Femoroacetabular Impingement and Football Kickers. "That's Why My Hip Hurts!"

Femoroacetabular impingement (FAI) syndrome has become more widely recognized thanks to folks such as Kevin Neeld, Eric Cressey, Mike Reinold, and a plethora of other smart coaches.  FAI is a common* syndrome/injury in athletics and football kickers are especially susceptible due to the nature of the violent hip flexion during the kick off/punt.  At the end of the article I'll put some links for more information regarding testing for FAI, research regarding FAI, and other resources. The last two posts have been marathon length, so we'll keep today short and to the point. What is FAI?

FAI is essentially:

Femoroacetabular impingement or FAI is a condition of too much friction in the hip joint.  Basically, the ball (femoral head) and socket (acetabulum) rub abnormally creating damage to the hip joint.  The damage can occur to the articular cartilage (smooth white surface of the ball or socket) or the labral cartilage (soft tissue bumper of the socket).

from www.hipfai.com.  Athletes that participate in activities that include repetitive hip flexion and internal rotation or folks who have super crappy mobility in their hips are at a higher risk of developing hip issues. Also, athletes who are constantly in a state of anterior pelvic tilt (aka: nearly every one of them) are also primed for some impingement.

Now, look at a football kick off. Check out the crazy hip flexion and internal rotation (when his leg crosses over the midline of his body around the :29-:31 mark).

Can you see how a kicker might develop a problem? Especially if they're not a physically STRONG kicker?

Just so you know, FAI comes in three flavors, none of which include chocolate or vanilla:

     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.

How do I spot FAI?

IMPORTANT: Remember, unless you're a doctor, you CANNOT DIAGNOSE. The following are merely indicators that something is amiss. A visit to the doctor and possibly the Wonder Machine (MRI) will be the only sure way to diagnose any pathology.

Now, as a coach/player it's important to be aware of FAI and be on the look out for the symptoms. FAI will most likely manifest on the kicking leg simply because it is subject to that the crazy-hip-flexion. Bilateral FAI is found more often in sports with bilateral hip flexion such as hockey or powerlifting. However, this doesn't mean that both sides can't be affected, so be on the vigilant!

There are two simple tests that you can do yourself (though I STRONGLY recommend you see a professional..cough, cough.)

One is the Faber Test.

The other is a supine hip flexion with internal rotation of the femur.

If this lights you up, and you're also experiencing the symptoms below, you should probably high tail it to a person with the initials, "M.D." after there name.

A few other symptoms that as either a coach or a player you should be on the watch for (and probably perform the aforementioned tests):

1. Pain with squatting below 90 degrees. Speaking from experience, it feels "pinchy" in the front of the hip, just a smidge medial (inside) of the pelvic bone.

2. Pain with internal rotation and hip flexion. For example, getting into a car leading with the affected leg (one has to flex the hip to sit and internally rotate the hip to slide into the car).

3. Another potential, but not always present, is a history of repeated sports hernias or groin pulls.

4. As a coach, if you're watching a player squat, if one hip seems to drop more than the other. The hip that DOESN'T go as low, will be the affected hip. The player will also weight shift towards the affected side as they stand up from the bottom of the squat.

Don't be stupid and keep training through this pain (again, I speak from experience). Some of the associated symptoms/pathologies of FAI include: cartilage damage, labral tears, (the labrum helps keep the hip stabilized. It's really important.) early on-set osteoarthritis of the hip, sports hernias, and low back pain.

Speaking as someone who has bilateral FAI (and the labral tears), it sucks. Don't be a hero, go to the doc if you're experiencing these symptoms.

What are the Implications of FAI?

An athlete the has impingement of their hip will have limited hip flexion range of motion (ROM) on the affected side. What does this mean for a football kicker?

- No more squatting. Think about it: 1) hip flexion ROM is going to be limited on one side. 2) If you're bilaterally loaded, as in a squat, one hip will drop lower than the other, and if the hips can't move independently, as they could in a lunge, you're going to impose some wonky forces on the spine. 4) Wonky forces on the spine eventually lead to injuries and pain.  Not the best game plan. (You could get away with squatting above 90 degrees, but no sense in playing with tigers if you don't have to.)

