I’m in pigeon pose and the teacher says, “Let go—the hip is where emotional tension is stored.”

I think to myself, “I’m not that uptight!” while struggling to move deeper into the posture. But sometimes the sensation is deep in the hip joint. And it’s beyond uncomfortable—it’s painful. There is a good chance it isn’t all about holding on to emotional stress.

In recent years a growing number of yogis have experienced symptoms related to an injury referred to as femoroacetabular impingement. What the what? Talk about a mouthful. That’s why most folks just call it hip impingement (HI).

As a physical therapist and yoga teacher, I’ve seen so many yogis who have HI. It’s heart breaking when a student has experienced chronic hip pain but not received an accurate diagnosis or doesn’t understand what to do about the pain. The condition can significantly impact our yoga practice (and our life) but the good news is HI is something that is highly treatable.

An understanding of hip joint anatomy, causes of impingement, and how we can take steps to address HI on and off the mat may allow us to continue to have a healthy, pain-free asana practice.

Anatomy & Presentation.

Normal hip anatomy is that of a tight fitting ball and socket joint. Impingement may occur when there is excessive contact between the proximal femur (the ball) and the acetabular rim (the socket).

There are two types of HI: cam and pincer lesions. Cam lesions are caused by a nonspherical or an abnormally large femoral head while a pincer lesion is caused by acetabular overcoverage or acetabular retroversion (more backward facing—typically the opening is toward the front of the body). Often, these lesions occur in combination.

Hip motions that are often painful include a combination of hip rotation (internal or external), adduction and flexion. Repetitive and extreme movements may contribute to the onset of HI, which may be symptomatic during activities including squatting, twisting and sitting with crossed legs. Pain presentation may be variable. The nature of the pain may be described as a dull ache or a sharp sensation. Most typically the location of the pain may be described as a deep pain in the front of the hip, or pain in the groin. Pain can also occur from the front of the thigh to the back of the hip joint, which is described as a C-sign.

One of the challenging aspects of diagnosing HI is the variability in presentation, which may overlap with other hip injuries including stress fractures, muscular strains, and labrum injuries.

Early detection and correction is critical as HI may contribute to accelerated wear and tear of the cartilage.

On the Mat.

There are universal steps we can take as  yogis when dealing with any injury.

Acceptance. One of the constants we must embrace is change. Our physical, emotional, and spiritual states may change on a daily basis. Yoga practice in the aging physical body may necessitate long-term changes in the asana practice. Injuries may result in short or long term changes in our bodies. Respecting where we are at the present moment and embracing the asana practice at that moment may cultivate a healthier, more joyful practice.

Communication with our yoga teachers regarding any injury you may be experiencing is essential. The teacher will understand which physical adjustments may not be appropriate at that time. Your teacher may also provide modification options that may be unfamiliar.

Specific to HI:

Modify postures. Moving to the end range of available hip or pelvis motion may provoke symptoms therefore it is important to be willing to limit the range of motion of postures. This may be accomplished through active, conscious positioning, or through the use of props like blocks or bolsters.

Modified positioning. Supine or seated kapotasana may be a better option than a prone position. Changing the rotation in the back leg during standing separate leg postures may be necessary. Precise positioning of the foot (more inward versus outward) will depend on individual anatomy and what motions provoke pain. Similarly, pelvis positioning during side bending postures like trikonasana (triangle pose) and utthita parsvakonasana (extended side angle) may need to be more closed (rotate the top pelvis forward) or open (rotate the top pelvis backwards) to relieve symptoms. Remember to make the posture work for your body rather than manipulate your body for the posture.

Alternative postures may be necessary if we cannot eliminate pain with modification. Attempt to keep the alternative posture consistent with the pose the rest of the class is performing. For example, seated wide angle forward fold would be a better alternative posture than headstand if the rest of the class is in supta baddha konasana (reclining bound angle pose).

Enhancing your awareness of muscle activation will aide in recovery from HI. Recruitment of lower abdominal and gluteal musculature is important to promote joint stability. Engagement of the lower abdominals will promote a posterior pelvic tilt and create a low-intensity stretch in the front of the hip. Activation of the gluteals will promote strength in this muscle group and promote optimum pelvis positioning. During standing separate leg postures (parsvottonasana (pyramid pose), virabhadrasana I (warrior I) and crescent lunge), engage the gluteals of the lead leg. Cueing for bridge pose in yoga often includes letting go of the gluteals. This exercise can, however, promote hip extension strength. Consider engaging the gluteals during setu bandah sarvangasana (bridge pose). Excessive gripping or holding on to the contraction is not necessary, however, to promote healthy muscle activity. Increasing awareness and selectively activating muscular activity is the goal.

Off the Mat.

Consult a healthcare professional to obtain an accurate diagnosis and individualized plan of care. This may mean scheduling an appointment with a primary care physician, surgeon, or physical therapist. Depending on the insurance plan and the state in which you live, it may be possible to see a physical therapist without a physician’s referral. Ideally we want to have an office visit with a healthcare provider who has experience in treating HI.

Modify activities off the mat if they are painful. This may impact activities such as gardening, getting in or out of the car, sitting on the floor and running or sitting with your legs crossed legs. Sitting for long periods of time is likely to be painful, as the boney surfaces of the hip are exposed to long-duration compression. Presence of symptoms that impact our day to day activities should, however, serve as a prompt to seek medical consultation.

