03 Sep How To Manage A Hip Flexor Strain
Do you have pain in front of your hip with lifting your leg, sprinting, kicking, changing directions, with your leg straight behind you, or simply sitting for a while? It is quite possible you have a hip flexor strain. A hip flexor strain can be a real pain, however, they tend to do really well given the right education, proper exercise prescription, and time. In this article, you’ll learn what exactly is a hip flexor strain, what hip flexor strain rehab entails, and the fundamentals of how to manage a hip flexor strain!
First, we need to start with identifying what exactly are the hip flexor muscles. Typically the hip flexors are referred to as a group of muscles including the iliacus, psoas major, psoas minor, and rectus femoris. However, it is important to note there are more muscles that also slightly contribute to flexing the hip. As you can see the sartorius muscle above crosses the hip as well. So what is a hip flexor strain?
How To Manage A Hip Flexor Strain: How Do I Know If I Had An Injury?
A muscle strain is typically referred to as a pulled muscle. There are microscopic tears that occur within the muscle tissue itself as a result of overstretching or the demand imposed on the muscle is greater than it’s capacity. As defined by Weir et al. 2015, experts agreed that iliopsoas-related groin pain is more likely if there is pain on resisted hip flexion AND/OR pain on stretching the hip flexors. Refer to the image above to get an idea of where hip flexor related pain can be located compared to other sources of pain.
How To Manage A Hip Flexor Strain: POLICE Principle
With any soft tissue related injury, we are big advocates of the P.O.L.I.C.E principle. What does POLICE stand for?
- Optimal Loading
In laymen’s terms, you want to protect the hip right after an acute hip flexor strain. This means that if you injured your hip playing soccer, it may be best to take a break from playing soccer and not over-exert your hip for a short period of time. When it is appropriate, you want to optimally load the tissue involved. This is the tricky part, which we will cover throughout the article. You can ice the area immediately after the injury to reduce secondary cell damage within the first 48 hours. You can also use ice if you desire after the first couple days to help with managing pain and discomfort in the sub-acute phase, however, there is mixed evidence to support if it improves swelling (which is the common belief.) You can learn more about the real effects of icing here. On the other hand, compression has better evidence to support its effect on swelling, but it can be challenging to compress this area. Elevation is another option to help with swelling and managing symptoms in an attempt to get the injured tissue above heart level.
How To Manage A Hip Flexor Strain: Early Phase Rehab
After the immediate strain settles down and you can tolerate the pain and discomfort, its time to get moving! Gentle motion and physical activity are appropriate, the goal is to get back to your normal routine and be able to tolerate simple things like walking, sitting, stairs, etc. Sometimes sitting for long periods of time with your hip in flexion (knee at hip height), can be discomforting, thus you may want to limit how long you do this and mix up how you work. For example, if you have to sit for your job, sit for a time limit you can tolerate followed by using a standing desk and change between to the two positions throughout the day. Read more about how to optimize your understanding of posture, which is discussed in one of our previous blog posts HERE!
In the early phase of hip flexor strain rehab, you don’t want to overexert the tissue (this is where protection is important). The easiest way to think about it is to imagine there is a scab on your muscle you can’t see, in order to let the scab heal you have to protect it. Overexerting the muscle could lead to picking the scab off and re-starting the healing process all over again. Below you will find exercises that we have separated into mobility and strengthening to optimally load the tissue without over-doing it.
How To Manage A Hip Flexor Strain: Mobility Exercises
Standing Hip Flexor Stretch With Pelvic Tilts
There is debate regarding if you should stretch after a hip flexor strain. The challenge is with soft tissue injuries, the body wants to lay down scar tissue rather than new muscle tissue, which can limit the hip’s range of motion. In practice, I like to promote gentle, relative pain-free stretching just to keep things moving and to limit stiffness or loss of range of motion. You have to think about a soccer player with a hip flexor strain, getting into terminal hip extension with sprinting, kicking, and other motions are essential for the sport. That is why I like this stretch and the one below as early rehab hip flexor strain stretches, but remember – start easy and keep it relatively pain-free. It is not necessary to push through substantial pain and/or discomfort at this time, remember the scab analogy!
How To Manage A Hip Flexor Strain: Standing Dynamic Hip Flexor Stretch
- HOW: Get set-up standing with a box or object in front of you that you can put one foot up on. The side that remains down on the ground is the one getting the stretch. Put one foot up, perform a posterior pelvic tilt, and shift your weight forward until you feel a stretch. Hold that position for a moment, back out of it and then repeat to make it dynamic
- FEEL: You will feel a stretch in front of your hip that you are stretching
- COMPENSATION: It is important to get into the correct position at first by shifting your weight forward while maintaining a posterior pelvic tilt and squeezing your glute on the same side. See video for tips
Soccer to some, futbol to others, but to us it’s what got Arash & Craig into physical therapy in the first place! Just like any sport, soccer has physical requirements and demands a lot from your body. Prepare for the sport you love and protect your body from the most common soccer injuries with our program! You will train hard and expose your body to soccer-specific injury prevention (what we like to call risk-reduction) exercises so that you’ll be as ready as you can be to play! This program is rooted in scientific evidence, our clinical expertise as physical therapists, and of course our experience as soccer players! Find out more HERE.
