Mike Reinold ran a post about the importance of hip flexion strength when it comes to knee pain. He mentions hip flexion strength is often lacking in people with patellofemoral pain (knee cap pain) issues and how to assess hip flexion strength. I want to expound on this and talk about how to strengthen the hip flexors if they are weak, and how to get out of as much knee pain as you can until the hip strength catches up.
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1) Strengthening hip flexion (long-term fix)
It’s important to note the method used to test hip flexion strength in the other article is testing the strength of the psoas and not all the hip flexors. Because the test is done with the knee above 90 degrees the psoas is the only still active hip flexor, therefore being the only hip flexor tested.
-> The psoas is the only hip flexor which connects above the hip. Because the other hip flexors start at the hip, then go lower, they can’t pull the knee above the hip.
Although not talked about in the article, this is done because RARELY are any other hip flexors weak. The hip flexors bringing the knee to 90 degrees are often too strong relative to the psoas, causing an imbalance in strength between the various hip flexors. This is important when deciding what exercise(s) to use to strengthen hip flexion. We want to pick exercises where the knee is always above 90 degrees to make sure we selectively strengthen the psoas and not the other, already strong, hip flexors.
-> This is all very common in those with hip pain as well.
Here’s one exercise for strengthening the psoas:
Make sure you or your client does not lean back to try to accomplish the hip flexion. It’s subtle, but you can see the demonstrator actually arching the lower back despite trying to show proper form in the above video. Because this will often happen, and can be very hard for the person to recognize, I prefer to put the person against a wall:
This forces the person to stay tall and helps them recognize when they are arching their lower back, since they will feel when it comes off the wall. Just make sure you don’t tilt yourself to a side compensating for a lack of hip flexion. Try doing the exercise in front of a mirror if you’re not sure whether you are side tilting.
2) Short-term fix for the knee pain
Simple: do this exercise every hour, or as needed, and you’ll likely notice relief in your knee pain.
This works because people who need hip flexion strength often walk with their knees hyperextended:
Chronically hyperextended knees are a sign the quadriceps are working overtime, specifically the rectus femoris. The rectus femoris is one of those overactive hip flexors, which has become too strong compensating for the weak psoas.
Inferior patellar glides help loosen the rectus femoris and other quadriceps, and give some relief of that knee pain. Especially when that pain is most present on the knee cap.
Remember though, this is not meant to be a long-term fix, that’s what the psoas work is for. (And practicing “stand with a little give in the knees” / “unlock your knees.”) But it’s nice to not be in as much pain til that psoas can catch up strength wise.
Give it a shot.
Justin Archer (@ThePostureGuy)
January 7, 2014
Great way of explaining/illustrating the difference between the psoas and the other hip flexors, and the affects each has on the body. But I’m curious what do you think about strengthening the psoas in a posterior or neutral pelvic position vs an anterior position? For example, strengthening the psoas using something like the Wall Knee Raises vs sitting down, rolling your pelvis forward into an anterior tilt and then proceeding to lift one leg/knee at a time above hip height (90 degrees). Both seem good to me, but wouldn’t the later bring the insertion and origin of the psoas closer together, thus making for a stronger contraction? At the very least, a sitting version of the knees raises could prove to be useful for someone who wasn’t functional enough to perform the standing version. Justin thinking/typing out loud 🙂
reddyb
January 14, 2014
Hey Justin,
I don’t like the sitting version because the pressure of the chair can push the femoral head upwards (anteriorly). There’s not as much room for the femur to glide posteriorly when you pull the hip into flexion.
Using some anterior pelvic tilt can work well. What you want to look for, and what I didn’t do a good job covering in this post, is making sure the person isn’t generating what looks like hip flexion by leaning backwards. If you lift your hip into flexion, then lean backwards (lower back arching), your knee will be even higher, giving the illusion your hip is in more flexion, but it’s really not. This is where the wall can come in handy.
As of now, I rarely use the wall or the sitting variations. I do something like this:
This way you get the posterior glide of the femur to start with, then by using the support(s) and mirror(s) you get a feel for what the hips and lower back are doing. In this instance, you are more looking out for the lower back not flexing, coinciding with your comment: Making sure you don’t go into a posterior pelvic tilt.
Overall, I’d say you’re looking for a neutral spine, neutral meaning a little lordosis is fine, with hip flexion. In other words, full hip flexion without lumbar motion. Rather than worry about bringing the psoas into a complete contraction, I worry more about generating “good”, full, hip flexion with posterior glide of the femur. Do that, and the psoas gets taken care of.
Jason.p.clement@gmail.com
February 8, 2016
I’m seeing a lot of my Brazilian Jiu Jitsu friends complaining of lateral hip pain or just generalized hip pain on their right side. I associated my pain to my fai diagnosis… But as I learn more about this, perhaps the hip pain and fai were a byproduct of the over-activation of the other hip flexors. I notice myself trying every trick in the book to avoid activating my psoas on these exercises (right side only). And I still have lingering tendonitis in my RF and TFL, 3 months post op… probably from continued over usage.
Also, why the right side for BJJ??? I’m thinking because most people pass the guard to the LEFT side, which puts a lot of the stress on the defenders right leg. Just some thoughts. I love this article.
reddyb
February 9, 2016
The psoas can help keep the femoral head snug in the socket. So if there are issues with it, FAI can be more likely.
As far as BJJ, I’m pretty familiar with MMA, but not the specific disciplines. Feel free to send a video of what you’re referencing so I can be sure, but something else to consider is most are right handed, so most push off their right foot much more than their left. They push off in a position where the foot is fairly fixed, but the pelvis rotates. Without getting too technical here, you can end up rotating a pelvis on a fixed femur / a femur which doesn’t turn in the same way. When one thing is (violently) twisting one way, and the other structure isn’t, you open up room for issues.
Another aspect of this is my experience with baseball players, also a lot of pushing off the right foot, was the right hip changed structurally. (Retroversion.) Taking a hip which has changed in this manner and asking for the level of flexibility most MMA disciplines ask for can also potentially be problematic.
Jason.p.clement@gmail.com
February 10, 2016
Here is a quick link – https://www.youtube.com/watch?v=qv20uMvrCqU – skip to 1:27.
This and similar situations take place time and time again. The bottom player is trying desperately to flex their hip so that they can get their femur above the passer’s knee (to reclaim half guard). There is a pretty violent amount of flexion and also adduction taking place. I’d say this happens to the right side 80% of the time, as like you said — most people are right handed – aka pass the guard to the left.
My hips seem to readily recruit my RF/TFL, and my psoas is testing really weak, and has for a long time. I think its likely a result of the angle of the hip when contracting. Its well below 90 degrees, which I believe is less than ideal for psoas recruitment based on reading some of your WONDERFUL(!!) content.
It seems like in BJJ we spend a lot of time in hip flexion, but very little above 90 degrees.
reddyb
February 12, 2016
Interesting to see. Thanks for sending that over and explaining it. I’ll have to look out for this more when I watch fights now.
Jason.p.clement@gmail.com
February 10, 2016
Also – interesting take on the retroversion. I can’t speak for everyone, but like you said — I can “violently” twist my hips off a stationary right leg, through years of repetitive motion. The same is true for the left, but to a lesser extent for sure.