Fixing Hip Pain During Squats

The squat is the king of all exercises, unrivaled in its ability to build explosive hip strength, power, and develop athletes. Unfortunately, anterior hip pinching and hip pain during squats is one of the most common dysfunctions I treat….and one of the most poorly managed problems I see from the medical world! 

A better understanding of the causes of hip pain and pinching during squats will allow many to overcome this barrier to the high-performance benefits of the squat without pain.

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Causes of Hip Pain During Squats

A variety of mobility, stability, motor control, and bone abnormalities can cause hip pinching and hip pain during squats. The following are the most common causes of hip pinching we see clinically (in no particular order).

Ankle mobility…specifically dorsiflexion is the cause of many movement pattern faults. If an athlete is trying to squat to depth and lacks ankle dorsiflexion then that motion has to be made up somewhere else…usually the hips! This often leads to people with ankle restrictions having hip pain during squats.

To test ankle dorsiflexion, begin in a half kneeling position with the athlete’s big toe one hand-width away from a wall or box. If adequate dorsiflexion is present the athlete should be able to touch their knee to the wall without their heel rising or the arch of the foot collapsing.

In those that do not pass this test, it is important to distinguish between soft tissue and joint limitations decreasing ankle mobility. Joint limitations are the cause in athletes who feel a “pinch” in the front of the ankle versus soft tissue limitations that are felt in the calf muscle and Achilles tendon. This will be important when it comes to corrective exercises.

Hip Mobility…most commonly hip rotation (both internal and external) is another common cause of hip pain during squats. To assess, we have the athlete lie on his or her back with the thigh positioned vertically and the knee bent to ninety degrees. To test external rotation, the foot is moved inwards while keeping the thigh vertical. To test internal, the foot is moved outward. We ideally would like to see 45 degrees of external and 30 degrees of internal rotation.

 

Poor core stability…during the squat can be a recipe for anterior hip pain during squats. Whereas going into excessive posterior pelvic tilt and lumbar flexion at the bottom of the squat (aka “butt wink”) puts unnecessary stresses on the lumbar spine, staying in excessive ANTERIOR pelvic tilt and lumbar hyperextension can cause anterior hip pain during squats.

Why does this happen? Instead of effectively engaging and bracing the core in 360° manner, the athlete will just “arch” the low-back. Relying solely on lumbar hyperextension as a means of core stability encourages excessive anterior pelvic tilt, can limit efficient squat depth, and can cause the bones of the hip to pinch the soft tissues resulting in pain. Remember this the next time you hear that overused and often misguided “arch that back!” coaching cue.

 

Anterior pelvic tilt

 

For some, boney abnormalities can result in a physical block to getting into deep hip flexion and cause pain during squats. This is known as femoral acetabulum impingement (FAI). A review by Frank et al. (2015) showed that up to 50% of athletes had FAI development on x-ray analysis. Other research has shown that FAI is very common, even in individuals with NO PAIN!

In the author’s’ experience, FAI causing hip pinching during squats can often (but not always) be corrected by addressing the above mobility limitations and perfecting squat form (and occasionally taking some time off to allow the hip to calm down).

 

FIXING HIP PINCHING DURING SQUATS

Ankle Mobility

As mentioned before, one common cause of hip pinching during the squat is limited ankle dorsiflexion. This impaired motion can be the result of soft tissue mobility restrictions in the calf muscle or limitations in talocrural joint motion. Thankfully, with a few modifications, the utilization of the knee-break ankle mobilization can address BOTH of these issues.

Do you feel “tightness” in the back of your foot? You could be dealing with a soft tissue restriction. Utilizing the knee-break ankle mobilization provides a good stretch to the soleus to encourage mobility. Do you feel a pinch in the front of your ankle? You’re most likely suffering from a joint limitation. Add a band to the knee-break ankle mobilizations to fixate the talus and encourage improve tibial anterior translation. Improve your ankle dorsiflexion to relieve your anterior hip pinching.

The Banded Knee-Break Ankle Mobilization The banded knee-break ankle mobilization represents a fantastic drill to increase ankle dorsiflexion, a movement paramount to barbell training. Without adequate dorsiflexion, squat depth may be impaired and nagging injuries may arise elsewhere due to a compensation effect. To perform this, stand in a split stance and elevate the ball of your foot on a 10 lb. plate. Attach a band from behind and wrap around as LOW on your foot as possible to stabilize the talus. "Break" at the knees and mobilize into full dorisflexion. As the band stabilizes the talus, this will encourage an anterior glide of the tibia to promote increased dorsiflexion and thus performance! ____________________________________ Barbell Rehab and Performance – Bridging the Gap between Physical Therapy and Strength & Conditioning. For free articles and online consultation services follow me on IG, like my Facebook Page, and visit www.barbellrehabandperformance.com

A post shared by Dr. Michael Mash (@barbellrehab) on

 

Hip Rotation restrictions tend to be the most common limiters of hip mobility. While hip external rotation mobility fixes are often used by athletes (such as this one) we more commonly find that correctiving hip internal rotation deficits will have more significant and longer lasting effects. A detailed plan to correct hip internal rotation deficits can be found in the article “The Truth About Squat Depth, Injury Prevention, & The Knees Out Cue”. 

Alter Your Form.

