Hip and groin: biomechanical optimisation, exercises, post-op rehab

The following advice is designed for you to work through with your physiotherapist so it is important that you DO NOT try and do it alone. Hence why there is some juicy physiotherapy lingo in there!

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Pelvis, back and hip position/posture

  • Make sure you are not in posterior pelvic tilt and anterior hip sway with flat lower lumbar extension, increased lumbar/thoracic junction extension and fully extended or hyperextended knees. If you are you need to use a mirror to check this and your physiotherapist can help by using their hands to move your body into the correct position and even putting stickers on your ankles, hips and shoulders to help you get them aligned properly. They might also suggest taking a video or photo of you with your smart phone so you can refer it it later. If you have good gluteus maximus bulk then you might appear to be in neutral or anterior tilt when you are in fact in posterior tilt so make sure your physio checks this out.

  • Feel the muscles over the front and side of your hips using your fingers, particularly a muscle called the TFL (that’s tensor facia lata not the transport for London.) These muscles should not be tight when you are standing still or even when you are standing on one leg. Adjust your pelvis, hips and lower back to make these muscles soft and squishy. If you are feeling confident then you can also simultaneously put your thumbs on the outside of your buttocks and note that as the muscles at the front become softer, the muscles on the outside of your buttocks feel springier or firmer.

  • Make sure you are not standing with your knees fully straightened. They should be ‘soft’ not bent.

  • Tuck you ribs in. This one is impossible to do without a physio showing you how but basically it means stacking your rib cage on top of your pelvis so that they are in line. This will enable you to have a convex curve in the upper back (thoracic kyphosis) whilst maintaining a concave curve in your lower back (lumbar lordosis.) These are the normal curves in the spine and will protect the joints of the spine including the intervertebral dics. NB The spine is NOT designed to be straight, contrary to popular belief! Often people flatten their upper back (thoracic spine) to make their shoulders look less slumped. This can cause shoulder problems and back pain, never mind the effect it has on your hips and pelvis.

  • You need to be doing this all the time – standing, walking sitting etc. – but at first you need to do this really regularly in front of the mirror to make sure you are getting it right – at least four times a day at first. Then you need to practice holding the new posture when you are doing all your activities and sports.

  • It is common to get pain in your lower back when correcting your posture (from the facet joints) which is why it is so important to do this under the guidance of your physio. They will show you how to make corrections and help you to make the adjustments slowly.​

Gait re-education

  • The most important aspect is pelvic position (as above) so some people may need to just focus on this for a week or two. However, most will pick it up quickly and in which case observing their gait and making changes within the same initial session is possible.

  • Check your stance width – with hip and groin pain it can often be toonarrow, especially with those who have pain on the inside of the hip or groin. Slightly widening stance so that you are keeping your feet below their hips can make an immediate big difference. It will feel very strange at first but your physio can reassure you that you are doing it correctly.

  • Slighting increasing the amount you are bending forward from your hip (hip flexion) during gait may also make an immediate reduction in your pain but you may need to do some hip/pelvic dissociation (see below) exercises first so that you dont flex at the spine or poke the chin instead of purely flexing at the hip joints.

Hip/pelvic flexion dissociation in standing

  • This is an essential movement in all functional activities including walking, sit-stand, walking up stairs etc. and most people with hip pain will not be doing it naturally due to reduced proprioception and poor lumbar/pelvic/hip movement patterning.

  • The femur has to glide posteriorly in the acetabulum with hip flexion. In other words the ball of the ball and socket joint needs to glide backwards so that the thigh bone clears the socket. Your physiotherapist can explain this to you using models or pictures. It is very normal to find it difficult to understand, never mind to do! Don’t worry though, with perseverance and the right guidance you will be able to do it.

  • Waiters bow exercise or ‘butlers bob!’ It is worth noting that thisputs far less strain though the hip than non-weight bearing exercises ‘open chain’ exercises like clams, side lying exercises and standing leg lifts. This movement is an essential part of walking safely and therefore should be done very early on.d) ‘Running man exercise.If done too early this will be impossible to get the correct movement patterns and secondary compensations will occur so watch out for these and if they cant be corrected with prompting or facilitation or modification do not give the exercise: trunk shifting, unilateral pelvic dropping or hitching, femoral internal rotation and/or adduction on stance leg, spinal side flexion or rotation, moving in and out of pelvic neutral or fixing with the lats. If these things are occurring then you will need to spend longer working on strengthening the muscles that hold the pelvis in neutral and on single leg stand hip stability.

Core exercises

  • These exercises are key to activating the muscles that hold the pelvis (and therefore the socket part of the ball and socket joint) in the correct neutral position.*Breathing in crook lying (can normally go straight to doing this on the foam roller)*Foam roller* Breathing on the foam roller* Contract and maintain pelvic neutral with knee drops*Arm reaches with knee drops*Foot lifts*Foot lifts with arms*Full dead bugs (will take 6-12 weeks to get to this stage if done correctly and daily for 5 mins*Four point kneeling

  • Maintain lumbo-pelvic position with low core contraction and diaphragmatic breathing.

  • Arm reaches, leg reaches then combined.

Proprioception - The body's positional sense

  • * Standing on 1 leg with eyes closed correct alignment*Exercises on Bosu ball/wobble boards etc

Hip flexor exercises

  • With particular focus on iliopsoas* Hip centering in crook lying*Hip flexion in standing with foot on ball* Hip flexion in standing with foot on foam roller* Hip flexion in standing with band – eccentric bias* Hip flexion in standing

Thoracic (upper back) mobility

  • * Chair twists*Thread the needle*Lying on foam roller arm stretches

Single leg stand hip stability/alignment and glut med work

  • *Wall- ball exercise*Wall-ball with heel raise*Running man*Single knee bends off step*Single knee bends off bosu*Advanced running man*Landing*Jumping*Hopping​*Change direction

Strength/ global conditioning/ slings/ power

  • * Squats* Split squats* Romanian dead lifts* Lunges* Modified dead lifts* Slidy board exercises

Specific exercises for tendons - most commonly glut med, hamstrings origin and psoas

  • * Isometric* Isometric high load* Eccentric and concentic loading

Back To Exercises

Please note that although the advice and exercises provided are designed to assist your recovery they are not a replacement for seeing a Physiotherapist or Osteopath. It is essential that you always make sure you see your Doctor, Osteopath or Chartered Physiotherapist beforehand to diagnose your injury and guide you through recovery.

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