"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.
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)
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!
Athlete Spotlight: Conrad "The Man" Mann
Today's post is to highlight an athlete who has been frequenting SAPT for a number of years, Conrad Mann.
Conrad is the co-owner of David Mann Jewelers (in case you are looking for Christmas presents for that special someone)and has an extensive athletic background in soccer. In fact, he was actually the 2001 Boys' Coach of the Year for Virginia and served time as a Virginia Olympic Development Coach for the sport. Though he still loves soccer, Conrad has switched his focus to another passion in recent years, lifting heavy things.
Conrad has been training for powerlifting for a number of years now and we are psyched to have him as one of the lifters to represent SAPT in the upcoming 13th Annual USAPL American Open. Through these years, he has had to overcome several obstacles in his training and watching his determination to do so has been nothing short of inspiring. In August of 2011 Conrad went through a knee replacement, then in June 2012 he had the other one replaced. Now at 66 years young and with two fake knees, Conrad shows the meaning of, "no excuses."
Here you can see just how strong Conrad really is as he lifts 315 with plenty of speed(a new PR!). What you're not seeing is his 215 bench and 100 lb weighted chinup. We're proud of you Conrad and can't wait for the meet!
https://www.youtube.com/watch?v=0uoIP9KE--g&list=UU5TxLuwpeMisc6vJuPAmZ2w
Part 8: The Competition Period – In-Season Strength Training
The Triathlete Strength Training PrimerPart 8: The Competition Period – In-Season Strength Training
We’re back! I hope everyone had a fantastic Thanksgiving week, and enjoyed reading the fantastic blog posts written by our interns. If you haven’t read them yet, you can read them here, and here, and here. This week we’ll be discussing the competition season for triathletes, and going over the importance of maintaining a consistent strength training schedule. Most triathletes drop the weights as soon as spring rolls around, and suffer unwelcome drops in their total body strength and stability as a result. Don’t be one of these people! Keeping up with a consistent strength training plan is vital for maintaining these performance attributes, as well as fighting off injuries that can creep up from tens of thousands of foot strikes and hours hunched over your aerobars. Let’s get to it!
In-Season Training Goals
Maintenance
It’s very important to understand what our goals are when it comes to strength training during the triathlon season. We’re not looking to build muscle. We’re not looking to make huge gains in strength. We’re not looking to develop massive amounts of anaerobic power. These were the goals of the off-season. We then used the pre-season to focus more on muscular endurance and anaerobic capacity, effectively teaching our body to demonstrate strength over longer periods of time and exhibit high amounts of power consistently and continuously. Now that the in-season has rolled around, we want to maintain the fruits of our labor so that we can perform to the best of our abilities during competition.
Injury Prevention
There’s a concept called the Speed-Strength Continuum, and, in this video, Eric Cressey does a fantastic job of explaining how it applies to training. Triathlon sport training (running, biking, and swimming) would fall on the far left under the “Speed” category. You’re not working against a significant external load during these movements, and the involved muscles are moving at relatively high velocities (even if you may feel like you’re being passed by every runner under the sun).
During the season, when our mileage is at its highest and you’re putting the most time into your sport training, you’ll inherently be working on the far left (high-speed) for the majority of your training. It’s important to balance out this “speed-work” with some strength work in the weight room. Spending the majority of your time training “speed” is going to cause a loss of stability at your ankle, knee, hip, and shoulder joints. Dedicating some quality time strength training is going to go a long way towards maintaining that stability that you’ve gained in the off-season, preventing injuries that result from unstable joints, and protecting your body from the rigors of the season. As an added bonus, being vigilant with your in-season training is going to put you ahead of the game once you enter the next off-season. You’ll need to dedicate much less time to fixing your problem spots, and have the luxury of jumping into a strength phase that much quicker.
