So, it’s Wimbledon time again. I watched Johanna Konta’s victory in the quarter final against Simona Halep yesterday in awe of her pinpoint accuracy on backhand; but today Andy Murray lost to Sam Querrey, losing 12 of the last 14 games and clearly struggling with a limp. Of course, one of the major talking points this year has been Murray’s hip, and I am seeing an awful lot of patients with hip issues at the moment, so today I want to address some of the consistent factors I’m seeing.
It’s important to mention though that “hip issues” doesn’t necessarily mean “hip pain“. Hip pain can be the result of the hip compensating for issues elsewhere in the body; and pain elsewhere (commonly the knee, but also the back and neck) can result from the painful areas compensating for dysfunction at the hip. This is why I always recommend getting assessed by a good physio to work out the underlying cause of the pain: treating the painful area may work for a while, but if the pain is there because it’s compensating for something else and you don’t treat the something else, then you won’t get a long term solution.
However, when the hip is the cause of the problem, the primary issue I see at the hip is an imbalance between the muscles at the front and the back. Muscles that act on the hip include the hip flexors at the front, adductors at the inner thigh, gluteals at the back. And in the ideal world, these muscles should pull on the hip evenly in all directions, contracting and relaxing in harmony depending on what you’re asking your body to do, resulting in the body consistently balancing its weight directly through the centre of the ball and socket.
However, when there is dysfunction, muscle balance tends to go a bit haywire; and in the hip, the typical pattern I’ve found is that people start to dominate with hip flexors and adductors, while the gluteals get weak and lazy. This results in poor control of the hip joint and femur, as there is more force pulling the ball forwards, in and up (relative to the socket) than there is pulling it back and out. The nervous system also suffers: you should be able to contract the glutes, hip flexors and adductors separately, but dysfunction tends to lead to bad movement habits, which then perpetuate the dysfunction in a vicious spiral.
What to do about it? Well, in general, it’s about finding the underlying cause, and then going through the logical sequence of release/align, stabilise and then move.
Assuming the hip is the underlying cause, this first means reducing the tone of the overactive muscles (adductors, hip flexors, and the overactive portions of the complicated glute complex, some areas of which tend to become overactive in dysfunction). A good option for this is massage; or for a home solution, we recommend the release with awareness using a cork-filled tennis ball or similar.
We then have to teach the nervous system what a normally-aligned hip feels like, by manually holding it in a better position. This could mean using hands (your physio should be able to teach you how to lift your ischial tuberosity and then centre the ball within the socket) or tape can sometimes be helpful.
Next, it’s important to restore the coordination of the glutes and hip flexors. I will often start by getting people to wake up the glutes and be able to distinguish between left and right sides (it’s amazing how difficult many people find this; I even treated an Olympic gold medallist recently who struggled with it!); and then progress to differentiating between glutes and hip flexors. The clamshell exercise has come under fire from various physios lately; but I would argue that, if taught properly, it’s an important tool in restoring muscle balance around the hip.
Once you have coordination, you need to build up glute strength, focusing on form and quality to make sure you don’t start compensating again. Start with simple exercises – stepping forward (I’ve lost count of the number of people I’ve taught to walk properly; but gluteus medius should fire as your heel hits the ground, to control hip rotation, and gluteus maximus should fire to absorb the shock of impact) and then stepping up and down, relearning to lift and lower your body accurately against gravity. Gradually increase the complexity and challenge of the exercises – adding weight, reducing base of support, adding perturbation, adding distraction and full-body movements – until your central nervous system has the capacity to maintain alignment during any activity you’re likely to throw at it.
Got it? If you’ve got the concept but need some inspiration, why not try my online programme, Pelvic Pain, Pelvic Drivers, for only £19.99?
Too complicated and need help? Come on in and see me for an assessment, and I’ll help you work out a bespoke course of treatment to help restore the function of your hip (Sir Andy, are you listening!?)