Person clutching hip in pain.

Kinesiology THURSDAY – A Hip Flexor Strain That Wasn’t (A Case Study)

Golfer swinging club on tropical course

SUBJECTIVE:

“There’s only one thing that hurts,” he said pointing to his left groin. “It’s when I lift up my leg, like when I get out of a car or go to put my sock on.” He denied pain with walking or squatting or with prolonged positions. “My leg feels four times heavier than it should be,” he added, describing his pain as 8/10, sharp and fleeting.

It started about a month ago after he had hit over 100 golf balls at his home golf simulator, an activity he performed often and which did not elicit pain at the time. He is a right-handed golfer. He consulted with a physician who diagnosed him with a hip flexor strain after listening to his history and performing a seated hip flexion MMT.

“He said he could give me some exercises to do on my own or else I could come to PT.”

OBJECTIVE:

He stood with his left shoulder and iliac crest slightly higher than the right. This was confirmed with trigger points in the left quadratus lumborum and left upper trapezius. His pain was reproduced with active standing and seated hip flexion and with MMT of the left hip flexor, which was 3+ due to sharp pain elicited deep in the anterior hip.

He presented with a left inflare and left anteriorly rotated innominateLeft side lying thoracic rotation was 50% and normalized following thoracic sequence. Moderate trigger point noted in left posterior gluteus medius and severe trigger point noted in the left vastus lateralis. He had hypomobility passive left subtalar joint eversion.

He had a (+) left FABER test.

After correction of pelvic alignment, pain was still present. However, release of left vastus lateralis and posterior gluteus medius resulted in improvement of hip flexion MMT to 4 with minimal pain and patient was able to demonstrate pain-free high knee marching for 20 feet.

ASSESSMENT:

His left anterior hip pain was most likely caused by anterior impingement of the acetabular labrum and not a hip flexor muscle strain.

PLAN:

He was given a home program including:

  1. Closed-stance deep squat (improves dynamic flexibility of vastus lateralis)
  2. Pigeon pose (improves flexibility of posterior glutues medius)
  3. Revolving triangle (trains maintenance of subtalar joint eversion with hip internal rotation during functional rotation)

Clinically, I will work on:

  1. Correction of pelvic alignment (restoring functional hip IR will prevent SI joint malalignment)
  2. STJ eversion mobilization (closed stance walking, lunging and squatting and single leg balance activities will promote STJ eversion)
  3. Soft tissue mobilization and trigger point release of vastus lateralis and posterior gluteus medius (dynamic hip flexion/IR keeping the knee in line with the second toe will help decrease these trigger points. Think lateral low row.)
  4. Restoration of left side lying thoracic rotation (exercises involving alternating overhead reaching will promote thoracic rotation)

DISCUSSION (How, what and why?)

The persistent, sharp, fleeting nature of his pain only in non-weight bearing hip flexion alludes more to an impingement than a muscle strain. The picture above is a perfect example of a golf follow-through gone wrong. Notice:

  1. Supination of the left foot which is often caused by limitation of left hip internal rotation in end range of the follow-through
  2. Lack of hip internal rotation results in compensatory hip adduction to help dissipate the force.
  3. Repetitive hip adduction is a common cause of acetabular labral impingement
  4. Chronic supination yields trigger points in the vastus lateralis and posterior gluteus medius, resulting in anterior migration of the femoral head in the acetabulum which may lead to a “pinch” in the front during hip flexion, which requires posterior gliding of the femoral head

Why does it matter?

It’s clear that strengthening the hip flexor probably would not have been the answer in this case. The golf swing (and the pain that occasionally results from it) is a great lesson in biomechanics and “fixing what you find”. Next time someone has pain with hip flexion, don’t automatically blame the hip flexor. Take your ears and listen to the nature of the pain and then take your eyeballs and look elsewhere for the cause.

Because nobody has time to be in pain.

Until next time…

Kind Regards,
MoveWell Academy
[email protected]

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