Next time…
Now that we know the goals of our in-season training plan, we’ll take next week to go a little more in-depth and lay out an example of what an in-season strength training template should look like. Now get your butt off the couch and go lift some heavy weights! '
The Triathlete Strength Training Primer
Part 1: An Intro to Periodization - Seeing the Bigger Picture Part 2: The Repetition Maximum Continuum Part 3: The Preparatory Period a.ka. the Off-Season Part 4: Off-Season Periodization Part 5: Off-Season Periodization, cont. Part 6: The First Transition Period Part 7: The First Transition Period, cont. Part 8: The Competition Period - In-Season Strength Training Part 9: In-Season Template Part 10: Post- Season Training
Bench Press Prep for Combines
This week we are going to take a look at the bench press. The bench press is solid test of upper body strength and muscular endurance, depending upon the load. Bench pressing for reps is a common test in the football combine setting. Will the bench press make you a better footballer? I don’t see an obvious direct correlation to many of the sports’ activities but being weak sure won’t help your chances of getting on the team or field. Typically maximum strength is measured via a one repetition (1RM) max but in the combine setting a specific weight is applied to a barbell and pressed for as many full repetitions as possible. This saves time from having to find every athletes true 1RM. The athletes and coaches can then use the projected 1RM to calculate max strength. To sum things up according to the combine standards, whoever can complete the most reps is the “strongest”. Here are a few tips to squeak out more repetitions with heavier loads when combine time comes around.
Set Up and Technique
- Keep your feet flat on the floor with your hips, shoulders, and head on the bench
- Tuck your shoulder blades back into the bench and prevent your elbows from flaring out which can lead to shoulder injuries. Keeping your back tight throughout the lift and “pulling” the bar down to you will help in preventing this.
- Place your hands comfortably apart on the bar so that your forearms align in a vertical position
- Inhale as you lower the bar to your chest at a controlled tempo
- Exhale as you forcefully extend the arms back to the starting position
- Click here to check out solid bench press form from the front and side.
Regardless of the test weight, it is important to refrain from constantly training with that weight. Your performance in this assessment will not improve without increasing your overall strength in the bench press. Because of this it is important to spend time training strength with high weights for a lower number of repetitions. Due to the high-rep nature of this test (hopefully), another layer of complexity to training is athletes must also have high rep training days to become comfortable performing under fatigue and the onset of lactic acid.
Although this is an upper body pushing assessment, it is imperative to incorporate rows and pull ups into your training to help with muscle balance, posture, and injury prevention. A great tool to add some spice to these training days would be to use Fat Gripz or another grip strength tool so that when you return to a normal size bar you can crush it.
There are literally a ton of different bench press variations so try them all. The modifications with boards, bands, incline/decline angles, and grips widths open the door to many options. The bench press with some sort of incline is great for athletic performance as many pushing movements in competition will not be straight ahead but as long as the flat bench press is the standard for football and other sports testing it’s important we train for it as intelligently and efficiently as possible. In this throwback blog post (circa 2011) Sarah lists’ 40 bench press variations and 40 push up variations to add some strength to your life.
Hamstrings and Harry Potter Part 2: Injury Care and Prevention
Last week's post was about the potential reasons for “tight” hamstrings. Armed with that information, let us dive into the second part: hamstring injury care/prevention. I should make a note that I am NOT a doctor, therefore do not use this post to diagnose anything. If you suspect an injury please consult a doctor! Also, this advice should not supersede any licensed therapist’s recommendations. This is just lay-man’s stuff.
Ok, so let’s talk prevention. Hamstring pulls often occur because of a) a previous pull (number 1 reason!) or b) hamstrings are required to do something they can’t handle on their own (like sprinting full tilt with form resembling poop). The latter is like Neville Longbottom in Potions class: imposing demand that produces in disastrous consequences.
So how do we prevent hamstring pulls in the first place? In no particular order:
1. Soft tissue work- stay on top of it, literally, jump on that foam roller and lacrosse ball! Work out the nasty, gunky tissue that tends to form in the adductors (especially near the insertion points on the pelvis and knee joint), hamstrings, calves (specifically the gastronemius since it crosses over the knee joint), and of course, the glutes. If the glutes are gunked up, they’re not going to fire properly or contract with full force thus leaving an increased burden on the hamstrings to extend the hip. For example, if the glutes aren’t firing properly during a sprint, guess who has to extend the hip? Yup, the hamstrings. And as I’ve mentioned before, the hammies are strong hip extensors but they’re woefully under qualified to handle the brunt of it without the neighbors to the north. Gunky muscles = dysfunction = potential injury.
