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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!
What Is 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?
Hip Flexor Strain Rehab At Your Fingertips!
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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.
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?
- Protection
- Optimal Loading
- Ice
- Compression
- Elevation
In layman'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 of 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.
Early Phase Rehab
After the immediate strain settles down and you can tolerate the pain and discomfort, it's 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 changing between 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 restarting 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 overdoing it.
Exercise 01 of 05
Exercise demonstration
Standing Hip Flexor Stretch - Pelvic Tilt
View exercise instructions
- 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 then hold that position. In that same position, perform pelvic tilts, see video for tips.
- FEEL: You will feel a stretch in front of your hip that you are stretching, especially when you perform a posterior pelvic tilt.
- 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
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!
Unlock Your Hip Flexors: Exercises for Tight Hip Flexors
Hip Strengthening Exercises
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.
Exercise 02 of 05
Exercise demonstration
Bridge Hold
View exercise instructions
- HOW: Start by lying on your back with your knees bent and your feet flat on the ground spread slightly apart. Drive your heels into the ground lifting your hips up as high as you can go. Use your glutes and hip muscles to hold that position for as long as prescribed.
- FEEL: You should feel your hamstrings, glutes, and core muscles working.
- COMPENSATION: Don’t let your hips drop while you hold the bridge position.
Exercise 03 of 05
Exercise demonstration
Donkey Kick
View exercise instructions
- HOW: Start in a quadruped position on your hands and knees. While keeping your body still, lift one leg up and with your knee bent to 90 degrees kick your foot back and up towards the ceiling. Slowly lower and repeat
- FEEL: You should feel your butt muscles working to kick your leg and your core muscles working to resist body movement.
- COMPENSATION: Do not arch your low back as you kick back.
Middle Phase of Hip Flexor Strain Concepts
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 the 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 no 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.
Late Phase of Hip Flexor Strain Rehab
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.
Exercise 04 of 05
Exercise demonstration
World's Greatest Stretch
View exercise instructions
Exercise 05 of 05
Exercise demonstration
Standing Psoas March - Alternating
View exercise instructions
- HOW: Get set-up with your hands supported on a wall with your elbows straight and a band around the top of your feet. While standing tall with a slight lean forward, lift one leg up driving your knee forward until your thigh is parallel to the ground. Hold this position, slowly lower down and repeat on the other side.
- FEEL: You will feel your hip flexor muscles working on the side that you lifted the leg. You will also feel your core muscles working and your opposite hip muscles working to maintain balance and single limb stance stability.
- COMPENSATION: Do not round or arch your back when you lift/lower your leg. Try to isolate hip movement during the exercise. See video for tips
Closing Thoughts
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!
Take Control of Your Hip Flexor Issues
It's all in the hips! Okay, maybe not ALL but in most activities the hips are the main driver of movement. The surrounding hip musculature provides stability and force production for walking, lunging, single-leg stance, and squatting patterns. It's a unique design that requires mobility, stability, strength, and power. If mobility and stability become compromised discomfort becomes the result. In this program you learn to take control and earn back meaningful activity by improving hip mobility, stability, and strength, or a better way to put it: function!
REFERENCES
- 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.
About The Author
Craig Lindell, PT, DPT, CSCS
[P]rehab Co-Founder & Chief Content Officer
Craig is a South Jersey native & Penn State Kinesiology Alumni. When the opportunity came, Craig packed his bags and drove to California to pursue his Doctorate in Physical Therapy from the University of Southern California. With [P]rehab, Craig oversees all digital content creation and multi-channel publication that reaches millions of people on a weekly basis. As a PT, Craig has a wide array of experience from working with various neurological conditions to working with collegiate & professional athletes across the Big Five in North American sports. Experiencing physical therapy first-hand as a soccer player in high school, Craig has a passion & special interest in adolescent athletic development working with young athletes to overcome injuries. In his spare time, Craig enjoys exercising, playing golfing, hiking, traveling, watching Philly sports, and spending quality time with his family.