- There's a study found here that looked at hip flexor strength a group of people with diagnosed FAI. The study found that those with FAI had weaker hip flexors than the controls. (I can personally attest this is true.) Whether the people had FAI because their hip flexors were weak, or the hip flexors became weak with FAI onset, doesn't matter for this discussion. What does matter is that the HIP FLEXORS ARE WEAK! Now, in a football kicker, what's the main group of muscles used to kick? HIP FLEXORS! Do you see a problem? If a coach is oblivious to this, yelling at a kicker to kick harder isn't going to do much. Also, without proper training (perhaps some focused work for the hip flexors such as SL marches or hanging leg raises), other muscles are going to take over for the lack luster hip flexors and then you have a whole new set of problems.

- Hip dominant exercises (deadlifts, RDLs, glute bridges, and swings) and single leg work (split squats, step back lunge variations, step ups (as long as the hip stays >90 degrees), and single leg RDLs) must be the bulk of lower body work. All of these tend to keep the hip out of excessive hip flexion + internal rotation. They also hammer the glutes, which will help keep the femur from gliding forward in the socket and causing more ruckus in the pelvic region. Food for thought: I've personally found that walking lunges/forward lunges tend to make my hip ache as do back-and-feet elevate glute bridges.

- As far as corrective work goes, hammer hip stabilization and anterior core. Low level glute work such as double- and single leg glute bridges, monster walks, and bowler squats will challenge the smaller stabilizers of the hip. This in turn will keep the femoral head from gliding around and causing more damage. Anterior core is necessary to, hopefully, control anterior pelvic tilt (which most athletes sit in anyway) and even, possibly, pull the pelvis a little posteriorly. This will, again, keep those bony overgrowths from grinding on each other. Here's a great video by my better half on anterior core progressions.

Another note: I've found that single leg anterior core exercises (such as a single leg plank) bother my hips. Be mindful and if it hurts, don't do it.

Wow, so I broke my promise of writing a lengthy post. However, this is an EXTREMELY important issue that many kickers are faced with (we've had one walk through our doors, not to mention the other handful of other athletes from a range of sports).

*Just chew on this; a recent study of asymptomatic people found that  of the 215 male hips (108 patients) analyzed, a total of 30 hips (13.95%) were defined as pathological, 32 (14.88%) as borderline and 153 (71.16%) as normal. That means potentially 1 in every 3-4 males have some sort of underling hip "thing" going on. (thanks Kevin Neeld!) That's a lot.

As promised here are some links for more information:

Post on Mike Reinold's site with more in-depth diagnoses.

Kevin Neeld has a bunch: 1, 2, and 3 (and the one linked above)

And Tony Gentilcore, who does a fantastic job communicating a complex topic to the lay population, while adding some humor to boot.

Whew!

SAPT's Baseball Summer Training Program

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For the past 6-years, the coaches at SAPT have been helping pitchers and position players alike achieve their potential on the field. Set up a comprehensive evaluation today and start down your path to superhero status!

Our New Coach & The Double Knee Bend

Our New Coach

I'm pleased to welcome SAPT's newest coach, Tadashi, to our staff! Tadashi interned with us last spring, then went on to the University of Maryland for another internship, and is now on our staff permanently!

From the word "Go," Tadashi established himself as a coach with an excellent eye for detail and a passion for the field. Please help us welcome him to the blog and the training floor over the next several weeks!

The Double Knee Bend

Have you ever wondered about the elusive double knee bend in the clean? Well, if you want to see what it is, check out my video below. I've attempted to breakdown the footage to illustrate how the legs straighten, then re-bend right before the second phase of the pull. (Bear with me on the video... I just got this program and I'm not super smooth with it yet.)

Some people say the double knee bend cannot be taught... that you either have it or you don't. I can't say I necessarily agree with that, as I was taught to execute it in this fashion. Regardless, this technical point is so fine and specific that it is a PRIMARY reason why some strength coaches (like those of us at SAPT) choose to explore other variations of triple extension and speed/power work well before we would implement a clean or any of its variations.