2. Strengthen your glutes- as mentioned above, the hamstrings need help extending the hip. The glutes are MUCH better at doing so and are at a more advantageous position, mechanically, to do so anyway. Check out this diagram:
See how LONG the hamstrings are compared to the glutes? Also note the fibers: hamstrings have long, parallel-to-the-femur (thigh bone) fibers whilst the glutes’ fibers are short and diagonal to the femur. The glutes can produce more force because they’re shorter and can do so with less stress to the fibers. Every hear about anyone tearing their glute? Didn’t think so. Anyway, all that to say, GET YOUR BUTT STRONGER, and you’ll be half way there to hamstring ouchie prevention. (I could also go into activation, teaching your glutes to fire sooner during the movement, but this post will get too long if I do so).
3. Don’t be stupid- don’t jump into do intense exercise without warming up or without working up to it. If you haven’t sprinted in a while, probably not a good idea to go out and do 100 m sprints all out. Use your brain.
There you have it, simple yet rather effective preventive measures.
But what happens if you’ve already pulled it? Couple of methods that we use with our athletes:
1. Don’t be stupid- This is a common one isn’t it? Don’t do anything that irritates the injured hamstring. It’s already pissed off at you, no point in angering it further and prolonging the recovery period. Seriously, if it hurts, don’t do it. We tend to take a very conservative approach with out athletes and we’ll replace any exercise that might hurt it.
2. Soft tissue work- Oh look, this one is back too! It’s almost as if we turned the Time-Turner and are reading the prevention methods.
Be careful with this though. Sometimes the injured tissue should NOT be touched, but this doesn’t mean you can’t work on the surrounding areas. Depending on the severity of the injury, a good ART or massage therapy session might be in order. Gently working on the tissue can aid in the healing process. Perhaps some gentle stretching is in order, but be careful with that too.
3. Rest- Lay off of it. It’s not going to heal if you keep aggravating it. This is often the hardest part of recovery for athletes; they want to jump back in too soon. One day pain-free does NOT mean the hamstring is healed. Sorry. Give it a couple weeks and ease back into your regular activity with pain as you guide.
There you have it. Hamstring injuries are usually not terribly complicated, thus prevention and care should not be either. Honestly, if you follow the given rules, particularly Number 3 on the first list, your hamstrings should be safe!
Intern Blogs Part 3
Today's blog comes from SAPT intern Nick Allevato. Nick is in ROTC at Mason and brings us a great post about the state of the physical training requirements of the Army.
The Immobile Army:
Why the Army Fails at Fitness. Why it needs to change.
As I read through past blogs and noticed Mike’s Navy post, I feel compelled to rep the Army (Go Army, Beat Navy). However, I am going to focus on a major issue I perceive in our Army; it’s the Army’s physical fitness testing and it’s failing our troops. In fact, when Army fitness specialist Dr. Edward Thomas tested Soldiers on the World War Two era Army Physical Fitness Test (APFT) in 2000, the results showed that even the current APFT “studs” could not keep up with Greatest Generation fitness. So, why has such a decline occurred in Army fitness? Why are our Soldiers looking like this guy?
Well, it’s all about the “standard” and they’re actually meeting it.
