If you missed part 1 of this article on what is hip impingement be sure to check it out!
Hip Impingement Exercises
When attempting to heal hip impingement without surgery, you won’t necessarily be changing the bony deformations or integrity of the labrum, but you’ll focus more on improving the joint mechanics through muscle reeducation, addressing muscle imbalance, and strengthening to reduce or even eliminate your symptoms. One of the biggest components to set you up for success when approaching this conservatively is being willing to step back to assess what you are doing and how your body is doing it. One sure thing that happens with surgery is you are forced to have relative rest and start back at ground zero due to surgical precautions and acute discomfort, so why not try that without going through surgery first?
Pelvic Repositioning
The first thing to address when working on hip impingement is to address the position of the pelvis. With hip impingement, the pelvis is often in relatively more of a tipped forward position (an anterior pelvic tilt), bringing the roof of the socket over the femur and resting in relative hip flexion as well as a more splayed out position, orienting the femurs more out to the side.
People will often feel like their hamstrings are tight and want to stretch them, or they find that a wider squat with feet turned out feels more comfortable. In this forward position, your hamstrings are actually overly lengthened. The hamstrings attach to the sit bones (proximal) as well as behind the knee (distal). The reason they feel tight is that they are already at their end range position, and often the glutes aren’t good at lengthening while doing things like a hip hinge or touching toes, so all of the movement is coming from the hamstrings. The proximal hamstrings can pull the pelvis back into a posterior pelvic tilt, bringing the roof of the pelvis back and giving the hips a better position to go into flexion from to help lengthen the glutes. Strengthening your proximal hamstrings can then actually make your hamstrings feel less tight because the load of lengthening is more distributed and your glutes are set up in a better position to function.
Here’s a fun example of how that works and how to test out the effects on yourself
The trick with finding proximal hamstrings is to make sure you are actually finding the hamstrings as they attach to the pelvis and not just at the knee, where they bend the knee and don’t control pelvic movement. It is also important to make sure you work the hamstrings in isolation at first, keeping hip flexors and glutes quiet and allowing for abs to flatten automatically.
Hip flexors pull the pelvis into more of an anterior pelvic tilt, so keeping them quiet helps your pelvis not be in a tug of war to better accomplish the act of repositioning the pelvis out of the anterior pelvic tilt. Keeping glutes relaxed in this specific exercise will then make sure you’re able to control the pelvis in exercises where you want to eccentrically lengthen the glutes (like squats and hip hinges) and assist with the lower abs to keep the pelvis in a neutral position. If you’re using your glutes to tuck your pelvis, then you won’t be able to lengthen them as you go into a squat or hip hinge, meaning you’ll get the length through your back or hamstrings instead.
It can be challenging to find the hamstrings when they are in an overly lengthened position, and stiffness in the pelvis also limits the movement if it has been stuck in this position for a while. Doing some release work around your sacrum with a small ball can help decrease that stiffness, as well as foam rolling your hip flexors, and then doing some release work on your hamstrings can also help. Another move that can feel great is using a foam roller to help passively reposition the pelvis and open up the back side of your pelvis.
Some other great ways to incorporate hamstrings into your exercises are with side and front planks. You can even use the same front plank activation for push ups. This will help you find your hamstrings in various positions to improve your connection and their strength as well as improve your rib cage position over pelvis for better core strength, which is also important when addressing hip impingement.
Hamstring work is a great time to start reflecting on any asymmetries that might be happening in your pelvis. Often the side that’s in more of an anterior pelvic tilt and has a harder time engaging the hamstrings is the side of impingement, so when doing double leg hamstring work, instead of engaging them as your body perceives as equal, think about engaging the side that’s in more of tipped forward pelvis position by reaching through the opposite side more (almost pulling back more with the weaker side) or think of unweighting the opposite side to help you consciously ground and engage the weaker side more. Just make sure when you pull back more that it’s with the intention of getting more of a tuck on that side. That being said, we are full of layers… so make sure to explore the movements yourself and see what feels best to you. You can even recheck your symptomatic movement afterwards to help know if your range improved, and what that end range feels like. If symptoms decrease, you're on the right track
Glute Lengthening
Once you have established an improved position of your pelvis, then glute and lower ab strength is the glue to help it stick. The first step in glute strength is working on eccentrically lengthening the glutes. Those who have impingement will often have a hard time maintaining a neutral pelvis as they lengthen their glutes, causing them to go in and out of an anterior and posterior pelvic tilt, creating what is sometimes called a “butt wink.”
