Hip Flexor Tightness
What are the Hip Flexors?
As the summer starts to close many people will be noticing the after effects of increased running mileage. I hear a lot of people mention tight, aching, or painful sensations over the front of the hips which may also be accompanied by a painful lower back. This is partially down to a tightness of the hip flexors which is a collective name for a group of muscles known as the rectus femoris, psoas, and illiacus.
The hip flexors primary function is to flex the hip, this basically means that they lift the thigh forwards and up towards the torso. If you think about the cyclic pattern of running we are repeatedly lifting the thigh in our swing phase. Not only this but the majority of jobs and lifestyles nowadays involve a lot of sitting; at a desk, in the car, or in meetings. The seated position puts the hip flexors in a shortened state. If we hold this position for prolonged periods these muscles will become very tight.
What does this mean for my body?
If the hip flexors are tight when the thigh is pulled backwards during walking, running, or standing it will stretch these tight muscles and cause some discomfort. The other issue is that the prolonged sitting position and the tightening of the hip flexors causes their counterparts (the gluteals or buttocks) to become lengthened and weaker. This results in a stronger pull on the pelvis in the forward or anterior direction which causes our pelvis to tilt forwards. This has a knock on effect on the lower back causing it to arch inwards hence the common lower back aches and pains.
What can I do?
The fix seems very straight forward, if the hip flexors are tight and short we need to lengthen and loosen them. As well as this to create muscular balance we need to retrain and strengthen the gluteals. By restoring balance in these muscles the postural imbalances will be rectified and hopefully relieve any aches and pains as well as regain a normal range of movement.
Perform the following 1-2 times per day (or every other day depending on time) or it can be added to your warm ups for any activity you currently do.
1. Hip Flexor Kneeling Stretch
Kneel on one knee, so your leg trails behind you, lunge the other foot out in front of you. keep your torso upright and thrust the pelvis forwards until you feel a stretch up your thigh and over the hip. Hold this position for 30secs and repeat 2 times on each leg. Once you can balance effectively introduce raising the arms straight up over the head, remaining upright through the torso. (See Image 1)
2. Pigeon Pose
Place one leg and knee flat on the floor in front of you, then trail the other leg flat behind you. Use your arms to control your weight and lower your weight down so your hips drop towards the floor. you will feel this stretch around the buttock and hip area. Hold this for 30 secs and do 2 sets each side. (See Image 2)
3. Fire Hydrants
This gets its name from the pattern of movement mimicking that of a dog and fire hydrant. Kneel on all fours so your hands are under the shoulders and the knees under the hips. Then keeping your back flat and straight raise one knee off the floor and take the leg out to the side, as though cocking the leg (hence the name). return the leg back in and repeat. Do 2 sets of 15 each leg. (See Image 3)
4. Gluteal Bridges
Lie on your back and bend your knees so you feet become flat on the floor. Then, keeping your shoulders and upper back flat on the floor, raise your hips up off the ground as high as you can, squeezing the buttocks. Once at the top hold it for 1-2 seconds then slowly return to the floor and repeat. Do 2 sets of 15. Once you can do this with great control you can try the same movement but using one leg only (make sure you work both legs thought). See Images 4 & 5.
What are Shin Splints?
There is much debate into what shin splints actually is, some say it is small tears and inflammation in the muscles spanning down the tibia bone, or inflammation of the sheath of the bone. Now shin splints is a term applied to general shin pain, but one of the major areas that are assumed to be shin splints are down the inner edge of the tibia. Symptoms down the edge of the tibia is known medically as Medial Tibial Stress Syndrome (MTSS), this is the most common I have come across in the athletes I have treated.
Symptoms of MTSS…
The affected area may be tender and swollen, highlighting the inflammation in this area. You may notice your pain will come on as your start exercise and may ease off as you start to warm up and activity continues. However, you may then notice when you stop or towards the end of exercising the pain returns and may be worse than before. The pain you usually feel will often be described as a dull ache, or throb.
Why Do You Get Shin Splints?
The occurrence of shin splints is described as an overuse injury, which means you may notice it presents after you have recently increased your activity (especially running), or after prolonged, frequent high impact activity, such as road running.
