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Hip Pain In Athletes: Understanding Femoral Anterior Glide Syndrome

Written on April 13, 2009 at 7:28 pm, by Eric Cressey

Hip pain – particularly of the anterior (front of the hip) variety – is a very common problem in the weight training population.

In her book, Diagnosis and Treatment of Movement Impairment Syndromes, Shirley Sahrmann discusses Femoral Anterior Glide Syndrome in excellent detail.  And, while it may seem like an obscure diagnosis, it’s actually a really common inefficiency we see in a weight training population.

In order to understand this syndrome, you have to appreciate the attachment points and functions of the hamstrings and gluteus maximus.  With the hamstrings, you’ll notice that they attach to the ischial tuberosity of the pelvis (with the exception of the short head of the biceps femoris, which attaches on the femur), and then run down to a point inferior to (below) the knee.  In other words, they are a two-joint muscle group.  All of the hamstrings aid in knee flexion, and all but the short head of the biceps femoris also aid in hip extension.

hammy1

Conversely, the glutes attach on the pelvis and the femur; they’re a one-joint muscle – and this is why they can so directly impact hip health.

glutemax

You see, when the hamstrings extend the hip (imagine the hip motion that happens when one comes out of the bottom of a squat), they do so in a “gross” fashion.  In other words, the entire leg extends.  In the process, there is little control over the movement of the femoral head (“ball” in the “ball-and-socket” hip joint) – and it tends to migrate forward during hip extension, giving you a femoral anterior glide syndrome.  In the process, it can irritate the anterior joint capsule, and this irritation can give a sensation of tightness in the front of the hip.

Fortunately, the glutes can help prevent the problem.  Thanks to their point of attachment on the superior aspect of the femur (closer to the hip), they have more direct control over the femur as it extends on the hip.  As a result, they can posteriorly pull the femoral head during hip extension.  So, in an ideal world, you get effective co-contraction of the hamstrings and glutes as one extends the hip; they are a system of checks and balances on one another.  If you use the hamstrings too much in hip extension, you’re just waiting to develop not only femoral anterior glide syndrome, but also hamstrings and adductor magnus (groin) strains and extension-based back pain.

As an aside, this hamstrings/glutes relationship is somewhat analogous to what you see at the shoulder with the subscapularis posteriorly pulling the humeral head as the infraspinatus and teres minor allow it to drift forward.  That’s another newsletter altogether, though!

Once the femoral anterior glide issue is in place, the first course of action is to stop aggressively stretching the hip flexors.  While the issue gives a sensation of hip flexor “tightness,” in reality, stretching the area only exacerbates the anterior hip pain.  A better bet is to just ditch the stretching for a few days, and instead incorporate extra glute activation work, as detailed in Assess and Correct.  Eventually, though, one can reintegrate both static and dynamic hip flexor stretches.

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Just as importantly, it’s important to identify the causes.  We’ll see this issue in runners who have no glute function, but more commonly, I’ll see it in a weight training population that doesn’t understand how to complete hip extension.  Here’s what a hamstrings-dominant hip extension pattern would look like with squatting.

The final portion of hip extension is when the glutes are most active, so it’s important to “pop the hips through” at lockout of deadlifts, squats, pull-throughs, and other exercises like these.  In the same squat example, it’s really just as simple as standing tall:

Of course, this is just the tip of the iceberg when it comes to hip issues in athletes, but it’s definitely something we see quite a bit.

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8 Responses to “Hip Pain In Athletes: Understanding Femoral Anterior Glide Syndrome”

  1. Tony Ricci Says:

    Fascinating look into the hip–just when I thought I knew it all…

  2. Eric Beard Says:

    Nice work EC,

    Sahrmann was ahead of her time in the 70′s when she started teaching her work and is right on it today. Great text to reference! I see the “knee” squatting that you demonstrated in your “incorrect/hamstring” video in plenty of people. The adductor magnus seems to become dominant here as well. The sacroilliac joint really takes a beating due to the pull from the magnus on the sacrotuberus ligament and the insertion from the biceps femoris tendon.

  3. JLak Says:

    It makes sense, but I have a problem with this. Every time I stand tall when squatting, I feel the menisci pop and crunch under the patella, so I’ve been keeping pretty shallow on the way up. Yeah, yeah, VMO activation etc… but what if arthritis has already stiffened the joint?

  4. Bob Parr Says:

    Thanks for explaining anterior Femoral Anterior Glide Syndrome so well. You don’t mention leg curls, but I figure this is what makes leg curls a poor exercise choice – they teach you to preferentially recruit the hamstrings more than the glutes. Too much isolation seems to be one of the causes of faulty motor patterns.

  5. Robbie Says:

    Great info EC!

  6. Nykes Says:

    I must be the poster child for you Eric! I constantly fight lower back pain, likely due to some sort of poor movement pattern (injured while doing deadlifts and/or heavy squats). And now I have the anterior hip pain as you described here. I will try stopping the hip stretching – which of course i have been doing, and pull out my Magnificent Mobility info again. Thanks and keep it up!

  7. Jeff Cavaliere Says:

    Eric…thank you for discussing this issue in print. I can’t tell you how often I see someone complain about a perceived “tight” feeling and the automatic advice by the practitioner is to stretch. As you show in this example, stretching is not always the treatment of choice. Yes, it requires more work on our part as health care providers, but it is our responsibility to dig deeper to uncover the TRUE cause before recommending the proper treatment. Keep up the good work.

    Former Head Physical Therapist NY Mets – Jeff Cavaliere

  8. Ron Says:

    Hi Eric. Interesting article. What is your opinion if one with femoral anterior glide were to activate the glutes while stretching their hip flexors? Does it make any difference whether or not the patient with femoral anterior glide has medial or lateral rotation of the hip? What I am getting at is an attempt to stretch the TFL (for ones with medial rotation) but at the same time not allowing too much migration of the proximal portion of the femur to glide into the anterior hip capsule. When people refer to the fact of not stretching their hip flexors while with femoral anterior glide, do they mean all the hip flexors or certain ones? Doesn’t it depend on the angle of the stretch and position you put your hips and leg in? Seeing as though certain hip flexors have separate responsibilities. Ie, internal or external rotation, ABduction or ADDuction etc. Sorry if that was overkill. Just trying to get an experts opinion. Thanks Eric.

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