Hip Pain in Athletes: The Origin of Femoroacetabular Impingement?

Written on August 22, 2011 at 6:39 am, by Eric Cressey

Over the weekend, I attended my third Postural Restoration Institute seminar, Impingement and Instability.  I’ve written previously about how this school of thought has profoundly impacted the way that we handle many of our athletes – and this past weekend was certainly no exception.  This weekend was also my first chance to meet and learn directly from Ron Hruska, the man initially responsible for bringing many of these great ideas to light.

While I am admittedly still processing all the awesome information from the weekend, I wanted to write today about one big “Ah-Ha” moment for me over the weekend.  At some point on Day 2, Ron said something to the effect of (paraphrased):

“A superior acetabulum isn’t much different than an acromion on a scapula.”

My jaw practically hit the floor.  I joked with the seminar organizer that I needed to go into the restroom to yell at myself for a few minutes for not thinking of this sooner.  Let me explain…

Over the past few years, there has been a huge rise in hip injuries in athletes (I’d even written about it HERE in response to a New York Times article about number of hip injuries in baseball).  Sports hernias, labral tears, and femoroacetabular impingement (FAI) are commonplace findings on the health histories that I see every day on first-time evaluations. In terms of FAI, you can have bony overgrowth of the femoral head (cam), acetabulum (pincer), or both (mixed), as the graphic from Lavigne et al. below demonstrates:

Many folks say that we’re getting better diagnostically and that’s why the prevalence has increased in recent years.  Let’s be real, though, folks: if we’d had hip pain and dysfunction on this level for decades, don’t you think anecdotal evidence would have at least tipped us off?  I find it hard that generations of athletes would have just rubbed some dirt on a painful hip, cowboyed up, and put up with it.

Consider those over the age of 60, though.  Sher et al. reported that a whopping 54% of asymptomatic shoulders in this population have rotator cuff tears; that doesn’t even include those who actually have pain!  Why does this happen?  They impinge over and over again on the undersurfaced of the acromion process secondary to poor thoracic positioning, scapular stabilization, breathing patterns, and rotator cuff function.  The end result is reactive changes on the acromion process that lay down more and more bone as the years go on.  And, an anteriorly tilted scapula kicks that impingement up a notch.  The “early” cuff irritation likely comes in those with Type 3 (beak-shaped) acromions, whereas the Type 1 (flat) and Type 2 (hook) acromions need time to lay down more and more bone for their anterior tilt to bring them to threshold.

Conversely, consider femoroacetabular impingement of the hip.  You can get bony overgrowth of the acetabulum, femoral head, or both.  It’s widely debated whether those with FAI are born with it, or whether it becomes part of normal development in some kids.  Well, I guess it would depend on whether you consider playing one sport to excess year-round “normal.”

You know what?  I’d estimate that over 90% of the femoroacetabular impingement cases I’ve seen have come in hockey, soccer, and baseball players.  What do these sports have in common?  They all live in anterior pelvic tilt – with hockey being the absolute worst.  Is it any surprise that the incidence of FAI and associated hip issues has increased dramatically since the AAU generation rolled in and kids played the same sport all 12 months of the year?

Conversely, I’ve never seen a case of FAI in a field hockey player.  Additionally, when I just asked my wife (who rowed competitively in college) if she ever saw any hip issues in her teammates in years of rowing, she joked that there weren’t any until they added distance running to their training. Field hockey players and rowers live in flexion (probably one reason why they have far more disc issues).  And, taking it a step further, I’ve never seen an athlete with FAI whose symptoms didn’t improve by getting into a bit more posterior pelvic tilt.

Finally, a 2009 study by Allen et al. demonstrated that in 78% of cases of cam impingement symptoms in one hip, the cam-type femoroacetabular impingement was bilateral (they also found pincer-type FAI on the opposite side in 42% of cases).  If this was just some “chance” occurrence, I find it hard to believe that it would occur bilaterally in such a high percentage of cases.  Excessive anterior pelvic tilt (sagittal plane) would be, in my eyes, what seems to bring it about the most quickly, and problems in the frontal and transverse planes are likely to blame for why one side presents with symptoms before the other.

People have tried to blame the increased incidence of hip injuries on resistance training.  My personal opinion is that you can’t blame resistance training for the incidence, but rather the rate at which these issues reach threshold.  Quality resistance training could certainly provide the variety necessary to prevent these reactive changes from occurring at a young age, or by creating a more ideal pelvic alignment to avoid a FAI hip from reaching threshold.