The lower leg and ankle have to absorb a lot of force and if this force is repeated and of high intensity such as running on hard surfaces, some structures are having to absorb these high forces. This may then lead to micro-damage in the structures such as the muscles. If you continue to engage in your activity, the damage to these structures then doesn’t have time to heal and thus you get the reoccurring pain.
If this was the sole cause then everybody who ran would experience shin splints. However, not everybody does. But why?
There is usually a domino effect of altered mechanics that will lead to a dysfunction in lower leg movements.
One tell-tale sign you may notice is that your feet may flatten during a squat movement or when you run. This alters the pull of your Achilles tendon, alters muscle firing patterns, and also puts pressure on the function of the lower leg. This could be due to weakness of some of the ankle stabilisers such as the inner calf, the muscles surrounding the tibia (Tibialis Anterior and Posterior). This may be combined with a tightness of the outer-lower-leg muscles (Peroneals, Outer Calf). This combination will pull the foot flatter and the weakness will inhibit the
ability to resist and stabilise this.
Your knees may also cave in as you squat or run. This will only further contribute to flat feet and thus the pressure on the lower leg. This occurs usually because the outer Hamstring (Biceps Femoris) and Ilio-Tibial Band (ITB – tendinous tissue on the outer thigh) are tight. This will pull the tibia outwards causing the knee to cave in. This dominance of the outer muscles coincides with weaker inner muscles such as the inner Hamstrings (Semitendinosus and Semimembranosus) and the gluteal muscles.
As a general overview these two factors are the most noticeable, and the common things I have experienced. The simple solution to this is to release and stretch the tight, shortened tissues and activate and strengthen the weaker, long tissues. This will rectify the compensatory, altered function of the knee, lower leg and ankle. In turn this will help reduce the stress on the lower leg and therefore reduce the likelihood of shin splints.
How Do I Treat Shin Splints?
• Reduce your running/high impact exercise – swap for lower impact training such as cycling, or swimming. Refrain from painful activity. This may mean putting a rest day from running in between your normal running days.
• Apply ice to your shins after activity, and on a daily basis to reduce swelling and inflammation.
• Apply compression to the area – compression bandage or stockings whilst exercising and during recovery
• Invest in mouldable inserts for your running trainers.
• Self-Massage – rub along the edge of the shin bone, down the tender areas. This is uncomfortable but helps breakdown scar tissue.
Longer Term Fix/Management…
• Stretch short, overactive tissues:
o Peroneals (Outside of the lower leg down into the outer ankle)
o Outer Calf
o Outer Hamstring
• Activate/Strengthen longer, underactive tissues:
o Inner Calf
o Tibialis Anterior & Posterior
o Inner Hamtsrings
Example Rehab Programming…
1) Shin Stretch – Kneel down flat on your shins, then lean back and attempt to sit on your heels or as close as you can get. Ensure your shins and knees remain flat on the floor throughout. This can be done one leg at a time if you require a stronger stretch.
Perform 3 sets of 30 secs.
2) Wall Calf Stretch – place your hands against a wall, split stance your legs, keep you back foot flat and leg straight, lean your body forwards towards the wall stretching up the calf. The leading foot can be placed at an angle out to the side to target the outer calf.
Perform 3 sets of 30 secs on each leg.
3) Towel Hamstring Stretch – lie on your back, bring your leg up straight, wrap the towel around the lower leg, pull the leg back straight, you can then pull diagonally across the body to stretch the outer hamstring more.
Perform 3 sets of 30 secs on each leg.
4) Active Oblique Stretch – Lie on one side, keep bottom leg straight, bend the top leg to 90 degrees out in front of you. Place your top hand on the back of your head, with the elbow pointing to the ceiling. Grasp the underside of your top thigh with the other hand. Then try touch your top elbow to the floor by rotating body outwards and trying getting your shoulders flat.
Perform 3 sets of 30 secs on both sides.
1) Tibialis Anterior Activator – Sit down with legs straight out in front of you. Perform dorsiflexion repetitions (pointing and raising the foot). However, it is important when doing this that you keep your foot rolled outwards so your sole faces inside, and also keep your toes curled in as your raise your foot. This can be resisted with a resistance band.
Do 3 sets of 15-20 each foot.
