"My Hip Hurts!" Training Around Femoroacetabular Impingement

During Thanksgiving I contemplated the turkey legs before they were devoured and mulled over femoroacetabular impingement (FAI). Yes, I know, I'm nerdy even on my vacations. What is FAI? In brief, it is an excess of friction within the ball-in-socket hip joint. The femoral head (the "ball") and the acetabulum ("socket") get a little too friendly with one another and can create damage within the joint. Damage can be incurred either on the articular cartilage -the smooth, white surface of the ball or socket; the cartilage helps the two glide well together- or to the labrum- a ring cartilage that deepens the socket to decrease the chances of the femur slipping out. It essentially acts as a suction cup for the femoral head.

Why does this friction happen? Can't the femoral head and acetabulum just get along?

Typically, FAI occurs when the femoral head glides too far forward within the socket. Often this happens when the hip is flexed and internally rotated- such as at the bottom of a squat or getting into a car (on the lead leg). Consequently, one of the tests replicates that motion. (pictured at left)

Another hip position that is an FAI aggravator is extreme extension, such as a gymnast sitting in the splits. The test that mimics that is called the Faber test.

Both tests can be a starting point to explore whether or not you or your athletes have FAI. REMEMBER, WITHOUT AN M.D. YOU ARE NOT A DOCTOR, DO NOT DIAGNOSE. However, if there is pain with either test, it might be a good idea to mosey on over to an M.D. for further exploration. There are other symptoms such as pinching pain in the front of the hip with squatting motions, a history of groin strains/pulls, or, even if there's no pain present, a shifting of the hips towards one side during squatting.

faber test
faber test

Excessive friction occurs when the femoral head is allowed to roam wild and free within the socket. This happens when the glutes are not strong enough or are not firing properly to control that crazy femoral head. The glutes have enormous influence over the femur, due to its attachment points, and should keep the femoral head centered within the socket. When that doesn't happen, that's when the femur goes crazy.

Another factor is anterior pelvic tilt- the state that nearly every athlete lives in. If the pelvis is already tilted forward, it closes the space between the anterior borders of the acetabulum and the femoral heads, so at the onset of movement there's a predisposition for impingement.


FAI comes in three flavors (none of which include chocolate or vanilla)

FAI image
FAI image

CAM- bony overgrowth on the femoral head (ball)

Pincer- body overgrown on the acetabulum (on the socket on the pelvic bone)

Mixed- a lovely combination of both.

FAI can produce complications ranging from minor irritation in the front of the hip, at best, or tears of the labrum, at worst.

Who is at risk for FAI?

1. Athletes who play sports that require repetitive hip flexion and internal rotation- think football kickers, soccer players, powerlifters (especially if they sumo deadlift and squat deeply), baseball pitchers, hockey players

2. Hypermobile athletes, particularly if they're involved with sports that require extreme hip extension- gymnasts (including rhythmic gymnasts), baseball pitchers

3. Folks with anterior pelvic tilt, weak glutes, and a weak anterior core.

Now, let's say you are (or one of your athletes is) one of these at-risk people and/or you are already experiencing symptoms, what are you going to do?

Lucky for you, I've already gone through this! I have bilateral labral tears (both hips) and have had to adjust my training considerably. Do not lose hope! FAI (assuming there's no structural damage) can be reversed with intelligent training and patience.

First: stop doing what the activity that is aggravating FAI. It could be squatting, sprinting, kicking... whatever it is that's causing the pain stop it. The continual irritation to the hip joint will prevent the inflammation from dissipating, which only prolongs the process of recovery.

Second: train the heck out of the glutes and anterior core. Why? As mentioned above, the glutes have tremendous influence over the femoral head, so those bad boys will keep the femur centered in the socket. Remember good ol' anterior pelvic tilt? Both a strong anterior core and strong glutes work in concert to bring the pelvis into a more neutral alignment, thus increasing the space in which the femoral head can move.

How? Below are several exercises that I've incorporated into my own training. Not only is my hip pain greatly reduced, in fact, unless I directly provoke FAI (for example, by squatting deeply under load) I don't even feel it any more.

Kettlebell swings

Deadlifts (or any other hip dominant bilateral lift)

Split Squats or Lunges*

I particulatly like a front-loaded stepback lunge (barbell or dumbbell) as it challenges the anterior core to resist excessive extension. Two birds, one stone.

*With FAI, you have to be cautious with lunge variations. I've found that forward lunges really bother my hip- I assume it's from the deceleration component as it can jam the femur into the socket. Bulgarian split squats are awesome, however, we must be careful how deeply the lunge goes: both for the sake of the front leg and the back leg (which can go into aggressive extension if the back leg is too high).

Glute Bridge Variations (on the floor or back elevated)

BB Back Elevated

Suspension Strap Glute bridge

Anterior Core Work (thinking beyond the plank)

Deadbugs or Single-Leg Lowerings

Or, if you want it all in one shot, my awesome husband made a video a while back on anterior core training progressions.

Last, but not least and my personal core training fave, loaded crawls.

I performed forward/backwards baby and bear crawls-respectively- but you're certainly not limited to those two.

By strengthening both the glutes and core, FAI can be reversed and, if damage already occurred, you can still get wicked strong focusing on the lifts and activities that you CAN do. FAI is something to be aware of and programmed for accordingly. Pay particular attention to your hips if you're in the "at-risk" category of folks, but honestly, the training advice -stronger glutes and anterior core- applies across the entire spectrum of trainees. Strong butts make strong athletes!