, but the most glaring deficit was a lack of external rotation in both hips, as well as excessive internal rotation. She also had a substantial amount of myofascial tightness in her lateral hips, which we addressed through manual techniques.

So we started with stretches for posterior hip flexibility.

Next she did a stability exercise using a step to accentuate hip flexion, which also will improve hip external rotation.

And another stability drill to ensure control during hip extension.

So after these stretches and stability drills, here is what her form looked like.

Notice the improved hip extension, as well as the improved efficiency in her upper body more visible from behind.

Again, her form is deceptive initially because it appears to be just an issue of stretching her hip flexors. But she has been faithfully doing this for some time. The lack of external rotation of her hips is playing a huge role because it also limits her functional hip flexion, which causes a quicker push-off on the rear leg limiting the extension. She responded well to these drills and should make steady improvements with consistent performance of these. Great job Kaylie!

Rough Landing: Hip External Rotation, is it needed for runners?

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This is Jonathan, an aspiring Boston marathoner. We met for a session without any significant pain or known issues, so everything should be perfect right? Here’s a video of his run form initially.

My first observation is how his left hip behaves upon impact, as well as the increased left side bending of his upper body at foot strike on the left side compared to the right side. Upon closer assessment, we found that his left hip is limited in external rotation (turning out), as well as extension.

Now why is external rotation significant with running? The hip just flexes and extends right? At the risk of getting too geeky here, it’s worthwhile to give a brief synopsis of why rotation is needed. As Jonathan’s left leg swings forward, it is flexing with the ground as it’s frame of reference, and the right leg is extending. This creates a natural right rotation of the pelvis, again with the ground as the frame of reference. So, relative to the ground, his left hip is flexing, but relative to his pelvis, the hip is also externally rotating (abducting too, but that’s for another time!). So, to answer the question, a healthy amount of external rotation is needed to allow for a graceful loading of the hip and core, without it, he has to compensate by loading his core in an asymmetrical and inefficient way. This can be a cause of low back pain with running, but thankfully Jonathan isn’t having any issues and addressing it now, is much easier than scrambling as you get closer to race time.

So here’s what we did to get the hips moving better. A general hip flexor stretch with the upper body helping (a good one for runners and anyone stuck at a desk!)

Next, a hamstring biased hip external rotation stretch.

Thirdly, a glute biased hip external rotation stretch.

And lastly, a stability exercise to tie it all together.

So after these drills, this is what he looked like.

Not a dramatic change, but he certainly looks more graceful and symmetrical through the hips and core. With consistent performance of these drills his form should become more efficient. Keep it up and perhaps we can do a ‘Jonathan reloaded’ post as training progresses. Great job Jonathan!

As a bonus, here’s another way to get improved hip external rotation. This is my favorite way to do it, but as part of this post’s session, we used the equipment on hand as this is where he will likely be doing his stretches most consistently.

Back pain due to hip weakness

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This is Taylor, a collegiate runner. She has had back pain off and on for several months. Her Athletic Trainer has told her that she has ‘dumb butt’ syndrome. I’m not particularly a fan of the term, but it’s understandable what he was referring to. I asked her what his basis was for that statement and she mentioned lying prone on the table and raising her legs. This isn’t a bad test, but we need to know what this looks like with running and what we can do about it. Here’s video of her running initially from the side and behind.

From the side, notice the poor knee drive and landing with her knees relatively extended and moderate overstride. With landing like this, the ground reaction forces will be accentuated and not properly absorbed throughout the calves, quads, and more importantly the glutes.

From this angle you can see how her hips have to travel side to side with each stride, this indicates that it’s requiring extra effort for the glutes to tolerate each landing well. The fallout of this is how much her spine is having to rotate to accommodate for this. Any wonder where the back pain is coming from?

So here are some drills we did to get the hips working properly. Full disclosure, we also did some manual therapy for hip flexibility that isn’t shown, but complemented the movements done here.

First, hip flexor flexibility in all three planes of motion.

Next, glute activation/loading in all planes.

Lastly, a simple form drill on the treadmill to practice knee drive.

After all this, here is what she looks like from the side and behind.

Notice the improved knee drive from the side which allows for happier landing and loading through the hips. From behind you can see that she has less side to side motion in her hips and low back. In the videos she’s certainly working hard to focus on the drills we worked on. As with anything, it will become more natural as she consistently works on these things. Great job Taylor!