Welcome back to Squat University! For the past few weeks we’ve been discussing the topic of groin pain. This week we’re going to discuss another common cause of anterior hip pain in athletes called Iliopsoas syndrome.

A hip flexor injury often starts a little differently than your classic pulled groin. As we discussed last week, an adductor strain will often occur at one specific time. You’ll be able to pinpoint one jump, cut, squat or deadlift where you felt a sharp pain in the inner groin (this is the point of the muscle tearing).

Iliopsoas syndrome however is often an overuse problem. This means it doesn’t start at one specific time but instead slowly becomes an issue over weeks and months. This injury usually presents a few different ways as well:1

Iliopsoas tendinopathy (inflammation and/or degrading of the tendon)

Compression of the underlying bursa sac

Snapping of the muscle over bony areas of the pelvis causing a “pop” feeling

How to Fix

Mobility

If you found stiffness in your hip flexors during the Thomas Test, your first line of treatment should be to work on improving this flexibility. We can go about this two ways: stretching the hip flexors and releasing tension with soft tissue mobilization tools.

½ Kneeling Stretch

The stretch I want to show you is called the ½ kneeling hip flexor stretch. Start in a lunge position with one knee on the ground. Place your hands in a “C” shape around the sides of your hips so you can get a good feel for the position of your pelvis (your 1st and 2nd fingers should be positioned on top of the bony part of your pelvis that is in front called your ASIS). To perform this stretch correctly you’re going to have to really hone in on the position of your pelvis.

Start by arching your low back and tipping your pelvis forward excessively. This is called an anterior pelvic tilt. If you did it correctly the bony nub your first two fingers covered (ASIS) should be pointing more towards the ground and lower than the position of your thumbs on the back of your hips. This is a bad position to be in, but will help you understand what a good position (what we’ll go to next) will feel like.

Next, perform the exact opposite movement. Flatten your back and pull your hips under your body while you squeeze your butt muscles and core muscles. This is called a posterior pelvic tilt. If you did it correctly your first two fingers should now be much higher than the position of your thumbs. When you do this motion and squeeze your glutes, it should have brought out a good stretch sensation to your hip flexors. You can also lean forward for a deeper stretch as long as you maintain your posterior pelvic tilt! Hold this stretch for 10 -20 seconds before relaxing.

Recommended sets/reps: 10 reps for 10 second holds

Prone Leg Lift Stretch

Another way to stretch tight hip flexors is with an ‘active stretch’. This type of stretch can increase flexibility of tight muscles while at the same time ‘turning on’ muscles that are often inactive (like the glutes) in order to re-establish balance to the hip muscles and fix the root cause for the original tightness.3,4

The active stretch I want to show you is called a Prone Leg Lift. Start by lying on your stomach. Next, bend your knee of the leg you want to stretch to 90 degrees. Try to relax your hamstring as much as possible and lift your thigh off the ground by squeezing your glutes. Hold your thigh off the ground for 3-5 seconds before lowering your leg. Make sure your torso doesn’t twist during this movement. You can also perform this same active stretch with your leg completely straight if the first method causes cramping in your hamstring.

Foam Rolling

Next, we can perform some soft tissue mobilization. Using a small ball or the edge of a foam roller can be a great way to decrease tension in stiff muscles and release myofasical trigger points that limit flexibility and cause pain.2,5 One of the most common trigger points can be found just to the inside of the ASIS.1

Grab a lacrosse or tennis ball and lay on your stomach. Position the ball just to the inside of the ASIS. This area will often be a little painful to put pressure on. Slowly roll the ball around until you find the tender area of muscle. Apply direct pressure for 1-2 minutes before slowly moving forward and back over this area in a wave like motion.

Core Stability & Hip Strength

The hip flexors have two functions. They can raise your thigh (called hip flexion) and they can be used to stabilize the pelvis/low back. They are ‘turned on’ during activities while lying on our back, sitting and standing. For this reason, we need to perform our corrective exercises that improve strength and proper core stability and coordination in a number of different positions and activities.

In my experience, a number of hip flexor injuries occur because the body is over-relying on the Iliopsoas to create core stability. The low back (lumbar spine) as a whole, is an area that requires a ton of stability especially when barbell training. As we lift the barbell, all of the muscles that surround the spine must work in coordination to keep our back from buckling in two. In other sports, like throwing a shot put or swinging a baseball bat, a stable core allows for proper transfer of power from the lower body into the upper body. Unfortunately the low back also has a tendency to become unstable. And when this happens our body develops negative compensations.

If the core isn’t doing its job of stabilizing the spine, the body will search for stability elsewhere in an attempt to avoid serious injury. Because the Iliopsoas is the only muscle group that connects the spine to the lower body, its proximity makes it one of the first go-to’s to try and create this stability. This is a big reason why the Iliopsoas becomes stiff/tight and eventually pain develops. Therefore, if we never address how to correctly create core stability in our rehab programs, we miss the big picture and may never find lasting results with Iliopsoas syndrome.

