Anterior Hip Pain and the Anterior Chain / Posterior Chain Relationship

I was invited to be a panel member this last Saturday at the Sports Related Injuries Continuing Education Symposium sponsored by Inland Orthopedic Surgery and Sports Medicine Clinic, Pullman Regional Hospital, and Gritman Medical Center. Included on this panel were myself and another secondary school athletic trainer, an orthopedic surgeon, a fellowship trained osteopathic sports medicine physician, a family medicine primary care provider with a specialty in sports medicine, and an orthopedic surgeon specializing in the hip. All four of these physicians are also team physicians for NCAA Division I Universities.

Topics included biologics, cardiac screening and pre-participation physicals, biomarkers and concussion, health care networking (essentially what is an AT and where can you find them), and hip pain: evaluation and management in athletes. Each of these talks included question and answer time with a panel discussion/question and answer session at the end of the symposium. While all of these topics served to educate the community and inform our fellow health care providers. It was the orthopedic surgeon's discussion regarding femoral acetabular impingement (FAI) that sparked my interest most. During his 30 minute lecture on FAI, the speaker mentioned, almost in passing, that cases of FAI regardless of type may be aggravated by anterior pelvic tilt. I immediately reached for my note pad as he described findings, signs, and symptoms that included pain, alterations in hip alpha angle, and pitting on the anterior/superior surface of the femoral neck due to contact with the anterior surface of the hip socket during hip flexion as well as classics like snapping hip syndrome and anterior hip pain.

My notes read as follows: FAI and Anterior Pelvic Tilt = Posterior Chain Strength/Anterior Chain Mobility?

Consider anterior chain dominance and anterior pelvic tilt, lower crossed syndrome, and the training methods often employed by athletic populations where lower extremity and abdominal strength are concerned as we continue to explore anterior hip pain and FAI. While the opportunity did not present itself to start a discussion about poorly designed 'core' exercise, quad dominant training methods, anterior chain dominance and immobility in athletes, and the flexion postures in westerners during the symposium, I sought out the presenter afterward and asked a few key questions coupled with some findings from my clinical practice as an AT and S&C Coach. Asking him if he thought that potentially alterable hip positions such as anterior pelvic tilt could provide relief in athletes with anterior hip pain, reduce the likelihood of some FAI related findings, and potentially change the need for surgical intervention given the quad dominant nature of many athletes, he became mildy interested. As evidence, I offered up my strength and conditioning program emphasizing hip hinge patterns including the deadlift and various hinge patterns utlizing kettlebells while avoiding any 'core' strengthening that potentially involves repetitive hip flexion. I supported this with the lack of time loss injury during basketball season and the incidence of only one hamstring injury (suffered by someone not involved with the winter strength and conditioning program) and one anterior hip injury throughout all spring sports (baseball, softball, and track and field). He responded with a good natured smile and a comment about future research which got a chuckle out of both of us as we walked out and went off in our respective directions. Though I suspect he is correct, this could be an area where further research is most certainly indicated including logitudinal studies and inquiry about family history given the evidence suggesting genetic predisopision to FAI.

Interactions like these serve to increase my curiosity surrounding strength and conditioning and injury prevention. When I analyzed the FMS data at the end of last basketball season I was intrigued and disappointed to find that sagittal trunk stability was an area that my strength and conditioning programming appeared to not address directly based on a decrease in average trunk stability push up scores. This is not surprising given the posterior chain dominant nature of the training program. While I thought my emphasis on trunk stability and anterior hip mobility during warm up activities may have addressed this, I appear to have been mistaken. However, aggregate scores, deep squat, hurdle step, in line lunge, active straight leg raise, and rotatory trunk stability, all showed statistically significant increases (aggregate pre-season mean=14.33±1.84; post-season mean=16.44±1.72; p< 0.001), DS (p < 0.001), HS (p=0.001), INL (p=.009), ASLR (p=.017), and RS (p=.003). Each of these individual tasks involves active hip flexion and three dimensional trunk stability. Is it possible that reducing exaggerated anterior pelvic tilt may increase active mobility at the hip and reduce incidence of anterior hip pain and injury potentially related to FAI? It seems we have another area of potential research.