How could that guy be meeting the Army’s standard?! An institution who is supposed to be ready for combat 24/7! Well, the current APFT involves timed push-up, sit-up, and a two-mile run tests. Soldiers are to do as many repetitions as possible and run the two-miles as quickly as they can. It replaced the old APFT in 1992 and has not been modified since. The events are scored on a point scale, with “60” in each event as "passing" and “100” being "maxing". So, a minimum of 180 points are needed to pass the test and a solider can achieve up to 300 points. The point system is scaled to age and gender and is based off repetitions and the run time. To provide you some perspective of the required “standard,” take a look at the required passing scores for 17-21 year-old males and females:
Gender
Push-ups
Sit-ups
2-Mile Run
Male
42
53
15:54
Female
19
53
18:48
Just to briefly interpret the table, which is based on 17-21 year olds (prime fitness age); males only need to do 1 push-up every 3 seconds for 2 minutes; females only need to complete 19 push-ups in TWO MINUTES; females can average nearly a 9:30 minute per mile pace for the 2-mile and males only need to average around a 8:00 minute per mile. While it may seem somewhat sad, these are the standards for the world’s greatest fighting force! Regardless of job description, for example an infantryman or a doctor, all Soldiers train for the same test; this test is the Army's interpretation of proper fitness.
But is this an effective and relevant standard? Is it accurate to evaluate a doctor stationed in a hospital on the same test as a paratrooper? Perhaps not, seeing as that would be like taking Spongebob and Squidward both taking a clarinet test when Spongebob’s job is to be a fry cook. Not to mention that the event techniques aren’t even taught properly! Just take a look at the push-up image to the left, which is the exact standard from the Army PRT Manual; the elbows flair out, the lumbar spine is in hyperextension, and the hands are not underneath the shoulders. This poor education of proper technique only makes an irrelevant fitness standard even worse. See for yourself here as Army Drill Sergeants grade a Best Warrior Competition APFT:
Soldiers are simple individuals. Not as to be interpreted as "stupid," but simple in how they perform, train, and execute. Give a Soldier is a task with a standard to meet and they will do everything they can to meet and exceed that standard (standard=success). This is especially true in today’s Army where downsizing occurs regularly. Adherence to the standard, and only the standard, is how Soldiers ensure they still have a job. Since the current APFT involves timed push-up, sit-up, and the two-mile run test, Soldiers are going to work solely on improving those scores.
Interestingly, the current Army Physical Readiness Training (PRT) program, which is the physical training doctrine, calls for Soldiers to perform certain crawling movements, hip stability work, and proper techniques. But as mentioned earlier, Spongebob going to practice his fry cook skill if he is clarinet performance? Of course not, because he would fail, then lose his job and his pineapple house. In the same way, Soldiers are going to do push-ups, sit-ups, and running every training session because that’s their test; to them, doing anything else doesn’t make sense.
The result of this terrible standard of fitness is an immobile, unfit Army that doesn’t even realize how bad it is. In fact, even the Army Master Fitness Trainers seem to lack understanding of how the body should move.
They are supposed to be the “coaches” of their units, yet they do not even understand a basic hinge pattern.
A change in the Army’s fitness standard is long overdue and the Soldiers are suffering as a result. We are developing weaker, injury-prone Soldiers. Who knows how many cases of low-back pain are due to the monotonous torque of the spine in the sit-up test? Or how many ACL tears could be with proper agility training? Or how much money the Army could save in rehabilitation costs by simply developing proper movement patterns in Soldiers?
The Army needs to change to a job-relevant, comprehensive APFT that reflects Army PRT and evaluates the basic principles of fitness (muscular strength, endurance, flexibility, etc.). Recommendations could include an obstacle course, a timed ruck march or step-up test, an agility T-test, a sled push, pull-ups, and shuttle sprints. These performance tests would be much more reflective of a properly moving, combat-ready Soldier. At this point, the semantics of scientifically choosing one exercise over another is not as crucial as a simple step in the right direction. In the words of General George S. Patton, “A good solution applied with vigor now is better than a perfect solution applied ten minutes later.” An overhaul of the Army’s PT is needed, and it is needed now.
Useful References:
-“Army Physical Fitness Test is not effective for measuring a soldier’s ability to function effectively in today’s battle space”
http://cgsc.cdmhost.com/cdm/ref/collection/p15040coll2/id/3024
-“World War Two Army Physical Fitness Test”
http://www.ihpra.org/1946%20(World%20War%20II)%20Army%20Physical%20Fitness%20Test.htm
-“The Old Army, It Turns Out, Was the Fitter One”
http://partners.nytimes.com/library/national/science/health/062500hth-men-fitness.html