2) Single Leg Gluteal Bridges – Lie on your back, bend your knees so your feet are flat, then raise one leg off the floor straight, then raise your hips up squeezing your buttocks, but keep your shoulders flat on the floor. Hold at the top for 2secs then lower.
Do 3 sets of 20 each leg.
3) Glute Clams – Lie on your side and place yours knees on a 45 degree angle. Keeping your feet together open your knees out rotating the hip, ensure your torso remains still and you are not twisting it to aid the hip movement.
Do 3 sets of 20 each side.
4) Pigeon Toe Calf Raises – Stand against a wall, rise up onto your toes, but as you do this pull your heels out.
Do 3 sets of 20 (can be done single leg once two foot is too easy).
5) Single Leg Step Up – Stabilise – Curl and Press – In standing keeping the core tight and spine neutral step up with one leg onto a stepper or box until the leg is straight, and bring the opposite thigh parallel to the floor. Ensure that the pelvis remains level and you don’t lean to one side. Your core and pelvis position should remain constant throughout. Once this can be achieved with the leg raise introduce and curl and press then return to the floor and repeat.
Do 3 sets of 12-15 each leg.
6) Heel Walks – In standing, raise the forefoot off the ground so you are stood on your heels, turn your foot outwards so the sole faces inwards and curl the toes in (as in the above exercise).Once in this position walk around in this position. It looks silly but this causes the underactive shin muscles to become reactive during walking which will help with better lower leg function.
Do 3 sets of 20-30 steps.
Working As A Unit – The Body’s Subsystems
When we experience pain, injury or stiffness we instinctively focus on that particular area or body part. The way we treat ourselves or manage this complaint then takes the same specific focus, targeting the painful or restricted area. This may help reduce any of the local trauma and be temporarily relieving. However, in order to fix any underlying dysfunctions that may be contributing to any pain, or stiffness we sometimes need to approach the body a series of “chains” or systems. These systems work together to allow efficient movement, and aren’t just independent muscles.
The Body’s Subsystems…
Five of the main subsystem identified in the health and fitness world are the Anterior Oblique Subsystem (AOS), Posterior Oblique Subsystem (POS), Lateral Subsystem (LS), Deep Longitudinal Subsystem (DLS), and the Intrinsic Stabilisation Subsystem (ISS). Each system offers a different function but they all need to be working effectively together to ensure the body is stable and moving properly. This then helps prevent injury or dysfunction.
Should any of the subsystems be not be functioning optimally it will have a debilitating effect on movement efficiency, joint function, and cause potential alterations in posture. If we can understand the function of these subsystems, and how they can affect our posture and movements then we may be able to rectify any dysfunctions, improve our posture, and maintain pain free function. This blog post will therefore discuss each of the five subsystems and provide an overview to help recognise common dysfunctions so we can address these systems in our daily training.
Anterior Oblique Subsystem…
The AOS consists of the External Obliques, Abdominal Fascia, and opposite side Adductors (National Association of Sports Medicine). Additional muscles have been considered part of this subsystem such as the Internal Obliques, and Rectus Abdominis (Brookbush Institute).
This subsystem stabilises the anterior or front chain and trunk during functional movements such as walking. It also helps transfer force between the lower and body, specifically integrating pushing and twisting movements. This system helps reduce any excessive or forceful rotation or extension through the trunk, anterior pelvic tilt or sacroiliac joint (SIJ) motion within the Lumbo-Pelvic Hip Complex (LPHC). The muscles of this subsystem achieve its function by actively lengthening or eccentrically contracting.
This system can commonly be either overactive or underactive, which can contribute and present as a dysfunction in certain areas of the body.
…Overactivity of AOS…
The AOS can be overactive and can cause a dysfunction in the upper body. This may present as certain adaptations during an overhead squat assessment. Specific things to look for are and excessive forward lean of the torso, scapula winging, excessive internal rotation of the shoulder, increased curve of the upper back (thoracic kyphosis). It is common for an over-active AOS to be paired with and underactive POS which will be discussed later.
If these adaptations arise and you think your obliques, and adductors being overworked then you can approach this by reducing any core flexion exercises in your program i.e. crunches, and release shortened, tight structures associated with the dysfunction such as the pecs, and obviously adductors and obliques. You will also want to increase the activity of the POS which will be discussed later.
