A few weeks back I briefly mentioned that I’ve been working with a lacrosse player with femoroacetabular impingement (FAI). I’ve written quite a bit about FAI in the past, and the posts seem to attract a lot of attention, probably because so many athletes (and especially hockey players) suffer from related symptoms and haven’t had much success in traditional rehabilitation approaches. If you’re new to FAI, I’d highly encourage you to quickly breeze through these previous posts, which discuss a bit about what FAI is, how prevalent it is among hockey player and general populations, and what can be done to train around it:
- Training Around Femoroacetabular Impingement
- Hockey Hip Injuries: FAI
- An Updated Look at Femoroacetabular Impingement
I’ve received several emails requesting to see the video that I posted at Hockey Strength and Conditioning of the lacrosse player with severe FAI, so I decided to throw it on youtube and wanted to share it with you today. Check it out below:
Training Around Femoroacetabular Impingement
This video is of a Division I lacrosse player I’ve worked with over the last several months at Endeavor. He has undergone 4 separate operations (2 on each side) to address his FAI and associated labral damage, and a bilateral athletic pubalgia (sports hernia) repair. He also has significant retroversion, bilaterally, meaning he has plenty of external rotation, but extremely limited internal rotation in both hips. When he first came in, he wasn’t able to jog (let alone sprint), shuffle, or do anything high impact or explosive. In fact, I would say he was generally cautious about movement in general. He’s now in his 6th month of training and can sprint, transition, and move explosively as well as ever. We were able to start moving him toward these types of exercises about 4-6 weeks into the training process. Each week, for the last month, he’s told me that he feels better than ever. I wanted to post this video to demonstrate how important it is to recognize each athlete’s individual limitations. Can you imagine if this athlete was told to squat to full depth, deadlift off the floor, do high box jumps, etc.?
I recognize this athlete’s case is a bit extreme, but the overwhelming majority of the hockey players we work with will be somewhere between this athlete and what is taught as normal. In other words, most players will have some sort of structural deviation that will need to be appreciated in your assessment of their movement quality and exercise technique. In this example, we spent a lot of time early on going through how he would need to move to to stay within his individual confines, but still accomplish what he needs to on the field. After grooving and improving these patterns for several weeks, he now does them without conscious thought, which is the ultimate goal if he’s to be successful.
A few things to look for in the video:
- When he sets up in a quadruped position, his lumbar spine is already in a state of slight flexion secondary to hitting hip flexion end range. Attempting to drive further into hip flexion results in a SIGNIFICANT spinal compensation.
- He can only squat to about 45-50 degrees of hip flexion beefore his lumbar spine begins to flex.
- His hip only flexes about 45-50 degrees during the wall drill, which will have implications for how he runs.
- He is still able to sprint, but he must maintain a more upright posture and de-emphasize his knee drive more than would typically be recommended.
- He has almost no hip internal rotation on either side. The left appears to be slightly better, but this is because his pelvis is not neutral. When I measured this with a goniometer when he first started, he was under 20 degrees on each side.
- Not having internal rotation will have significant implications for rotational movements, which are of paramount importance in most team-based sports (especially ones like lacrosse and hockey). Notice how, when he steps behind during the med ball exercise, he maintains a slight position of external rotation and how he opens up instead of rotating OVER the front leg like most athletes would. Both of these patterns were intentional, and ones that took time to groove.
Another important take home from this video is that this athlete is post surgical and STILL presents with significant range of motion limitations. This is certainly no challenge to the proficiency of the surgeon. In fact, this particular surgeon is regarded as one of the best in the world for this type of work. I’ve worked with several athletes that have had FAI-related surgeries from this surgeon, and some present with “normal” range of motion, and others still have restrictions. It’s likely a result of the complications of the individual case and the risk-reward associated with more invasive or destructive options.