If you fall into an anterior pelvic tilt, then you are further exacerbating the impingement, bringing the roof forward and overly lengthening hamstrings, and will often feel the deep hip external rotators working instead of your glutes. On the flip side, if you’re preventing this by engaging your glutes or psoas (hip flexor) to tuck your pelvis, then you’re not actually getting any lengthening of your glutes that would allow space for your femur to slide back into. Blocking this movement can create extra stress through the front side of your hip that can contribute to labral tears. Either can also contribute to overactive front side muscles of the quads and hip flexors which will then pull your pelvis into more anterior pelvic tilt because they attach to the front hip bone, and when shortened, this will pull your pelvis forward. It’s about maintaining a neutral pelvis and using lower abs and proximal hamstrings to stabilize as you learn to eccentrically lengthen your glutes (under load and control) and then contract your glutes.
Hip hinges and squats are great ways to work on learning to eccentrically lengthen glutes and work on pelvic control in a loaded position. Just like anything, it’s about how you do it and not just what you do, particularly with squats that could worsen hip impingement (or other hip pathologies) if not performed correctly.
Check out this video for helpful tips on how to find more glutes and not deep hip external rotators.
In general, you can break up a hip hinge to a more horizontal pelvic movement and a squat to a more vertical pelvic movement. With a hip hinge, watching for the knees to stay over your ankles or even mid foot while sitting back into your hips helps make sure you focus on lengthening your glutes and not overly lengthening your hamstrings. If you have a lot of hamstring flexibility or are in a lot of anterior pelvic tilt, presetting your hinge by thinking of dragging your leg back (without straightening your knee) to get your hamstrings to engage will allow for a better position to find length in your glutes.
You will be using your quads with a squat, but it’s important to make sure you still find your glutes. Using a hand hold assist can help unload your body a bit so you can work on repatterning your movement and finding your glutes.
You can try switching up your lunge by using a dragging or a pushing action on the back leg to affect what’s happening in your front hip.
Our hips work in three different planes of motion with different glute muscles working in all three planes. It’s important to strengthen your glutes in all planes of motion for optimal balance in strength and pelvic control. This can also help improve your hip hinges or deadlifts and squats.
If you're struggling with finding length in your glutes and controlling your pelvic position, you could need more support; either by improved proximal hamstring or core strength or by regressing the exercise. If your glutes are working to stabilize your pelvis, then they won’t be able to eccentrically lengthen. You’ll get the movement from somewhere else, resulting in hip impingement and other forms of hip irritation, continuing to overly lengthen your hamstrings, or feeling the exercise in your back. This can mean that you need to stick with two legs or a split stance position or use a lighter weight to help. For all of these exercises, you’re thinking of keeping your rib cage stacked directly over your pelvis (no matter if it’s completely upright or bending forward).
Another trick you can use to help an exercise work better for you is using heel wedges to adjust your starting position, giving you more space to sit back into your hips without feeling like you’re going to fall over and taking ankle range of motion out of the picture, which can often be limited in those with hip impingement.
You can also see how holding a light weight can actually help you; this could be holding a weight at your chest while performing a squat. An air squat (a squat with no weight) is actually more challenging than a slightly weighted squat because the counter weight on the front helps you to sit back into your hips. You can also check out this article for more details about what goes into a great squat.
Holding a weight on one side or the other can stimulate different muscles to help stabilize your pelvis as well, particularly as you transition into more of a split stance or single leg exercises.
So experiment a little bit, and see if changing your setup can help set you up for success to perform the exercises with the right intentions. Know that if a movement isn’t working for you right now even after some experimentation and change of intentions, that’s okay. You can put it on hold for now, work on other components, and then come back to it when it is the right time for your body. It’s about listening to your body and not forcing it to do something just because it is said to be good, but also remember to add the word “yet” to the end of that thought.
Glute Strengthening
Now that you’ve worked on pelvic positioning and stability and eccentrically lengthening the glutes, it’s also about making sure you are able to create a great glute contraction. This will help you with optimal hip extension mechanics so you’re not falling into an anterior pelvic tilt at the top position or shoving your femur forward in the socket.
A glute activation test is great to see what your primary mover is for hip extension. You can also use it as a neuromuscular rewiring exercise. Those with hip impingement will often use hamstrings over glutes (or glutes won’t be working at all) or they won’t be able to keep their hip flexors relaxed.
This will be more challenging if your pelvis is in more of an anterior pelvic tilt because the glutes are already in a compressed position, so working on pelvic repositioning by finding proximal hamstrings, lower ab strength (to assist in pelvic control for a better foundation for the glutes to engage from), and maybe even some glute lengthening is needed first. When transitioning into the prone glute squeezes and lifts as an exercise, oftentimes putting a pillow under your pelvis to passively position it out of the anterior pelvic tilt can help to begin with.
Then, when it comes to squeezing your glutes, not all glute contractions are created equal. To optimize a glute max contraction, you’ll want to think of a top down glute squeeze to help with pelvis and femur positioning, thinking of holding a pencil under one butt cheek rather than pinching a pencil between your butt cheeks which would create over activity of the deep hip external rotators.
