Hip Pain in Athletes: What’s the Scoop?

Hip Pain in Athletes What’s the Scoop

Today, I am back with another post from Eric Cressey.

It has to do with hip pain.

Enjoy the article!

Take it away, Eric.

Rick Kaselj

P.S. – If you missed yesterday’s article, you can check it out here.


Over the past few years, there has been a huge rise in hip injuries in athletes. Sports hernias, labral tears, and Femoroacetabular impingement (FAI) are commonplace findings on the health histories that I see every day on first-time evaluations. In case you’re not familiar with this term, with FAI, you can have a bony overgrowth of the femoral head (cam), acetabulum (pincer), or both (mixed), as the graphic from Lavigne et al. below demonstrates:

femoroacetabular impingement

And beyond injuries that are actually observed and reported, you can find something “wrong” with just about every athlete’s hips if you just do some diagnostic imaging.

Silvis et al. (2011) found that 77% of asymptomatic collegiate and professional hockey players had “findings of hip or groin pathologic abnormalities” on MRI.

Larson et al. (2013) reported that 87% of high-level college football hips imaged had findings consistent with FAI, but only 31% of those hips presented with actual symptoms. Not surprisingly, the more bony overgrowth present, the higher the likelihood of symptoms.

Some folks say that diagnostic imaging and functional tests are improving and that’s why the prevalence has increased in recent years. In other words, some people are asserting that we’ve always had significant hip “abnormalities,” but we just learned to clearly define them.

Let’s stop and think about that, though, folks: if we had hip pain and dysfunction on this level for decades, don’t you think anecdotal evidence would have at least tipped us off? I find it hard to believe that generations of athletes would have just rubbed some dirt on a painful hip and born with it for decades.

To draw a parallel, consider shoulders in those over the age of 60. Sher et al.(1995) reported that a whopping 54% of asymptomatic shoulders in this age group have rotator cuff tears; again, that doesn’t even include those who actually have pain! Why does this happen? They impinge over and over again on the undersurface of the acromion process secondary to poor thoracic (upper back) positioning, scapular (shoulder blade) control, and rotator cuff function.

shoulder blades on back

The end result is reactive changes in the acromion process that lay down more and more bone as the years go on. And, an anteriorly tilted scapula kicks that impingement up a notch. The “early” cuff irritation likely comes in those with Type 3 (beak-shaped) acromions, whereas the Type 1 (flat) and Type 2 (hook) acromions need time to lay down more and more bone for their anterior tilt to bring them to the threshold.

types of shoulder blades

This closely parallels the pincer overgrowth we see on the acetabulum, but you can also get bony changes on the humeral head, just as you would on the femoral head. Shoulders and hips aren’t that different, are they?

Bringing our focus back to FAI, it’s widely debated whether those with FAI are born with it, or whether it becomes part of “normal” development in some kids. World-renowned hip specialist Marc Philippon put that debate to rest with a 2013 study that examined how the incidence of FAI changed across various stages of youth hockey. At the PeeWee (10-12 years old) level, 37% had FAI and 48% had labral tears. These numbers went to 63% and 63% at the Bantam level (ages 13-15), and 93% and 93% at the Midget (ages 16-19) levels, respectively. The longer one played hockey, the messier the hip – and the greater the likelihood that the FAI would “chew up” the labrum.

I’d estimate that over 90% of the Femoroacetabular impingement cases I’ve seen have come in hockey, soccer, and baseball players. What do these sports have in common? They all live in anterior pelvic tilt – with hockey being the absolute worst. Is it any surprise that the incidence of FAI and associated hip issues has increased dramatically since the AAU generation rolled in and kids played the same sport all 12 months of the year?

Conversely, I’ve never seen a case of FAI in a cyclist. Why? It’s likely because they live in lumbar flexion and a greater degree of posterior pelvic tilt. And, taking it a step further, I’ve never seen an athlete with FAI whose symptoms didn’t improve by getting into a bit more of a posterior pelvic tilt.

Finally, a 2009 study by Allen et al. demonstrated that in 78% of cases of cam impingement symptoms in one hip, the cam-type Femoroacetabular impingement was bilateral (they also found pincer-type FAI on the opposite side in 42% of cases). If this was just some “chance” occurrence, I find it hard to believe that it would occur bilaterally in such a high percentage of cases. Excessive anterior pelvic tilt (sagittal plane) would be, in my eyes, what seems to bring it about the most quickly, and problems in the frontal and transverse planes are likely to blame for why one side presents with symptoms before the other.

People have tried to blame the increased incidence of hip injuries on resistance training. My personal opinion is that you can’t blame resistance training for the incidence, but rather the rate at which these issues reach the threshold. Quality resistance training could certainly provide the variety necessary to prevent these reactive changes from occurring at a young age, or by creating a more ideal pelvic alignment to avoid an FAI hip from reaching the threshold.

Conversely, a “clean-squat-bench” program is a recipe for living in anterior tilt – and squatting someone with an FAI is like overhead pressing someone with a full-thickness cuff tear; things get ugly quickly.

Honestly, this probably isn’t revolutionary for folks out there – particularly in the medical field – who have watched the prevalence of Femoroacetabular impingement rise exponentially in recent years. However, what may seem revolutionary is the realization that an entire generation of young athletes have been so mismanaged that we’ve actually created a new classification of developmental problems and pathologies: Femoroacetabular impingement, labral tears, and sports hernias.

How do we fix the problem?

First, we give young athletes more variety at a young age to ensure that they don’t live in these problematic positions year-round.

Second, we counsel them on what good posture really is – and it doesn’t look like this:


Third, we make sure that their strength and conditioning programming is appropriate by training them out of this heavily extended pattern. This includes a big focus on the anterior core, glutes, serratus anterior, and lower traps through a combination of corrective exercises, positional breathing drills, and resistance training in the right positions.

For your guide to eliminate your shoulder pain for good, check out Shoulder Pain Solved, here!

Shoulder Pain Solved