Nonetheless, it’s important for the athlete to understand that getting surgery doesn’t mean you’re going to come out “normal”. It’s likely you will still have significant restrictions that you’ll need to accommodate in your movement lexicon. Also, it’s possible that the FAI is the RESULT of an underlying issue that will still need to be addressed. In other words, in these cases FAI can be thought of as a symptom that provokes other symptoms, none of which are likely to fully subside until the elephant in the room is poached. In some cases, this may mean attacking diaphragm position to restore a more optimal zone of apposition (something I’ll discuss more in the future); in other cases it may require using specific exercises to help restore a more neutral position and orientation of the pelvis; and in others it may simply require strategic soft-tissue work and help restore balance in stiffness across the hips and allow for balanced movement. In most cases, however, a combination of these techniques is warranted.
If you’re interested in more information about FAI, check out the webinar and recent interview I did at Sports Rehab Expert.
Kevin Neeld
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Good stuff! This is a really great case study.
One thing that I have found with guys who have limitations like this is that, while it wont change the congruency of their hip, soft tissue work seems to help them in terms of maintaining tissue health and decreasing the amount of overload that they get from having to have such specific (and sometimes limited) patterns available to them.
patrick
Patrick-I completely agree. He’s been seeing a few different “manual therapists” since his surgeries and continues to go regularly now. I also think that getting quality soft tissue work done in parallel with monitoring postural and athletic stresses can help prevent a lot of these issues from developing in the first place.
Really interesting to see this, Kevin. I’m a posture alignment specialist in San Diego and have played roller and ice hockey as a goalie and skater since I was 12. Coincidentally, there were several years where my ability to play hockey was severely limited by limitations just like this, and we see this every now and then at my clinic (in fact my colleague underwent surgery for FAI — didn’t help her at all — before realizing how important the posture side of the equation was). There are a couple things that helped me regain hip flexion and internal rotation that may be useful to try for this guy. Forgive me if you have already covered them elsewhere!
1) Supine hamstring stretching with a towel under the low back to ensure that lumbar spine is unable to flex with hip flexion. Perfect form is important.
2) A very passive exercise called the supine groin progressive that Egoscue practitioners use a lot. You can find videos I believe on youtube.
3) Bridges (two leg, single leg, etc.) and other glute activating exercises. From the video, it looks like the guy has some pretty underdeveloped glutes. This is exactly what I fought with when my int. rotation was really, really crappy (not good for a goalie, as I’m sure you know). Obviously glutes aren’t internal rotators of the hip, but they do provide stability and proper dynamic positioning of the femur in the hip socket. As the glutes do more of their job in hip stabilization and the hamstrings stop trying to compensate, it can make a big difference.
Just a couple ideas to throw out there that have worked for me. Keep up the interesting posts!
Matt-Thanks for the note. That seems to be the case with a lot of the FAI cases I’ve seen, which reinforces the idea that the FAI may be a symptom of an underlying cause more than strictly a cause itself. Noted on the under-developed glutes. The FAI cases I’ve worked with generally fall in the no-ass or huge-ass AND pelvic anterior tilt column. In the case of the former, I haven’t had much success in causing significant hypertrophy of the glutes in these individuals, which makes me wonder if there’s a signalling process preventing development of this area secondary to limited hip flexion ROM. Just a thought. Thanks again for the insight into your experience.
I have yet to see the huge-ass version of FAI — I’m going to keep my eyes open for that one!
I’m on board with your suspicion that FAI is not a cause unto itself. I think this is one of those diagnoses that is useful as a description of a set of symptoms but not really as one that provides any meaningful explanation of cause.
I think you’re right on the signaling process preventing development of the glutes. For the longest time I wondered where the heck my glutes had gone and why I couldn’t get them to come back. It doesn’t help that lack of function there makes you super unstable for any fun exercises that would build them (like you mention, squats of full range are out of the question).
