My client complains of hip pain hours/days after performing tube walking or one-leg support exercises. Her lower body flexibility is good, and while she is somewhat pigeon toed, she generally perfoms these exercises in good alignment. What could be causing this pain, and what exercises could she do instead?
Both the exercises you describe are placing the greatest demand on the frontal plane stabilizers of the hip. The single leg stance is an excellent assessment to identify weakness in the frontal plane stabilizers. If the single leg exercises you are doing with her are more dynamic (i.e., lunges or step ups), there may be an opportunity for the body to “disguise” the instability with motions of the trunk and arms.
Ask your client to stand with her feet close together and on one leg. Don’t tell her what you are looking for or she may consciously or unconsciously correct for it. Have her flex the hip to 45 degrees and the knee to 90 degrees. This will place the foot of the free leg just behind the stance leg and the knee just in front. Observe if the pelvis shifts/lists toward the stance leg. Most clinicians consider a shift of one inch or greater significant. Check for compensatory shifts in the upper body. One strategy is for the torso to laterally flex away from the stance leg.
A second strategy (more common in men because of broader shoulders) is for the upper body to flex toward the stance leg. The movement of the torso over the stance leg will actually prevent the pelvis from shifting by requiring the pelvis to move in the opposite direction of the shoulders.
Weakness in the glute medius/minimus will stress the articulating surfaces and joint structures within the hip. As exercise specialist, it is outside of our professional boundaries to identify a specific structure, thereby diagnosing. Instead, realize that if you are able to address the mechanical factors that precede the onset of pain, you will be doing your client a tremendous service.
Additionally, you may not want to overlook that your client is pigeon toed. In-toeing is often associated with medial tibial torsion and antiversion of the hip. This proximal and distal medial rotation of the extremity can change the lever arm of the glute medius/minimus and make it harder for them to do their job. As a result, overuse of the piriformis is not uncommon.
To address both situations, you may want to begin with floor work at the beginning of your program that promotes abduction and external rotation of the hip. Allow your client to proprioceptively feel the muscles working from a different leverage point without the ability to compensate. We describe this as using a “novel” position so the motor system has to search for the most biomechanically effective way to perform the movement.
As you ascend your program, consider using posterior transverse plane lunges that require the hip to externally rotate prior to having to stabilize in the frontal plane. This external rotation prior to loading may actually place your client’s hip closer to neutral.