If you need an extra visual of what NOT to do, just search “Nacho Libre glute squeeze” and you’ll get an image that will stick with you. Thank you, Jack Black.
This is particularly important when you’re thinking of coming back out of a squat or deadlift and feeling that end range hip extension. Too often the thrust and tuck is overemphasized, so people are just shoving their femurs forward, leaning back in their upper body, and overly working those deep hip external rotators. Instead, think about the connection you made in bridges where you found hamstrings, lower abs, and top down glute squeeze and imagine rotating your pelvis under like a wheel. In a squat or deadlift, that action will pull your pelvis and rib cage as a unit up over your feet to get back to upright rather than just shoving your hips forward. This way you have worked on great lengthening of your glute max on the way down and great shortening on the way back up, all while maintaining a neutral pelvis.
Another commonly prescribed exercise to work glutes are clams or clamshells. With these, it is again about how you do them (rather than just doing them). It’s important to make sure you address pelvic positioning by finding your hamstrings first and maintaining that tucked position as you lift your knee up with some lower ab control.
Putting your feet on the wall as well as shifting your top knee forward through the underside of your hip can help with this and will also get a bit more glute max in the mix. Making sure your entire foot stays grounded (particularly your heel and the base of your big toe) as you shift your knee forward and lift it up will help you find more glute max over deep hip external rotators or outside quad. This might mean actually having your top foot further forward to begin to take any limitations in ankle range of motion out of it, but then still reach that top knee over your mid foot. Lastly, it’s important to make sure you’re not using your hip flexors, most often your sartorius, otherwise you’re just encouraging the muscles that pull you into an anterior pelvic tilt to work.
That being said, clams aren’t for everyone (read this article to find out more), and sometimes you need to work on more glute lengthening first before they’re introduced into a program, so just keep that in mind.
Core Work
The complement to glute and proximal hamstring work is core work. Your core helps to stabilize your pelvis and spine so the attaching muscles can function optimally. Just like glute work, you want to make sure your core strength is balanced and coming from the right places. First, looking at how you engage your abs and if you’re able to flatten them is key to making sure that you’re engaging your transverse abdominals, which are your primary stabilizing muscles and often a little sleepy.
Abs flatten with PPT
Then, it’s about taking that engagement to dynamic movements to help learn how to control the pelvis dynamically. Two common but often poorly explained and performed exercises are dead bugs (or leg lifts) and bird dogs. With both of these movements, you’re thinking of no movement at the pelvis and spine as you move your leg (and/or arm). Approaching the exercises with that intention and going very slowly can often make them more meaningful.
Dead bugs without the pop (might have to work leg slides first)
Bird Dogs
With both of these movements, you might have to focus on sliding the leg out first (in the bird dog, this might mean you think of dragging your toes on the ground) as you work on eccentric hip flexor lengthening (particularly with dead bugs) and hip extension range of motion. If you are lifting a leg up, remember to work through a pain-free range of motion and primarily feel it in your abs so your core work isn’t actually just hip flexor work. That being said, if you’re having pain or discomfort with this, you most often need to work on proximal hamstring strength, glute lengthening, ab engagement, and eccentric hip flexor lengthening first.
Like with the glutes, working in different planes of movement is important for well-rounded strength. You can take the same idea as the dead bugs and apply it to a rotational direction with leg fall outs.
Half kneeling rotations are great for building some connection in your core to open up your back and continue to diversify the planes of movement you’re working in. Proper performance of this will include a few things. Watch how you rotate, and really think of opposite side ribs and hip bones connecting toward each other to create the rotation. Visualize your rib cage staying directly over your pelvis throughout the movement. Being in a half kneeling position is a great way of working core stability while in a glute lengthened position and to assess for asymmetries. If you have a hard time keeping your hips level, you can always elevate your back knee on a block to lessen the depth of your lunge to the level where you can stabilize at your pelvis, or it can be a sign that you need to work on some more single-side glute lengthening and any asymmetries in your pelvis.
Rib Cage Position
If you’re having a hard time with these exercises, often the position of the rib cage needs to be addressed as well. You can think of the rib cage as a wheel that can be flared forward or tipped back at the lower ribs, just like your pelvis. With hip impingement, the ribs are often flared forward, lengthening your ab muscles and compressing your back. So, just like you had to reposition your hamstrings, you can reposition your rib cage. Core work will help, but you can also do some positional breathing drills to help set the stage for your core work and find better balance in your core.
Child’s pose breathing with overhead reach is a great one for this.