The supine groin progressive that I mentioned above does seem to help (allows the posterior hip muscles to relax their stranglehold and constant desire to externally rotate femur), as does some more aggressive hip flexor inhibition. In terms of sequencing a mini rehab routine for a no-ass FAI, this is what has greatly increased my int. rotation (and you’ll notice there were no exercises focused on int. rotation):
1) hip flexor stretching with focus on simultaneous glute activation (standing or kneeling hip flexor stretch)
2) supine hamstring/calf stretches with a strap in multiple planes
3) REALLY slow and controlled bridges with reps in the 12-20 range until something burns. Should that not elicit a burn, bridges with single leg descent definitely do the trick!
Doing that IN ORDER day after day has really helped wake the glutes back up and take the zero degrees of int. rotation while kneeling to about 10-20 while kneeling depending on the day and how long I’ve been sitting!
Kevin-
Thank you for posting this video. It is very inspirational for us FAI/Pubalgia post op patients who’ve had limited success. Although my operations are similar in # to this young mans I would fall into the huge ass/APT category.
I am thankful there are people who are specializing in this.
Cheers
Paul
[…] Training Adaptations for FAI by Kevin Neeld […]
Awesome post and great discussion! Thanks Kev.
Thanks Bret!
Great article! Just in time for me. I have a 33 year old female client, 6 months post-natal. She’s had knee and hip pain and finally went to a sports doctor. Turns out she has FAI, moderate osteo-arthritis in affected hip, and possibly a partially torn labrum, same hip. Weak glute med which is most likely the cause patella-femoral pain. She has good range of motion, pain free for the most part except for after running, which she doesn’t want to stop but at least is taking a break from.
My question is: Is this too much of a mixed bag to approach with the training recommendations listed in your article? I’m working with her doctor and PT on this, but getting limited suggestions and info from them.
Thanks in advance1
Hi Paul-I’m not sure I completely understand your question. These things can be a bit difficult to trouble shoot over the internet. There seem to be some commonalities among the people we see in terms of limited hip flexion/adduction/internal rotation, dense/fibrotic adductors, excessive lordosis and a poor breathing stereotype, etc. Those are all things that can be addressed through training. The big issue is that movement will potentially need to be modified based on your client’s individual structure. I’d also check ankles; we see a lot of concomitant hip and ankle issues, but more importantly, runners need dorsiflexion. I hope this all makes sense.
[…] Neeld has written an excellent blogpost about training around FAI HERE. Watch the video embedded in the link – it’s one of the most serious cases I’ve […]
[…] and therefore squat depth (among other patterns): Training Around Femoroacetabular Impingement, Performance Training: Adaptations for Femoroacetabular Impingement. For another good example, check out this article from Dean Somerset on how pelvic structure can […]
I am a goalie and have FAI as well. I have done extensive research on the subject mainly through peer reviewed medial journals and articles. I highly highly recommend that everyone with FAI and those who deal with FAI, diligently research the medical findings. Not only is the surgery highly controversial, it actually has a very low success rate (success meaning decrease in pain, increase ROM, decrease in symptoms). In addition, the surgery has not been medically tested in anything other than humans, therefore the long term results of bone shaving is not known. There has been evidence in other studies that show it increases the likelihood and intensity of osteoarthritis. Standford medical school is highly skeptical of this practice as well providing there is no true empirical data on the subject. Good luck fellow FAI sufferers. Exercise and stretching is keeping me from having killer pain.
Marcus, I think everyone should always do their homework before getting a major operation and agree that surgery is no guarantee of the resolution of symptoms. FAI is STRONGLY linked to labral degeneration and future osteoarthritis, so any connection between surgery and OA needs to be interpreted within the context that it’s almost guaranteed without surgery. Every case needs to be treated and interpreted based on the severity of the individual symptoms and the activity goals of the individual. There are a lot of conservative approaches that bring relief to some, but surgery has also helped a lot of people. As a society that spends the overwhelming majority of our time sitting, we’re only going to here more about these structural changes, so it’s important that people are aware of risk factors and exacerbating positions/movements so we can all be proactive in slowing the development.