A few weeks back I briefly mentioned that I’ve been working with a lacrosse player with femoroacetabular impingement (FAI). I’ve written quite a bit about FAI in the past, and the posts seem to attract a lot of attention, probably because so many athletes (and especially hockey players) suffer from related symptoms and haven’t had much success in traditional rehabilitation approaches. If you’re new to FAI, I’d highly encourage you to quickly breeze through these previous posts, which discuss a bit about what FAI is, how prevalent it is among hockey player and general populations, and what can be done to train around it:

  1. Training Around Femoroacetabular Impingement
  2. Hockey Hip Injuries: FAI
  3. An Updated Look at Femoroacetabular Impingement

I’ve received several emails requesting to see the video that I posted at Hockey Strength and Conditioning of the lacrosse player with severe FAI, so I decided to throw it on youtube and wanted to share it with you today. Check it out below:

Training Around Femoroacetabular Impingement

This video is of a Division I lacrosse player I’ve worked with over the last several months at Endeavor. He has undergone 4 separate operations (2 on each side) to address his FAI and associated labral damage, and a bilateral athletic pubalgia (sports hernia) repair. He also has significant retroversion, bilaterally, meaning he has plenty of external rotation, but extremely limited internal rotation in both hips. When he first came in, he wasn’t able to jog (let alone sprint), shuffle, or do anything high impact or explosive. In fact, I would say he was generally cautious about movement in general. He’s now in his 6th month of training and can sprint, transition, and move explosively as well as ever. We were able to start moving him toward these types of exercises about 4-6 weeks into the training process. Each week, for the last month, he’s told me that he feels better than ever. I wanted to post this video to demonstrate how important it is to recognize each athlete’s individual limitations. Can you imagine if this athlete was told to squat to full depth, deadlift off the floor, do high box jumps, etc.?

I recognize this athlete’s case is a bit extreme, but the overwhelming majority of the hockey players we work with will be somewhere between this athlete and what is taught as normal. In other words, most players will have some sort of structural deviation that will need to be appreciated in your assessment of their movement quality and exercise technique. In this example, we spent a lot of time early on going through how he would need to move to to stay within his individual confines, but still accomplish what he needs to on the field. After grooving and improving these patterns for several weeks, he now does them without conscious thought, which is the ultimate goal if he’s to be successful.

A few things to look for in the video:

  1. When he sets up in a quadruped position, his lumbar spine is already in a state of slight flexion secondary to hitting hip flexion end range. Attempting to drive further into hip flexion results in a SIGNIFICANT spinal compensation.
  2. He can only squat to about 45-50 degrees of hip flexion beefore his lumbar spine begins to flex.
  3. His hip only flexes about 45-50 degrees during the wall drill, which will have implications for how he runs.
  4. He is still able to sprint, but he must maintain a more upright posture and de-emphasize his knee drive more than would typically be recommended.
  5. He has almost no hip internal rotation on either side. The left appears to be slightly better, but this is because his pelvis is not neutral. When I measured this with a goniometer when he first started, he was under 20 degrees on each side.
  6. Not having internal rotation will have significant implications for rotational movements, which are of paramount importance in most team-based sports (especially ones like lacrosse and hockey). Notice how, when he steps behind during the med ball exercise, he maintains a slight position of external rotation and how he opens up instead of rotating OVER the front leg like most athletes would. Both of these patterns were intentional, and ones that took time to groove.

Another important take home from this video is that this athlete is post surgical and STILL presents with significant range of motion limitations. This is certainly no challenge to the proficiency of the surgeon. In fact, this particular surgeon is regarded as one of the best in the world for this type of work. I’ve worked with several athletes that have had FAI-related surgeries from this surgeon, and some present with “normal” range of motion, and others still have restrictions. It’s likely a result of the complications of the individual case and the risk-reward associated with more invasive or destructive options.

Nonetheless, it’s important for the athlete to understand that getting surgery doesn’t mean you’re going to come out “normal”. It’s likely you will still have significant restrictions that you’ll need to accommodate in your movement lexicon. Also, it’s possible that the FAI is the RESULT of an underlying issue that will still need to be addressed. In other words, in these cases FAI can be thought of as a symptom that provokes other symptoms, none of which are likely to fully subside until the elephant in the room is poached. In some cases, this may mean attacking diaphragm position to restore a more optimal zone of apposition (something I’ll discuss more in the future); in other cases it may require using specific exercises to help restore a more neutral position and orientation of the pelvis; and in others it may simply require strategic soft-tissue work and help restore balance in stiffness across the hips and allow for balanced movement. In most cases, however, a combination of these techniques is warranted.

If you’re interested in more information about FAI, check out the webinar and recent interview I did at Sports Rehab Expert.

To your success,

Kevin Neeld

P.S. Don’t forget to sign up for Sports Rehab Expert’s 2012 Sports Rehab to Sports Performance Teleseminar! It’s 100% free and features some of the top minds in sports rehab and performance training.