Learning to Brace

This first exercise is one I have demonstrated before in prior articles. It is based on the teachings and research from renowned expert Dr. Stuart McGill. The goal is to improve your sensation and perception of stability. Basically, I want you to feel the muscles that should be activated when you correctly brace your core.

Just because you have a shredded stomach with rippling 6-pack abs does NOT mean you know how to brace your core correctly. Bracing involves activating all of the muscles that surround your spine (back, abs, diaphragm, and pelvic floor) to create 360° of stiffness.6,7

Step 1: Lie on the ground with your back to the floor. Your knees can stay bent for comfort.

Step 2: Place your hand on the side of your stomach (into your obliques). Next, brace your core like you’re about to get punched right in the stomach. This should create a firm feeling of stiffness around your entire stomach. If you did this correctly you should feel tension under your hands. If you did this incorrectly, your stomach will balloon out (this means you only activated your 6-pack or rectus abdominus). Hold this brace for 10 seconds before relaxing.

Recommended sets/reps: 2 sets of 20 reps for 10-second holds

Isometric Hip Flexion

Once you have the ability to create proper core stability, we then need to re-introduce strengthening of the hip. I want to show you an exercise progression that I got from Dr. Jacob Harden.

Step 1: Lay on your back with your knees bent and feet up at a 90° angle. Place a small resistance band loop around your feet.

Step 2: Brace your core like you learned in the first exercise and then straighten one of your legs. Make sure your other leg remains in a bent position. Hold the extended leg for 3-5 seconds before returning to the start position. This exercise creates an isometric contraction (activation with out joint movement) of the hip flexors in order to maintain the top leg from moving. Isometric contractions can be a great way to strengthen injured tissues without pushing them into pain during the early phase of the healing process.

Recommended sets/reps: 2-3 sets of 10 kicks with a 3-5 second hold.

Marching Resisted Bridge

Next, we can progress to a more dynamic resistance movement. This exercise requires you to maintain your brace, while at the same time activating your posterior chain and strengthening your hip flexors.

Step 1: Lay on your back with legs extended and heels resting on a bench. Keep the resistance band loop around your feet.

Step 2: Brace your core and raise your hips from the ground in a bridging movement. Squeeze your glutes hard in this position.

Step 3: Next, pull on knee to your chest at a time while the other remains on the bench. Keep your core braced during the entire movement.

Recommended sets/reps: 2-3 sets of 10 alternating reps

Side Plank Clamshell

The last area we want to concentrate on is the lateral rotators of the hip. Research has shown that athletes with Iliopsoas syndrome can often present with weak hip rotation strength and coordination (poor muscle timing).8 To work on this possible weak muscle group, I want to share the side plank clamshell exercise with you.

Step 1: Lay on your right side, with your legs bent and a resistance band loop around your knees.

Step 2: Keep your right elbow and right knee in contact with the ground as you raise your hips and hold then in a side plank position.

Step 3: While maintaining this side plank, rotate your left leg open against the band resistance. Hold it for two seconds before lowering it back down. I will often cue my patients to imagine their legs are the mouth to a clamshell opening and closing.

Recommended sets/reps: 2 sets of 15 reps on each side

Final Thoughts

Most experts believe Iliopsoas syndrome is due to overuse. For this reason, treating this injury requires both rest and addressing the root cause for the overuse in order to find lasting relief. This comprehensive treatment approach requires soft tissue mobilization, pain free stretching, and purposeful strengthening.

I hope this article helped shed some light on Iliopsoas syndrome. Remember, none of these exercises should create or worsen your current pain symptoms. If you are unable to find any relief with these exercises, I recommend going to a medical professional (doctor or physical therapist) to assist in your recovery.

Until next time,

With

References

Tyler TF, Fukunaga T & Gellert J. Rehabilitation of soft tissue injuries of the hip and pelvis: invited clinical commentary. IJSPT. 2014 Nov; 9(6): 785-797 Ingber RS. Iliopsoas myofascial dysfunction: a treatable cause of “failed” low back syndrome. Arch Phy Med Rehabil. 1989;70(5):382-386 White SG, Sahrmann SA. A movement system balance approach to management of musculoskeletal pain. In: Grant R, eds. Physical Therapy of the Cervical and Thoracic Spine. New York, NY: Churchill Livingstone Inc; 1994:339-357 Winters MV, Blake CG, Trost JS, et al. Passive versus active stretching of hip flexor muscles in subjects with limited hip extension: a randomized clinical trial. Phys Ther. 2004;84(9):800-807 Paolini, J. Review of myofascial release as an effective massage therapy technique. Athletic Therapy Today. 2009; 14(5):30-34 Grenier SG & McGill SM. Quantification of lumbar stability by using 2 different abdominal activation strategies. Arch Phys Med Rehabil. 2007; 88:54-62 Gardner-Morse MG & Stokes IAF. The effects of abdominal muscle coactivation on lumbar spine stability. Spine. 1998;23(1):86-92 Johnston CA, Lindsay DM, Wiley JP. Treatment of iliopsoas syndrome with a hip rotation strengthening program: a retrospective case series. J Orthop Sports Phys Ther. 1999;29(4):218-224