Relieving hip pain while walking

Posted on June 13, 2013

15


Before we can appreciate how to alleviate hip pain while walking, we need to discuss what causes hip pain.

Common reasons for hip issues

Here are some common things people will say are causing their hip pain:

Structurally people will go:

    • Labral tear
    • Femoractebular impingement (FAI)
    • Bursitis

More generally people will go:

    • “I get this aching in the front and or the side of my hip.”
    • “I feel this catching / clicking / pinching when I bring my leg up too high or back too much.”
    • “My hip snaps during certain movements.”

Let’s make this easier: When it comes to the hip, pain is nearly always centralized to the front of the hip / groin area. There may be pain on the outside too, but hip issues disproportionately manifest in the front of the hip.

What causes the causes of hip pain?

Bursitis, tendinitis, clicking, pinching, etc. are not causes of pain; they are symptoms. What causes the labral tear? What causes the snapping? That’s what we need to address. In other words, why do we get pain in the front of our hips?

Simple anatomy talk

When it comes to anterior hip pain, a common issue going on starts at the top of the leg, the femoral head.

retroversion

The muscles acting on the femoral head are not working optimally. Therefore, the femoral head acquires a tendency to travel too far forward, too often.

Hip picture normal

Hip pain ABnormal

It travels too far in the direction of where we typically get pain. Where are most labral tears? Where do people feel clicking, pinching, snapping? The front of the hip. Right where the femoral head is moving too much.

So, when trying to alleviate hip pain, we want to implement things which limit the amount of force in the anterior direction. We want to eliminate the amount of stress on the front of the hip as it’s already stressed too much, hence the pain.

“What do I need to make stronger?”

The first question people inevitably ask is what muscles do I need to make stronger? I’ve extensively gone over which muscles need to be trained when hip pain is present here and hereThat’s not the point of this post though. We’re dealing with hip pain while walking. Therefore, we need to talk about walking.

One of the muscles I’ve gone over training wise is the glutes. The glutes help pull the femur backwards, helping to avoid the excessive forward travel in hip issues.

Gluteus max and gluteus medius

Because of this, and the plethora of information out there about the glutes not being activated enough, it’s often advocated to squeeze the glutes during walking. Something like, “Each time your heel hits the ground you should squeeze your butt.” Over the years I’ve played around with this. In my experience, it just doesn’t work well. People have enough trouble squeezing their glutes during something like a prone straight leg raise.

Asking them to do it while walking is simply too hard.

Also, while getting the glutes to fire better during walking may help the excessive anterior glide, it’s not diminishing the overall work (stress) at the hip. Because of these factors I’ve gone to a different method.

The relationship between the ankle and the hip during walking

To simplify things we’re going to say while walking we have the hip, knee and ankle joints. (I say simplify because aspects such as arm swing can contribute, but we’ll ignore that here.) These three joints, and the muscles acting on them, help us do the work to get from point A to point B.

Let’s say it takes 100 units of work for us to get somewhere. Therefore, the ankle, knee and hip joint have to combine to give us 100 units. To get there, it doesn’t matter if the ankle does 10%, knee 40%, and hip 50%. Pretty much as long as all 100 units are attained, we’ll get there. In terms of being in pain though, how we get there matters very much.

Back to our cause of hip pain: Too much stress primarily on the front hip structures. This gives us a plausible way of lessening hip pain while walking: Diminish the amount of stress on the anterior hip. How do we do that? Get the other joints to do more work.

Now, the knee doesn’t contribute to walking the way the hip and ankle do. While the hip and ankle primarily help us propel into each stride, the knee primarily helps us slow down from each step. The hip and ankle have a propensity to produce force, the knee a propensity to receive it. Because the ankle and hip serve similar functions, by getting the ankle to do more work we can diminish the amount the hip does. Diminish the amount of work on the hip = diminish the amount of stress on the hip = diminish the amount of pain in the hip.

How do we get the ankle more involved?

Pretty simple. Each time you take a step think, “Push off from my ankle more.” Other ways to think of this are, “Lift my heel off the ground higher,” “Lift my heel off the ground quicker,” “Walk with a little bounce in your step,” etc. Whatever works. The principle is to use the ankle / foot / calves more than you normally would. Essentially we’re trying to do more of a calf raise with each stride.

Visualizing why this works

Let’s diagram this out a bit more. Here’s a person whose right foot just hit the ground during gait:

Standing right leg early stance

From this point the leg is going to travel backwards a bit, then need to swing forward.

Standing no push off

What needs to happen to swing the leg forward? Plantar (foot) and hip flexion. The ankle and hip both need to lift.

Standing ankle push off

By having a greater focus on the ankle the achilles can serve as a nice spring all the way up to the hip.

Standing ankle push off one line

The hip can “come along for the ride” due to the momentum from the achilles.

Standing ankle push off two line

The achilles tendon

achilles tendon

Some people may think, “Ok, we’re helping attenuate stress at the hip, but aren’t we adding a bunch of stress to the foot? Could this cause foot pain?” This is unlikely because the main component of the ankle helping our push-off here is the achilles tendon. Tendons are made for this type of work (elastic / springlike movements).

More anatomy

(Again, more extensively covered elsewhere on the site.)

A big component of hip pain is an imbalance in the hip flexors. Pretty much all the hip flexors become too active except for the psoas.

Psoas

The psoas is one of the muscles helping to keep the femoral head nice and snug so it doesn’t travel too far forward.

