PT on the Net Research

Hip Pain with Squats


Question:

On squatting, my client tells me that at the bottom of her squat, she feels a pain around her hip flexor area (only a 6/10). I’m trying to understand what this may be. She does lean forward on her squat, and I thought it maybe something to do with her pelvis. Help!

Answer:

The questions you raise can have many variables that may need to be ruled out. This response will assume there are no medical issues such as a nerve entrapment or labrum issue.

The first thing I would look at is your client’s pelvic alignment. Is she anteriorly or posteriorly tilted? Does she have a rotation of one pelvis versus the other? If there is a rotation to one pelvis, often there is an accompanying anterior obliquity that occurs as well. If either pelvis is anteriorly rotated, the common issues that create the environment are tightness of one or more of the hip flexors (i.e., psoas, iliacus, sartorius, rectus femoris). Typically, the erector spinae are tight as well, which causes an upward pull upon the posterior superior iliac crest. If this is the case, as the squat is performed, the pelvis will anteriorly tilt. If it is already anteriorly tilted, this can create further tension as the pelvis goes through that motion. Think of it as the motion is partially used prior to the movement and then reaches its threshold during the action of the squat. I find it interesting that your client leans forward during the squat. This is a signal to me that she is compensating for a tight hip flexor and is reducing the length/tension relationship on the hip flexor by flexing forward, thereby shortening the tissue. My suggestion to “test” this is have your client do an anterior (forward) lunge. When the affected hip is the forward hip, or the lunging leg, that hip is in a posterior tilt in relation to the spine, and the hip flexor should not be under nearly as much tension. When that same leg is the trail leg, the hip of the trail leg is now anteriorly tilted and will cause the hip flexor to be under greater tension due to the lengthening of the tissue. The knee of the same trail leg often flexes as the hip is at its terminal range of extension and the knee will flex to cause the hip to flex and reduce the tension at that moment.

If this scenario is correct, historically our industry would stretch the hip flexor that is on the tight side. However, we must look at the functional and structural relationship of the pelvis to the spine and how the tissue is affected. If there is an anterior pelvic tilt, the hip flexor may already be lengthened and may give the sensation of being tight. However, if the tightness is due to structural positioning, stretching the already lengthened muscle will not correct the condition but will add to it. The fitness professional must address the structural alignment to alleviate the tension/length relationship on the tissues. Therefore, with an anterior pelvic tilt, create the environment for the client to be successful and lengthen the erector spinae, strengthen the abdominals and be sure the proximal quadriceps (i.e., rectus femoris, sartorius and lateral gluteals) have good range of motion. I would suggest the following as an alternative to the squat for a couple of weeks:

If your client is getting relief from these movement patterns, then add the squat back into the program. My recommendation is to do the squat first, then the integrated movement patterns, as this will get greater multi-directional motion after a predominantly single plane exercise. But reduce the total volume of reps and sets and supplement with some of the above suggested movement patterns.

One additional region to explore is the ankle dorsiflexion of your client. Often during the squat, when there is limited ankle dorsiflexion, a common compensation is to go into deep hip flexion by bringing the torso forward. Check the range of motion of the ankle during the dorsiflexion moment, especially of the ankle on the same side hip that she has been complaining about. If it is limited, compensations are often seen in the hips and back.

Good luck and please keep us updated on her progress. If this is not getting results, there are other approaches we can strategize to find her issues.