Conversely, a “clean-squat-bench” program is a recipe for living in anterior tilt – and squatting someone with a FAI is like overhead pressing someone with a full-thickness cuff tear; things get ugly quickly.

Honestly, this probably isn’t revolutionary for folks out there – particularly in the medical field – who have watched the prevalence of femoroacetabular impingement rise exponentially in recent years, but Ron made a great point to reaffirm a thought I’d been having for years and strengthened the argument.  And, more important than the simple “Ah-Ha” that comes with this perspective is the realization that an entire generation of young athletes have been so mismanaged that we’ve actually created a new classification of developmental problems and pathologies: femoroacetabular impingement, labral tears, and sports hernias.

Thanks, Ron, for getting me thinking!

For more information on appropriately managing kids during these critical development time periods, check out the International Youth Conditioning Association’s High School Strength and Conditioning Certification, which I helped to write.

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Random Friday Thoughts: 5/8/09

Written on May 8, 2009 at 6:52 am, by Eric Cressey

1. It’s going to be a quick one this week, as I’m doing some last minute preparations for this weekend’s Perform Better Summit in Providence, RI.  To all the poor abandoned souls who count on my blog for companionship each Friday, I apologize for not giving our relationship the tender romance it deserves this week.

2. Congratulations to Cressey Performance athlete and Auburn High pitcher Tyler Beede, who threw a no-hitter on Wednesday.  Tyler struck out 15 in his complete game performance.

3. I contributed on the fourth installment of Mythbusters at T-Nation this week.  It also includes contributions from Chad Waterbury, Tony Gentilcore, and Christian Thibaudeau.  Noticeably absent from this esteemed crew of contributors is Mr. Celery – so I thought I’d give him some love.

4. For the foam rolling aficionados in the crowd, here’s a great variation to use for those hard-to-reach grundle adductor region.  Thanks to Tony Gentilcore for the video:

This is a really important one for those of you in the crowd with a history of groin strains and sports hernias.  Hockey players, soccer players, and powerlifters should commit this one to memory.

5. It’s official: Mike Robertson, Bill Hartman, and I are filming a new DVD on June 7th.  Lots to prepare before then!

Have a great weekend!

Off-Ice Performance Training for Hockey

Written on March 11, 2009 at 12:40 pm, by Eric Cressey

Cressey Performance was lucky to have Kevin Neeld around the facility last summer, and all our coaches were much better off thanks to this experience.  Kevin always makes some great points and is never afraid to question the norm – and do a ton of research.  Kevin’s specialty is hockey, and he recently introduced an Off-Ice Performance Training E-Manual for hockey players and coaches that is absolutely fantastic.  I was fortunate enough to get an advanced copy, and it was so good that I couldn’t wait to get an interview with him up here at EricCressey.com.  So, without further ado, here it is.

EC: I’ll be the first to admit that if I see another seminar presentation or article on “core training,” I’m going to lose my lunch.  Interestingly, though (and to be blunt), yours in this product doesn’t suck.  In other words, there is a lot to be learned both specific to hockey and in a general sense.  Can you explain for my readers in a bit of detail?

KN: Sure thing.  In my experience, the reason core training is so poorly practiced is because people don’t understand what muscles are involved in the core and what their collective function is.  Beyond the rectus abdominis (“6-pack” muscles) and the external and internal obliques, the core encompasses over a dozen other muscles that attach to the hips, rib cage, and spine.  Collectively, these muscles serves a few major, inter-related functions: 1) Control movement of the hips; 2) provide a stable base for leg and arm movement; and 3) create stiffness for efficient force transfer between the upper and lower body.

My approach to core training is pretty straight forward: 1) Teach athletes awareness-what core stability is and feels like; 2) Train for core stability; 3) Progress to dynamic stability (stability challenged by internal or external forces); 4) Progress to training core stiffness and force transfer; 5) Combine force transfer and dynamic stability into one exercise.

The progressions are explained in more detail in the course, but to give you an idea of what that looks like:

1) Abdominal draw-ins (for awareness, NOT transversus abdominis isolation…which is a stupid concept), and simply having the athlete put their hands over their stomach, fill their belly up with air, squeeze their core and continue to breathe.

2) Planks and bridges

3) Planks and bridges with partner perturbations

4) Medicine ball throws, tosses, and slams

5) Combined med ball exercises with holds in various positions challenged by a partner perturbation

I hope that all makes sense.  The course doesn’t go into full detail on medicine ball exercises because I really wanted to make the exercises and progressions realistic for a team setting, and typically there isn’t a lot of equipment available.

EC: Along these same lines, what are the specific injury issues that you prioritize in this e-manual?