If you are having hip impingement getting into the position, make sure to approach it by starting forward and sitting back into your hips. Think of sitting back and lengthening your glutes, and then fold over. Sometimes even approaching it from the top down in standing and doing full squat breathing can be great, and can also help with eccentric glute lengthening. If you’re feeling discomfort in your hip here, check in to make sure the fronts of your ankles are relaxed, and you can also try a small book under your heels to see if that helps.
If this position still doesn’t feel good, you can use a similar towel setup over your lower ribs and a pillow under your hips and simply lay flat on the floor in what’s known as crocodile breathing to help compress the front ribs and expand the back.
Another position that can be more hip friendly is working on rib cage compression in a side lying position.
Hip Impingement Exercises to Avoid
One movement to be mindful about doing is hip flexor stretches. Hip flexor tightness can be deemed as either functional hip flexor tightness or structural. Functional is when you’re using your hip flexors to stabilize your spine so they’re always engaged, but the muscle fibers themselves aren’t actually shortened; it is more that you are hanging on them at end range in a lengthened position. This is a case where even though people feel the need to stretch the front of their hip because it feels tight, this will only make the symptoms worse. Instead, we want to work on pulling the pelvis back, addressing rib cage position, and improving core connection to take pressure off of the hip flexors through improved position.
Structural hip flexor tightness is where the hip flexor muscles are actually shortened and you do need to bring some length to them to better help with finding glutes and hamstrings.
When people need stretching in their hip flexors, they will often go into a hip flexor stretch without anchoring their spine or pelvis; so yes, they may be going into hip extension and lengthening on one end, but they are arching their back or letting their pelvis fall forward which just shortens the other end instead of lengthening from both sides.
These are two variations of commonly found yoga poses where you can make sure you’re actually getting length through your hip flexors while also maintaining stability in your pelvis. This can be good for those who fit into either category, and those who actually have structural tightness will feel a stretch in their hip flexors.
The other moves that are best to hold off in the beginning are any active hip flexion strengthening and internal rotation. With those who have hip impingement, the hip flexor muscle group is often overactive already. Yes, it might be weak; but first you have to work on unloading it, establishing a great foundation for it to work from, and giving it a little vacation, particularly if you’re in more of an acute stage. Then it’s about coming back and teaching them their role, particularly the psoas which has a primary role of keeping the femur centered in the socket. You’ll already be doing this to some extent with well-performed dead bugs, but then you can start to add some external resistance for your lifting leg to flex against while maintaining all the good form and quality behind it without the load.
In the beginning of hip impingement, working internal rotation often does not feel good due to pelvic positioning. You’ll hit a bony end range as well as use your TFL (hip flexor muscle) over your adductors and glute medius to be the main driver of internal rotation, and this would further pull your pelvis into internal rotation. To address this, you’ll first need to find hamstrings to get you out of the anterior pelvic tilt and get your hip flexors to relax. Then, you might also need some eccentric glute work from the ideas listed above, particularly where you’re rotating the pelvis over the femur to create positional internal rotation.
You can start some isometric adductor work early, and then add a pull back motion to strengthen your iliacus. The adductor squeeze will help reposition the pelvis from being wide and turned out to a more forwardly-positioned pelvis to clear the path for internal rotation to occur. The iliacus will help pull the femur back into the socket and open up the back of your hips.
You can then work on actively finding those adductors and glute medius to do the internal rotation work. At first the movement might be small or not as glorious as you want it to be, but making sure it’s coming from the right places is important. This will help bring balance in your glute strengthening and complement eccentrically loading your external rotators as well as keep the femur centered in the socket so you can actively control hip internal rotation and where it comes from.
Other than that, you can let your symptoms be your guide. Even if it’s not specifically pain, having congestion or “feeling something” in the front of your hip when your hip is in a flexed position (knee coming up toward hip height) is a sign that you’re getting some compression in the front side of the hip. You may be able to use that as feedback for addressing your pelvic position while in the movement itself, either by engaging your hamstrings to help you get out of the anterior pelvic tilt or watch for glute lengthening to help create space for the femur to sit back into the socket. If you can’t use props, intentions, or adjustments in a position to decrease that discomfort, then you should not go into that depth yet or choose a different exercise for the time being.
The idea is that you’ll be able to do whatever movements you want, but you just have to build up to those movements. If you’re struggling with making progress, seek out the help of a professional for hip impingement physical therapy. They can help you identify and improve your movement patterns and strength. Sometimes an overlooked professional is a pelvic floor physical therapist – even if you have not had a child or are a man – as everyone has a pelvic floor, and it is intimately connected to your hips, pelvis and SI joint.
Here are some symptoms that might help you know if you have pelvic floor tightness that needs to be addressed.
So, just like hip work can help your pelvic floor; pelvic floor release work and reeducation can be missing links in improving your hip function.
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