…Underactivity of AOS…
An underactive AOS can contribute to a dysfunction in the LPHC. This dysfunction will display an anterior pelvic tilt, and an excessive curve in the lumbar spine (lumbar lordosis) as a result of excessive extension coupled with no resistance or stabilisation from the AOS. This again is often paired with an underactive POS.
You can approach this underactivity of the AOS and pelvic tilt etc. by loosening the tight structures, usually the hip flexors and the erector spinae muscles in the lower back. You should also then activate the AOS by including the following into your program.
1. Cable Chop Patterns – to activate the AOS, squeeze glutes, legs stabilise and AOS resists the extension and rotation of the cables as you chop from high to low.
2. Ball Catch-Twist-Throw – sit on a yoga ball, have a partner throw you a medicine ball, catch the ball whilst maintaining stable, twist to one side then twist back throwing the ball back. Repeat on the other side.
3. Standing Cable Chest Press – this increases the workload for the anterior trunk and legs. Stand with cables behind so you have to resist their pull. Then perform your chest press keeping the trunk stable.
4. Step Up to Press – Step up, raise trailing leg knee to 90° (forcing single leg balance and stability), then press the arms without the trunk folding and becoming unstable.
• Progression 1: drop to one band resisting the rotation pull of the band. Hold band in opposite hand to lead step up leg. Look for a good reach and avoid leaning back and turning out with the band.
• Progression 2: start side on, lead leg nearest step. This starts you in a turned out position forcing AOS to activate to turn the body into the step up, press and stabilise.
Posterior Oblique Subsystem…
The POS consists of the Gluteus Maximus, the opposite Latissimus Dorsi, and the Thoraco-Lumbar Fascia. The Gluteus Medius has also been considered as part of the POS by Brookbush Institutes.
The role of the POS is to stabilise the posterior “chain” (Lumbar Spine and SIJ). It transfers forces between the lower and upper body, and in particular combines pulling and turning out movements as well as decelerating whole body turning in or face down (pronation). It also helps control spine flexion and rotation, and hip flexion, adduction and internal rotation.
This subsystem runs from the Glute Max diagonally across the SIJ into lumbar fascia and into the opposite Latissimus Dorsi. The POS plays a big part in asymmetric movements such as walking with one side decelerating and one side accelerating thus requiring high levels of stabilisation.
…Underactivity of POS…
The POS is almost always underactive and often in combination with either an overactive or underactive AOS. This can then contribute to dysfunctions in the upper body or the LPHC as mentioned.
To approach an underactive POS we obviously need to activate the muscles of this subsystem (Glutes and Lat Dorsi). This can be done using the following examples.
1. Glute Bridge Progressions – focusing on a good squeeze of the glutes.
2. Cable Squat to Row – squat holding cable out in front, under tension, as you stand tall, stabilise the trunk and row the bands in. Resist the pull of the band and avoid forward lean or sway.
• Progression 1: progress to single arm row, maintaining stable trunk position minimalizing twist of the trunk.
3. Step Up to Row – This is similar to the AOS step up to press, but the press is substituted with a cable row. But again focus on keeping trunk stable.
• Progression 1: progress to single arm row, maintaining stable trunk position minimalizing twist of the trunk.
Deep Longitudinal Subsystem…
The structures of the DLS are the Sacrotuberous Ligament in the hip, the Biceps Femoris (one of the hamstrings), Tibialis Anterior, and Peroneals. Other muscles have been suggested as part of this subsystem such as the Erector Spinae, and Piriformis (Brookbush Institute).
The job of this subsystem is to stabilise the Lumbosacral Joint Complex as well as the Medial Arch of the foot. It also controls the lower leg and foot during walking. It helps decelerate the lower leg during the swing phase of walking. It also controls foot position when striking the floor during walking by controlling lifting of the toes (dorsiflexion) and controlling the tilt of the ankle (inversion-eversion).
It also helps with proprioceptive communication (sensory feedback) of forces between the foot, knee and hip complex during high intensity activities. Therefore it helps ensure good positioning, balance and alignment of the lower body joints thus preventing injury. However, if this system isn’t functioning optimally this may not be the case.