Sometimes altering your form is all you may need to rid hip pinching during squats. When it comes to squat form and hip pain, there are generally two recommendations that can be made:

Find YOUR Right Stance. Here’s the truth. People successfully squat very heavy weights, pain-free, with a variety of stance widths and degrees of toe-out. One thing these lifters have in common is that they have found the squat stance right for THEM. Are you experiencing hip pinching with a wide stance and a large degree of toe-out? Due to hip joint and soft tissue restrictions, It can be difficult to successfully align the knees with the 2nd toe with an excessively wide stance.Try narrowing a bit and reassess. Do you have pain with a narrow stance? Widen a bit and reassess. Squatting with the femur in more of an abducted position has also helped many relieve their hip pinching. The bottom line is this: Find a stance that is right for YOU.  

Tests such as the following can be helpful in determining optimal squat stance. This test is part of “Master The Squat” available here.

Ensure Correct Knee Position.  Correct knee position is imperative to reduce hip pinching while squatting. Contrary to popular belief, correct knee position is NOT simply “shoving them out” as far as possible, as this may actually exacerbate your pain. Correct knee position involves ensuring that they are inline with the 2nd toe to prevent hip internal rotation at the bottom of the squat. Optimize your knee position to reduce hip pain during squats.

Core Stability and Motor Control Fixes

For athletes needing to develop better core control we use 90/90 breathing and the psoas march to help them relearn neutral spine positioning.

90/90 breathing gets athletes understanding how to coordinate muscle contraction throughout the core (including the diaphragm) to stabilize the spine and pelvis during squats.

The psoas march gets the athlete using a reverse squat pattern while focusing on core and pelvic positioning.

Now that the athlete understands how to coordinate the core musculature to maintain a neutral position we perform quadruped rocking to practice the squat pattern without gravity and then progress to the goblet squat (more on that later). hip pain during squats

The above core control drills are also part of Master The Squat.

TRAINING THROUGH HIP PINCHING DURING SQUATS

Now, don’t misinterpret what we are preaching here! Hip pinching during squats and the above corrective exercises should NOT stop you from training hard or building strength.

If you are in the category of athletes that need avoid squatting for a certain period of time to allow the hip to calm down, you can still push your performance to the next level. Heavy emphasis on training the muscles of the posterior chain (glutes, hamstrings, and lower back) will be hip-pain friendly. Exercises like romanian deadlifts, kettlebell swings, and hip thrusts will strengthen the posterior chain while teaching the athlete to be stronger in a posteriorly tilted pelvic position so when squats are resumed, the athlete can perform squats with the pelvis in a more neutral position.

To continue building quadriceps strength in these athletes, we program quad difficult exercises like sled pushes/pulls, step ups, lunges, and Bulgarian split squats will continue building athletic strength and power without further irritating the hip.

Sled Push

 

SQUAT VARIATION PROGRESSIONS

There are numerous variations of the squat and due to different mechanics, each variation will stress the musculature and  joints in a different manner. A more upright torso, typically seen with goblet squats and front squats, will challenge the quads to a greater degree but require more knee and ankle range of motion. A more bent-over torso, as seen with the low-bar back squat will challenge the posterior chain to a large degree, but also requires more hip range of motion.

After assessing and correcting ankle and hip mobility restrictions and enhancing core stability, it’s time to begin squatting again…but where do you start? For someone who has a history with hip pain, it is recommended to begin with variations that promote a more upright torso and progress to more inclined torso variations. Squatting with an upright torso tends to be less stress on the hip joint, effectively giving it “more room to breath”. Once this position is mastered, we can begin to progress as followed:

Goblet Squat —> Front Squat —> High-Bar Back Squat —> Low-Bar Back Squat

Squat Variations

Goblet Squat

The goblet squat represents a fantastic exercise to essentially “retrain” the squat pattern. Due to the vertical torso and lighter weight, this variation is the least stress on the hip joint and a great starting point for those who previously experienced hip pinching during squats. Additionally, performing eccentric isometrics, by doing these slowly and pausing at the bottom, will further enhance the effectiveness by improving motor control.

Front Squat

After mastering the goblet squat, it’s time to reintroduce the barbell and begin front squats. Although the form is very similar to the goblet squat, the front squat allows for much heavier loading. Due to the relatively upright torso, this exercise can be considered a “quad-dominant” squat variation and will be a great way to return to your olympic lifts. Progressively loading the front squat in a PAIN-FREE MANNER, represents the next progression in the continuum.

High-Bar Back Squat

After one can successfully front squat pain free, the high-bar back squat can be initiated. Due to moving the bar from the front rack position to the upper traps, the high-bar back squat will require more forward lean to center the barbell over the midfoot. The more forward lean that occurs, the more “hip intensive” the exercise becomes. For those of you who train the Olympic lifts, the high-bar back squat may be the final squat variation you perform. However, if you are into powerlifting or train “The Big 3” in general, we still have one more step…

Low-Bar Back Squat

The low-bar back squat represents the most “hip intensive” squat variation. For those who suffer from hip pain during squats, the low-bar variation is often the most troubling. The accentuated forward lean of this exercise essentially “closes off” the hip joint. Without adequate mobility, stability, and core control, the low-bar squat has the most potential to flare up the hips. Thankfully, with the tips provided in this article, you no longer have to worry about those issues! Once you can successfully perform low-bar squats without hip pinching, progressively load this exercise and break some PRs!

 

 

This article was co-written with Michael Mash of www.barbellrehabandperformance.com. Be sure to follow Michael on Facebook and Instagram for more great content!

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