And, please, if we have any champion internet coaches reading this post... I know my form is not picture perfect, you don't need to tell me!

How to Improve the Vertical Jump and Agility of a High School Volleyball Player: Initial Assessment+Screening

Given that volleyball players make up a striking percentage of our student-athletes, I'm inevitably faced (and rightfully so) with questions from parents and coaches regarding our approach to "assessing" them when they first walk in our doors. They are often surprised - sometimes skeptical or even borderline enraged - that we don't have them perform a vertical jump test, speed-agility test, and/or arm swing test on Day 1.

Furthermore, it appears that, for the most part, we're simply running them through a normal session during their first day, as opposed to putting them on a table for forty-five minutes, breaking out the goniometer, and measuring every single joint ROM.

What gives?

The Assessment

While, to the outside eye, it may look like we're just running the players through a normal strength session, here is what we're actually assessing as we take them through their "Day One" workout.

- Jumping Mechanics (both the technicalities of the movement along with strength+neural control) - Closed-chain Ankle Dorsiflexion - Gross hip stability, including upper gluteus maximus and gluteus medius function - Extensibility of the posterior aspect of the lower extremity, along with hip flexor strength - Valgus collapse (or lack thereof) in the knees when jumping and squatting, and bounding - Thoracic Spine range of motion (specifically, in extension and rotation) - Glenohumeral (shoulder) range of motion - Squat pattern (gives a lot of feedback regarding flexor length, latissimus length, core strength, along with ankle and hip range of motion) - Hip hinge patterning (the foundation for all athletic movement) - Lunge pattern (brings potential asymmetries to light, along with providing us another "angle" for assessing their glute strength/function) - Global movements and strength levels (gives us a much more *realistic* picture of how they'll move in a game-like scenario)

Will we do more "table assessments" as needed, too? Yes. But as you can see, there's a deep well of information one can draw up, simply from analyzing the athlete in the context of movement, and I didn't even list everything we look at!

This is a win-win for both the athlete and the coach. The athlete gets to have fun moving around on their first day (rather than spending the majority of their time on a table), while we as coaches are able to assess the athlete at the same time.

One final note on this front: every session is an assessment. I constantly find myself discussing our clients and their programs with my fellow coaches at SAPT, fine-tuning and tweaking what we do with them. This makes sense as the human body can be very amoeba-like; what was true on Day 1 may not be true on Day 30.

The Vertical Jump and Speed-Agility Test

Regarding these two sacred cows, here are the reasons we don't test them on Day 1 with the majority of our high school volleyball players.

1) We don't feel they are appropriate tests for initial assessment.

To put it simply, 99.99% of people who enter our facility can not jump or change direction correctly. As such, we do not feel it is an accurate -  or, more importantly, safe - action to take with them on their first day. Nearly all of them possess the motor control of a ham sandwich, as they allow their ankles, knees, and hips to collapse like crazy upon jumping, bounding, and/or changing directions. Naturally, this will:

A) Negatively affect their jump height/running mechanics, and, more importantly B) Place their lower extremity (knees and passive restraints) at risk. To have them perform a maximal jump, multiple times in a row, or an agility test for that matter, is downright foolish in our eyes. While many of the girls that walk through our doors are certainly great athletes and possess many strong qualities, very few of them are unable to leap, bound, and change direction without their ankles and knees collapsing in.

This being the case, we find it irresponsible, on our end, to force them into change-of-direction tests or standing vertical tests. While we certainly can't "bulletproof" our training sessions to make them completely 100% incident free, we do our absolute best to make it at least as close to this as possible. We haven't had any athletes seriously hurt themselves under our watch, or have them undergo a non-contact injury to date (knock on wood!), and we'd like to keep this track record going.