Credit to research paper "Effect of position and alteration in synergist muscle force contribution on hip forces when performing hip strengthening exercises"

Credit to research paper “Effect of position and alteration in synergist muscle force contribution on hip forces when performing hip strengthening exercises”

If you take someone who is lacking push off while walking they’re more likely to use excessive hip flexion (that reciprocal relationship we’ve been talking about). The issue here is while walking all this work happens below 90 degrees of hip flexion. The psoas gets the most amount of work above 90 degrees…Excessive hip flexion work during walking therefore either 1) Feeds into or 2) Causes our hip dysfunction and imbalance.

How to spot someone with poor ankle push-off

Analyzing push-off in the midst of walking is not easy. There are some other non-walking ways which can be indicative of what happens during gait.

Position of the feet / ankles

Are the feet pointed out (everted)?

tight peroneals foot pain

Are the ankles rolled in (overpronated)?

Standing overpronation ankles turned in

These are two very good signs the person has trouble with push-off.

Calf size

Another easy method is to assess calf size. Do they look atrophied? Is one significantly smaller than the other?

Calf atrophy

Here’s a a guy who had surgery on his right foot a few years ago. Watch closely as he does some heel raises. Notice 1) The size of his right calf (smaller than left) and 2) How the foot wants to turn out / roll in.

Now let’s watch someone from the side. When the plantarflexors -such as the calves- aren’t working optimally the person may also compensate with knee and hip extension in order to “get up.” Notice the trouble this woman has despite my continued cueing.

Contrary to the internet world, dorsiflexion is not the only issue at the ankle; proper plantarflexion is just as important.

Bringing footwear into play

Back to our achilles tendon. Look at someone standing barefoot.

Ankle barefoot

Let’s raise their heels up. Much like heels or sneakers with a high heel lift would do.

Ankle some plates

Notice how the achilles tendon gets shortened?

Shortened achilles tendon due to heel lift

An even higher lift.

If we think of the achilles tendon as a rubber band, how does a rubber band get launched? By getting pulled back.

Higher heeled shoes can limit how much the achilles tendon can be stretched, thereby eliminating how much the tendon can help us propel (launch) ourselves during walking. And what happens if we limit how much work the achilles / ankle can do during walking? We increase the amount of work the hip has to do.

We saw how heels affect the position of the achilles, but look at what they do to the knees and hips as well.

Standing no heel lift with line

Standing big heel lift with line

Lifting the heels also makes it more likely the person will stand (and walk) with the hips and knees in excessive extension. This is important because hip extension puts the anterior hip structures under more stress. When the leg moves backwards into extension is when the femoral head is more susceptible to moving too far forward.

(Of course the degree of lift matters here. A little heel lift is rarely worth worrying about.)

Thus, it’s probably a good idea to get rid of the heels and bulky shoes.

Treadmill considerations

I bring up treadmills because I know a lot of people get their walking done on one. Something I don’t think gets enough attention is the differences between being on a treadmill and being on regular ground.

Once you get to the point where you’re over 4mph on a treadmill is when problems seem to begin. 4mph is typically where people go from a brisk walk to a very fast walk / running. Because we’re talking about walking with hip pain, this is for being on a treadmill below 4mph. (And that’s probably as fast as most people should go anyways.)

One of the main concerns with a treadmill is the tread helps a person move their leg backwards, but the person still has to do the normal amont of work to bring their leg forwards. Because of this discrepancy it’s conceivable an imbalance between the hip extensors (bring leg back) and flexors (bring leg forward) could arise.

When comparing treadmill walking to regular, here’s what you seem to find:

  • In terms of timing, not much is different. Stride length, cadence, etc. stay very similar.
  • Same goes for range of motion. However much you flex your hip on ground is about how much you do on a treadmill.
  • Slightly greater moments at the hip. (Basically a bit more work is being done at the hip.) This isn’t ideal when dealing with hip pain, as we’ve gone over we want to diminish things like this.
  • There are quite a few differences in muscle activation patterns. Perhaps most interestingly, if you look closely at the numbers many of the muscles we want to activate more, like gluteus maximus, become more active, and muscles we want to calm down, like the hamstrings, become less active…both while on a treadmill.
  • However, the rectus femoris (hip flexor) becomes quite a bit more active on the treadmill.

So when getting on a treadmill we have a few things in our favor and a few things that aren’t.

My thoughts at this point are: When getting a person on a treadmill, if we get the person to focus on the ankle push off we’ve been talking about, that should help diminish 1) The extra hip moment present and 2) The extra rectus femoris action. How much? I’m not sure. But we should get a good effect. Then we still have the added benefits of better glute activation, less hamstring activation, and the ancillary aspect of it’s easier to focus on your walking form while on a treadmill.

Summing up

  • Hip pain is primarily caused by excessive stress on the front of the hip.
  • We can relieve hip pain by walking with a greater focus on using the ankle / foot / calf complex.
  • High heeled shoes are not ideal for making this transition.
  • Walking on treadmills is ok, but be sure to focus on the extra ankle push-off.

References (with poignant quotes and charts)

Acetabular Labral Tears

Anterior Hip Joint Force Increases with Hip Extension, Decreased Gluteal Force, or Decreased Iliopsoas Force

Biomechanics of overground vs. treadmill walking in healthy individuals

Click to enlarge.

Click to enlarge.

Effect of Hip Angle on Anterior Hip Joint Force during Gait

“The maximum anterior hip joint force occurs just before the hip reaches its maximum hip extension angle, further implicating an interaction between anterior hip force and hip angle. “

Effect of position and alteration in synergist muscle force contribution on hip forces when performing hip strengthening exercises

It pays to have a spring in your step

Walking with Increased Ankle Pushoff Decreases Hip Muscle Moments

Hip moments with increased push off

Click to enlarge.

Enter your email address to follow this blog and receive notifications of new posts by email.

Advertisements
Posted in: Hip Pain