KN: Hockey players are plagued by hip and lower abdominal injuries.  What’s scary is that the true causes and predisposing risk factors to these injuries are only starting to be explored in the research community.  Usually, creating an appropriate balance within and between the hip and core musculature can prevent these injuries.  For example, if you have a strength imbalance between the muscles on the outside and inside of your hip, your risk of adductor (commonly referred to as the “groin”) strain increases.  If you have a strength imbalance between your adductors and your anterior abdominal musculature, your risk of lower abdominal injury increases.  As with most injuries, the key is creating a balance.

As a quick note, creating balance often means utilizing unbalanced training.  Your readers may know this already since you talk about the same things with your baseball guys.  Hockey players take several dozens shots every week.  These shots usually involve forceful rotation in the same direction.  The best way to create balance would be to use an unbalanced training program with more rotation or anti-rotation exercises in the direction OPPOSITE to that in which they shoot.  This is where sport-specific training really threw people off.  Training “sport-specific” patterns again and again off the ice is likely to increase injury risk, not performance.

Getting back to hip and lower abdominal injuries…Typically these injuries are a result of under-preparation or overuse, both of which can be addressed with similar training methods.  I first implemented some of the dynamic warm-up and core training exercises outlined in the course with the University of Delaware Men’s Ice Hockey Team in 2006.  We had ZERO pre-season hip flexor or “groin” injuries.  Not a single player missed a single practice or game.  I’ve refined a lot of things since then, but a lot of the concepts are still the same.  Warm-up appropriately by improving range of motion around the right joints and activating the right muscles, and train the core for its true function, and you’ll likely avoid these injuries.

EC: Hockey players, like all athletes, have loads of competing demands – from on-ice technical work, to energy systems training, to resistance training, to flexibility training.  This manual does a great job of integrating all these features.  Where do you feel that most people make the biggest mistakes in this regard?

KN: It really depends on the team, but the three things that seem to come up most often are:

1) The training of most youth programs involves a couple laps around the rink, a long stretch, maybe some jumping, push-ups and sit-ups.  These programs leave out a lot of important forms of training (e.g. dynamic flexibility, core stability, reactive agility, acceleration/deceleration, etc.).

2) Conditioning is still horribly misunderstood.  The idea that hockey players need to train for a well-developed “aerobic system” by going for long runs is pretty ridiculous.  We’re talking about a sport that typically involves 30-45 second shifts, followed by several minutes of rest.  Within each shift, there are typically a few bouts of 3-5 second all out efforts, followed by periods of gliding, and usually a stoppage or two.  This breaks down into something like 20 seconds of high intensity effort every five minutes.  Repeated 20-minute jogs around the rink will make you well-conditioned for the wrong sport.

3) The largest problem I see in team settings is a complete disregard for the QUALITY of movement.  Hockey players and coaches are very driven, which usually means they want more, not better.  The first thing I do when working with a new team is sit them all down and tell them that focus will be placed on quality of movement before intensity or quantity of movement.  Moving the wrong way, at a high intensity or volume, will only make bad patterns worse.  I made a strong effort in the course to emphasize proper movement and technique and provide simple coaching cues so that people without a background in sport biomechanics can still move the right way.

EC: A large percentage of the folks reading this resource are going to be high school athletes and coaches – many of whom play multiple sports.  What pieces of advice do you have for these folks?  How can they make the most of this training when they’ve got other sports on top of the competing demands we discussed above?

KN: My advice: Keep playing multiple sports.  Early specialization (only playing hockey from a young age) will have detrimental effects on your development and movement quality as you get older.  Typically these are the players that dominate when they’re 12-14, then drop off the map or are plagued by injuries at 20.

To get to the heart of your question, good training is good training.  The course outlines quality training in the context of hockey, but the principles are mostly the same for all sports.  A strong, functional core will improve performance in all sports.  Training to improve acceleration, and your ability to rapidly decelerate and change direction explosively will improve performance in all sports.  I use many of the same dynamic warm-up progressions for hockey players as I do for athletes in all other sports (rowing, soccer, football, basketball, lacrosse, etc.).  All team-sport athletes need to be mobile, stable, strong, explosive, and quick.  I honestly can’t think of a sport that wouldn’t benefit from the training outlined in the course, which details how to alter the intensity and volume of your training in preparation for more important games (which becomes an increasingly important concept for athletes playing multiple sports at the same time).

EC: Thanks for taking the time, Kevin.  Great points – and definitely a great resource, too.

For more information on Kevin’s Off-Ice Performance Training Course, head over to HockeyTrainingU.com.

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