The safety of the athletes under our watch is, without question, our top priority when we design and implement our training sessions. While we do understand that these girls may be asked, on numerous occasions, by their club/high school coaches to perform agility drills and various vertical tests, we don't wish to play ANY role in putting their health at risk until they're taught (with our aid) how to perform these drills safely. It may not be common to take (what some would call) a "conservative" approach like this, but then again the injury rates of adolescent and high school athletes have never been higher....so we're doing our best to lower that statistic.

We take a very progressive and methodical approach to teaching sound jumping mechanics; all the way from showing them how to swing their arms/move their hips to strengthening them via resistance training. Once the girls make headway in these areas (the time frame is different for each individual), then we can administer these tests.

2) To help our athletes mentally.

Given that the Vertec tends to be the "bane of existence" for volleyball athletes, we don't want to throw them under the thing on Day 1 at SAPT. Our aim is that it will help promote a more positive environment for them, and a haven if you will, from the usual demands of volleyball.

Does this mean we don't push them, and refuse to help them strive to perform better? Absolutely not. However, we've found that having them learn to conquer challenging drills other than the ones they typically perform outside the SAPT walls, gives them a break mentally, and, ultimately, improves their performance on the court.

We will certainly have them test their vertical as they get further along in training (and after we've helped them with sound+safe jumping mechanics), but it's not something we'd like them to experience the first day they are in with us. We've found it crazy how the simple removal of the Vertec, yet still having them jump and leap appropriately, makes a HUGE difference with the experience they personally receive from SAPT - and ultimately, their skills on the court improving.

3) Performing an closed-loop (predictable) test is an extremely inaccurate indicator of how the athlete will perform during their actual event (an unpredictable, "open-loop" environment).

Our end and ultimate goal is to improve their performance on the Volleyball court. Not to obsess over a particular test. Sometimes I feel we forget to keep the goal, well....the goal.

For example, currently, in High School Football, there is a player who is ranked Top 10 on the East Coast for the high school football combine testing battery (obviously a HUGE accomplishment). However, you know what's surprising? He doesn't even start for his own team! He can slam dunk the tests and knock thousands of other players out of the park when it comes to the combine tests, yet his on-the-field performance is lacking.

The sad truth is that many people place superfluous emphasis on the testing protocols, yet often fail to acknowledge the "intangible" skills the athlete possesses (spatial awareness, court/field awareness, adaptability, quick decision making, etc.) that, in the end are what will help an athlete make a college (or high school, or professional) team and actually get to play during the games.

4) Their "strength numbers" (quantifiable), along with their biomechanics/motor control (less hard to quantify in numbers/metrics) are the primary scale we use to monitor improvement.

Why? Rather than reinvent the wheel, here's a quote from strength coach Tony Gentilcore that I hope will elucidate this concept:

Maximal strength is the foundation for every other quality imaginable.

In terms of any plyometric and/or jump training – it comes down to strength.  Simply put: you can’t have things like agility, power, endurance, strength endurance, and the like without first having a base of strength to pull those other qualities from.  Strength is the basis of everything.  Without it, you can perform all the ladder drills, sprinting drills, jumping drills, and agility training you want, but it’s not really going to mount to much until there is a strength foundation.

It would be akin to giving your 1994 Honda Civic (as an example) a sweet paint job, some spoilers, Mag tires, and a sound system that causes your ears to bleed in the hopes that, by doing so, it will win the Daytona 500.   Unless you actually do something about increasing the horsepower of the car, you can add all the bells and whistles you want, but winning that Daytona 500 won't happen until the horsepower/engine of the car is improved.

And this is especially true with the high school athlete population.

'Nuff said there.

Arm Speed Tests

I'll be blunt: this is something that we don't measure, and it would pretty idiotic to do so.

Coach Sarah is also the strength coach for the Division I women's volleyball teams over at George Mason, and she doesn't even have them do an arm swing speed test. Frankly, it would be insanely dangerous to the shoulder joint (to put it mildly) to have them perform a maximal swing like that, without having anything (ex. a ball) to slow their arm down. The girls swing speed will improve as they strengthen the structural integrity of the shoulder girdle, maintain mobility in that region, and continue to practice sport-specific skill.

And that's a wrap.