How To Manage A Hip Flexor Strain: Hip Strengthening Exercises
Below you will find a handful of posterior and lateral hip strengthening exercises primarily targeting the glutes. Why strengthen the glutes with a hip flexor strain? Well during the early phase of hip flexor strain rehab we have to protect the tissue involved, thus we are not going to program a ton of hip flexor exercises just yet. However, we want to maintain strength and physical capacity, so we need to strengthen other muscles around the hip. Also, as we strengthen the glutes we will be moving through hip extension range of motion, which can promote reciprocal inhibition of the hip flexors to get them to relax and lengthen. This can be beneficial for those that feel perceived tightness and muscle guarding of their hip flexors.
Quadruped Hip Extension With Knee Bent (Donkey Kicks)
Sidelying Hip Abduction With Extension
Quadruped Fire Hydrant
Quadruped Alternating Hip Extension
Hook Lying Marching
This is the first exercise introducing active hip flexion. Beginning in a hook lying position is a great start to introduce active concentric and eccentric hip flexion. However, if this is causing a ton of pain and discomfort, your hip may not be ready. Give it extra time and trial again in a couple of days.
How To Manage A Hip Flexor Strain: Middle Phase
What is next in regards to how to manage a hip flexor strain? Once you’re able to tolerate the early phase hip flexor strain rehab exercises without any issue for a week or two, it is time to progress optimal loading of the tissue. For the average person, optimal loading during rehab can be based on Rate of Perceived Exertion (RPE) as well as recovery time. An easy way to measure RPE is using a scale from 0-10, 0 being no difficulty at all and 10 being the most difficult thing ever. In rehab, RPE should range from 5-7/10 in the early phase and can work towards 6-8/10 once in the middle phase as long as there is not significant pain or discomfort.
RPE pairs nicely with recovery, meaning how long it takes for your body to return to baseline after training. If you performed the early phase hip flexor strain rehab exercises and your hip bothered you for 3 days after, you’re likely over-exerting the tissue as that recovery period is too long. However, if you performed the same exercises and felt fully recovered in a day you may be ready to move on and increase the challenge of the exercises. Below you will find hip flexor strain rehab exercises focused on progressive overloading of the tissue.
Below you will find excellent exercises that will help enhance mobility of the hip during the middle phase of recovery.
Standing Dynamic Hip Flexor Stretch With Shoulder Drivers
Get set-up standing with a box or object in front of you that you can put one foot up on. The side that remains down on the ground is the one getting the stretch. Put one foot up, perform a posterior pelvic tilt, and shift your weight forward as you simultaneously reach both arms overhead until you feel a stretch. Hold that position for a moment, back out of it and then repeat to make it dynamic. The arm reach is to help shift your weight forward into more hip extension for a greater stretch.
How To Manage A Hip Flexor Strain: Quadruped Hip CARs
Hip CARs (controlled articular rotations) are one of my favorite exercises for hip flexor strains. This is my take on quadruped hip CAR, it may be taught differently from others. Learn more about CARs here.
How To Manage A Hip Flexor Strain: Bretzel Stretch
It is not uncommon for the rectus femoris to be involved with hip flexor strains, especially when its a soccer player experiencing this type of injury. The bretzel stretch is hands down my favorite stretch to target this muscle.
Hip Strengthening Exercises
Building off of the progressive overload principle, below you will find progressive hip strengthening exercises targeting all of the hip and core muscles.
Single Leg Bridge with Straight Leg Raises (SLR)
Quadruped Fire Hydrant With Band
Supine Alternating Hip Extension
Supine Unilateral Psoas March
Get set-up on the ground with a band around the top of your feet. Lift both legs into the air with your knees bent and your knees positioned over your hips. If you’re targeting the left hip flexors, your left leg will not move from this position. While keeping your left leg still and your low back flat against the ground, kick the right leg in front of you straight, slowly bring it back and repeat.
How To Manage A Hip Flexor Strain: Late Phase
The same rules apply, think about your RPE and recovery with the mid-phase hip flexor strain rehab exercises. At this point, you shouldn’t have any pain with activities of daily living or at rest. If you’re an athlete, you may be back to jogging or getting back into your normal workouts. Now it is a matter of getting your hip’s capacity back to or greater than 100% to minimize the risk of this happening again. Below you will find exercises that should be programmed into your workouts, before/after your training sessions, and moving forward to [P]Rehab your hip.
World’s Greatest Stretch
Standing Hip CARs
Standing Hip Extension With Slider
Hip Strengthening Exercises
Below you will find a variety of excellent strengthening exercises that will help you overcome your hip flexor strain.
Standing Hip Flexion Lift Offs
Supine Alternating Psoas March
Standing Psoas March
Standing Psoas March With Band
A hip flexor strain can be a nagging nuisance that provides challenges when attempting to overcome this particular injury. Depending on the degree of the strain, one may have to spend longer periods of time within the certain phases of rehabilitation in order to optimize his or her outcomes. Although it may be difficult to cope with this injury, it definitely is one that has a good prognosis with appropriate care! You will take a systematic progression from early protection and rest, followed by early mobility, optimal loading, and ultimately functional specific exercises to get you back to your functional goals. This progression of rehabbing from the proliferative phase through the maturation phase can be further understood in our tissue healing blog!
- Weir A, Brukner P, Delahunt E, et al. Doha agreement meeting on terminology and definitions in groin pain in athletes. Br J Sports Med. 2015;49(12):768-774.