This system is almost always overactive meaning Biceps Femoris and Erector Spinae to become dominant. Individuals may then present with low back pain, hip pain and an alteration in functional movements such as squatting, running or jumping etc. This alteration is linked to an excessive pronation (rolling flat) of the foot during activities. The ability to dorsiflex (raise the foot) is also inefficient and places excessive force on the structures of the foot. You may also notice an inward buckling of the knees, thus putting the ankle, knee and hip out of alignment during movement.
As with all the other subsystem we approach this by releasing the tight structures of the overactive DLS such as the biceps femoris, erectors spinae, peroneals, and often the piriformis. This can be done by seeking manual therapy, foam rolling techniques or active stretching work. Isolated hamstring exercises should be avoided as this will further activate the already overactive structures.
POS activation exercises as described above should be added to help support this subsystem and reduce the responsibility place on the DLS. To activate the POS you should basically include any leg work (squats, step ups, lunges) with pulling movements (row).
This LS consists of the Gluteus Medius, Adductors, and opposite Quadratus Lumborum. Other muscles are considered to be involved such as the Gluteus Minimus, and Tensor Fascia Latae (Brookbush Institue).
The role of the LS is to stabilise the LPHC in side to side movements, it also transferring forces between the lower and upper body. It plays a significant part in single-leg movements, ensuring optimal alignment of the hip, pelvis, SIJ, and lumbar spine during both double and single leg stance.
This can be underactive on one side but the opposite side will compensate and become overactive. This can cause dysfunction in the SIJ, and lower leg function. You will notice a drop of the pelvis to the side of under-activity when standing on one leg. The standing thigh will also adduct, as well as some side flexion of the trunk. This will affect the alignment of the leg during single stance exercises and cause unnecessary forces will be placed on the structures of these joints.
Like the majority of dysfunctions in the other subsystems an underactivity of this system often pairs with an underactive POS and overactive DLS.
As discussed before tightness of the overactive muscles should be released. The common shortened muscles are the quadratus lumborum, and adductors. However muscles such as the gluteus medius can be underactive, and therefore the approach should be release the QL and adductors but activate the gluteus medius.
You can then include POS exercise as described earlier as well as single leg exercises with shoulder exercises such as:
1. Step up to single leg stabilisation then curl and press (keeping hips level and core engaged, avoiding side bend).
Also include glute medius activation:
3. Side Plank – but avoid dynamic side bending exercises.
Intrinsic Stabilisation Subsystem…
The ISS consists of the Tranversus Abdominis, Multifidus, Pelvic Floor, Diaphragm, and the Thoracolumbar Fascia. The Brookbush Institute considers the Internal Obliques as part of this system too.
Its role is to increase abdominal pressure, increase the stiffness of the spinal segments and SIJ, and stabilise the LPHC. The pressure created by pushes back on the vertebrae reducing any forward moevement that may be caused by excessive spine extension or over-activity of the QL, Latissimus Dorsi or Erector Spinae.
The Multifidi provide feedback to the central nervous system allowing continuous alteration of movement and postural, this helps with spinal alignment and stability during activity.
Like the POS this subsystem is almost always underactive which leaves us prone to disc herniation (slipped disc), sprains and strains of the spine, as well as LPHC and SIJ dysfunction. It will also affect posture, and stability of the trunk, spine and core during activity. Its ability to withstand sudden position or postural changes, or impacts to the body, this leaves us at risk of injury.
To approach this system the muscles need activating. They are only small muscle groups so there isn’t a huge amount of movement but the following exercises can be introduced to any warm up before training.
1. Draw belly button to the floor in lying position, this can be done by “squeezing the anus” (transversus abdominis activation)
2. Kneeling “superman” exercises – ensure the transversus abdominis is activated throughout.
3. Explosive Moutain Climbers – do these explosively keeping trunk straight and stiff.
Overview of Subsystems and Dysfunctions…
Below is a table of which systems are usually underactive or overactive in certain dysfunctions. Along with the discussion above this may help you approach how to deal with any issues you have and what to include and take out of your training.
|Upper Body Dysfunction||Underactive||Underactive||Overactive||Overactive|
|SIJ Dysfunction||Underactive||Underactive||Underactive on affected side|
Overactive on opposite side
|Underactive on affected side|
Overactive on opposite side
|Lower Leg Dysfunction||Underactive||Underactive||Overactive|