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Following Monday’s post on Training Around Femoroacetabular Impingement, I got this email from a fellow coach:

Dear Kevin,

I really enjoyed your webinar about assessment and totally agree with most of it. Congrats on your great work.

I have few questions:

1) When you mentioned the Tyler et al study you talked about that maybe skating could change the length-tension curve to the right and said that could be good to work the adductors in shorter length. Can you explain better this concept please?

2) If I understand this well, if an athlete has excessive anterversion or retroversion, it is not good to work end range right?

3) I am excited to know how you program a prevention plan for adductor strains as I read that you reduced these injuries in your athletes over the last couple of years: probably a multifactorial approach right?

Thanks!

First off, I appreciate the kind words and the inquiry for more information. Q&A’s make for great articles because usually a lot of readers/listeners will have the same questions and explanations can help clear things up for everyone. With regards to these questions specifically:

1) As a muscle’s length changes, so does its ability to produce force. Every muscle, and every joint due to the collective influence of all the muscles that cross it will have a point in the ROM where it can produce a peak force.

Length-Tension Curve

As the figure illustrates, during active tension (neurally-driven muscular contraction) the force producing ability of the structure will change in a U-shaped fashion, so that there is an optimal length for maximal force production and a decreased ability to produce force at shorter and longer lengths. This force producing ability coincides with the quantity of overlapping sarcomeres. While this figure, and most of its kind, represent the behavior of an isolated muscle fiber, when tension is represented relative to joint angle, a similar curve presents.

Muscles will adapt to the demands placed on them. Simply, this means that muscles trained in shorter lengths will shift their peak tension toward shorter lengths (to the left on the figure above), whereas muscles trained in longer lengths will shift their peak tension toward longer lengths (to the right). Because the adductors are under maximal tension toward the end of forward skating stride, where they are required to decelerate a high velocity hip extension, abduction, and external rotation at near maximal lengths, I’m suggesting that the high volumes of skating characteristic of most hockey players causes the strength of the adductors to shift to the right, toward longer lengths. As a result, these muscles will test weak if tested in a shortened position.

A great demonstration of a typical forward skating stride position

In the Tyler et al study (The association of hip strength and flexibility with the incidence of adductor muscle strains in professional ice hockey players), they assessed adductor strength in a sidelying position with the hip adducted so that the foot was ~12 inches off the table. They assessed abductor strength with the leg positioned slightly above horizontal. In my opinion, this biases the adductors significantly further to the left on their length-tension curve. This certainly isn’t to discount the results of their study, but I believe their results are more indicative of identifying players who have experienced the shift in peak tension more so than a true strength imbalance. In either case, the training initiative is to restore adductor strength in shortened lengths, a strategy that the same research group demonstrated efficacy with in a follow-up study.

2) Forcefully driving through end range is never good, but that’s not the whole story. When a player hits end range and still needs additional range of motion to complete the movement, they’re going to continue their momentum at another joint, usually an adjacent one. This isn’t a “compensation” per se, it’s just what the body needs to do to achieve the end goal. Knowing whether the athlete has excessive ante- or retroversion will be helpful in ensuring that we avoid forceful end range, but it also gives us a better understanding of what foot positions correspond with a neutral hip position. Typically a slight toe-out position puts the hips in a neutral alignment. If an athlete has severely anteverted hips, a slight toe out could be near end-range hip external rotation for them, which will effect their movement quality, especially in rotation-based movements.

Just as importantly, understanding version angles will provide insight into probable pathological compensations. Continuing with the example of an athlete with severely anteverted hips, pushing backward with their foot at a ~45° angle to skate forward requires a great deal of external rotation of the stride leg, which this athlete will not have. Because external rotation is linked with a tendency for the femoral head to translate anteriorly, it’s reasonable to be suspicious of athletes with excessive anteversion also presenting with anterior hip capsule laxity and/or hip flexor pain/weakness. To use the Postural Restoration Institute’s parlance, we can build in exercises meant to improve the function of “ligamentous muscle”, which simply means using muscles to help reinforce ligamentous integrity/function.

3) The prevention of all injuries requires a multi-factorial approach. Everything we do is leading us closer to or further away from optimal. This is one of the reasons why Charlie Weingroff’s DVD set Training = Rehab, Rehab = Training resonated so much with me. It’s all the same. We’re seeking to improve quality, and then gain capacity by systematically adding quantity. Breakdowns occur with excessive quantity and/or poor quality.

One of the best resources for performance training and rehabilitation professionals ever created

In more specific regards to adductor injuries, we have made a few simple program adaptations for high-risk athletes that has had a profound difference on the incidence and recurrence of these injuries. I don’t think these changes, in isolation, are the solution, but I think they fit into our overall system well to create the response we we’re after. I wrote an article detailing this approach about a year ago for Hockey Strength and Conditioning that you can find here: A New Approach to Handling “Groin” Strains

To your success,

Kevin Neeld

P.S. If you missed the webinar that these questions are in reference to, you can check it out at either (or both) of two of my favorite sites:  Strength and Conditioning Webinars, Sports Rehab Expert

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