Work on mobility. One step we can take to alleviate HI symptoms includes performance of mobility activities beyond the yoga mat. Hip mobility may be compromised as we avoid or limit painful movements. Self-mobilization techniques are one strategy for keeping muscles and connective tissue pliable. Two effective techniques include use of a foam roller for iliotibial band (ITB) mobility and a lacrosse ball for anterior and posterior hip mobility. For many individuals, especially mobile yogis, it is possible to have the sensation the hip flexors are tight. The overwhelming majority of individuals, however, are experiencing hypertonicity of the muscle and not a limitation in muscle length. The natural instinct is to perform deep stretching to relieve the sensation of tightness. Initially there may be relief after stretching but deep, aggressive stretching can evoke a reflexive response which results in a reflexive shortening of the muscle and actually exacerbate hip impingement symptoms. Alternatively, mobilization techniques, including use of a lacrosse ball or manual tissue mobilization, are more effective strategies to alleviate hip flexor “tightness.” If hip flexor stretching is performed, it is important to not stretch to the end point, but work the middle portion of the available motion. Adductor and quadriceps muscle tightness may be present, and effectively addressed with standing lunge (adductor stretch) and kneeling lunge (quadriceps) stretches.

Strengthening the muscles that surround and stabilize the hip is another key step we can take to promote a healthy joint. In other instances, pain can reflexively inhibit muscle function. Weakness of the gluteus medius (which abducts the hip) and maximus (performs hip extension and external rotation) are common in individuals with HI.

The clam exercise is effective in recruiting both muscles. To perform the clam exercise lie on the non-painful (uninvolved) side with legs stacked one on top of the other. Position the pelvis in a neutral position (top hip positioned directly over your bottom hip), flex knees to 90 degrees and flex hips to 60 degrees. Before performing any leg movement, engage the lower abdominals to stabilize the pelvis. Activate the muscles in the back of the top hip to rotate the top knee towards the ceiling while keeping feet in contact with one another. Pause at the top, and then slowly return to the starting position. The emphasis is not on the magnitude of the motion, but rather the quality of the movement: maintain proper pelvis positioning while engaging the posterior hip muscles to perform the movement.

The bridge exercise is one with which most yogis are familiar. This exercise is intended to enhance gluteus maximus strength. Set up for the exercise is identical to the posture performed on the mat: lie on your back with knees bent, feet flat on the floor and legs in neutral alignment. Before initiating active movement, engage the abdominals. Then, engage the gluteals and lift hips towards the ceiling. Pause at the top, and then lower to the start position. Unlike the posture performed during yoga practice, full gluteal engagement is encouraged. An advanced version of the exercise is the single leg bridge. Execution of this exercise is identical to the two-legged version, but simply performed with the involved side grounded and the opposite leg lifted (it may be bent or fully extended). A key point of attention is the hips do not drop to one side at the top of the motion. If the pelvis does not remain level, continue with a two-legged bridge.

Hip abduction targets the gluteus medius. To perform this exercise lie on the uninvolved side with legs stacked one on top of the other, knees straight, and a slight forward rotation of the pelvis. On the involved side (the top leg), the toes should be straight and the leg in slight internal rotation. Engage the muscles in the side/back of the hip, lift the leg, pause, and then return to the start position. A general progression for strengthening would be to start with three sets of 8-10 repetitions with a 30 to 60-second rest between sets, working towards three sets of 15.

Hip impingement has the potential to significantly impact daily life and our yoga practice. Repetition of extreme motions contributes to HI, making yogis vulnerable to this injury. Although self-management may be attempted, persistent symptoms necessitate consultation with an experienced healthcare provider.

With patience and a willingness to modify postures, one can expect to continue with a physical yoga practice. And the next time we are in Pigeon Pose, we won’t feel pain or emotional stress!

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References:

1.  Audenaert EA, Peeters I, Vigneron L et al. Hip morphological characteristics and range of internal rotation in femoroacetabular impingement. Am J Sports Med 2012;40:1329-36.

2.  Bolgla LA, Uhl TL. Electromyographic analysis of hip rehabilitation exercises in a group of healthy subjects. J Orthop Sports Phys Ther 2005;35:487-94.

3.  Brunner A, Horisberger M, Herzog RF. Sports and recreation activity of patients with femoroacetabular impingement before and after arthroscopic osteoplasty. Am J Sports Med 2009;37:917-22.

4.  Charbonnier C, Kolo FC, Duthon VB et al. Assessment of congruence and impingement of the hip joint in professional ballet dancers: a motion capture study. Am J Sports Med 2011;39:557-66.

5.  Loudon JK, Reiman MP. Conservative management of femoroacetabular impingement (FAI) in the long distance runner. Phys Ther Sport 2014;15:82-90.

6.  Willcox EL, Burden AM. The influence of varying hip angle and pelvis position on muscle recruitment patterns of the hip abductor muscles during the clam exercise. J Orthop Sports Phys Ther 2013;43:325-31.

7.  Yazbek PM, Ovanessian V, Martin RL et al. Nonsurgical treatment of acetabular labrum tears: a case series. J Orthop Sports Phys Ther 2011;41:346-53.

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Author: Wendy Hurd

Image: Nicholas A. Tonelli/Flickr

Editor: Katarina Tavčar; Nicole Cameron