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In this blog post, we will cover how you can solve your femoral acetabular impingement (FAI) conundrum and discuss the one thing you must do to squat deeper and pain-free.
As a refresher, femoral acetabular impingement classically presents in two ways. Either the hip socket is too narrow for the head of the femur (Pincer) or the head of the femur is too big for the hip socket (Cam). You can also have both types of FAI at the same time. This essentially creates a bony block as we go into a squat-type motion, and many will often complain of a pinching sensation or a dull ache in the front of their hip Pain along the outside of the hip in a "C" shape pattern is a common finding as well - this is known as the C sign.
Because FAI is a structural adaptation, making physical changes to the bone is not feasible without surgical intervention. This has led to the exponential rise of hip surgery to remove the excess bone and allow for an improved hip range of motion. The exciting thing is, however,
many people have FAI without pain, can squat deep, and do not require surgical intervention.
So what's their secret? What makes these people so unique and why can't you be like these people?
For the record, you can! Or at least significantly improve your ability to squat deeper with less pain, and avoid surgery. It's just a matter of understanding what makes these people different from you, and what you can do about it.
In 2018, a study was brought to light that aimed to answer this exact question - why do some people with FAI have pain with squatting, while others don't? The results were pretty interesting.
Within the study, there were three groups:
Group One: A healthy population without FAI that could squat pain-free.
Group Two: Those with FAI who had hip pain during squatting
Group Three: Those with FAI without hip pain during squatting. This group was known as the femoral acetabular deformity group (FAD).
Out of all the things the researchers measured, the significant finding was:
The FAD group had significantly stronger hip extensors than the other two groups.
Keep in mind the FAI group with pain didn't necessarily have weaker hip extensors when compared to the healthy population group; it's the FAD group, with regards to hip extension, was significantly stronger than either group.
Let us repeat, if you've been performing banded hip mobilizations, stretching aggressively, or even a general strengthening program - a focused emphasis on hip extensor strength could be your missing link. Not to say these other approaches don't have their place, however, if you've already been trying these things, maximizing hip extensor strength is your next stop.
The other significant finding was that the FAD group could maintain a better posterior pelvic tilt position throughout the squat...but more on this in a bit.
Other than producing a significant amount of hip extension torque, the gluteus maximus, and deep hip external rotators assist in keeping the head (ball) of the femur centered in the hip socket during dynamic activities. Liken this to the function of the rotator cuff for the shoulder but at the hip joint.
Essentially, even despite the bony deformity (remember some people have this deformity without pain), there is a belief that the head of the femur is gliding too far forward in the hip socket and thus impinging on the front of the hip joint.
Or stated another way - the gluteus maximus and deep hip external rotators are not able to keep the head of the femur centered in the hip socket during dynamic hip flexion.
Ironically the front of the hip joint is where the majority of labral tears occur as well. Hence where all the banded mobilization videos come from - the thought being we are trying to seat the head (ball) of the femur back into the hip socket during hip flexion and reduce the likelihood of impinging at the front of the hip joint.
What this means for you: As the research article showed, those in the FAD group had much stronger hip extensors than the other two groups.
Theoretically, the FAD group had supercompensated by increasing the strength of their hip extensors. Thus they were able to maintain optimal joint congruency and reduce the likelihood of impinging throughout the squat, despite the FAI deformity.
The second interesting finding of the study was that the FAD group maintained a much more posterior pelvic position throughout the squatting motion. Or they went into less of an anterior pelvic tilt.
When looking at the hip joint there is more than one way to get hip flexion - we can move the femur on the pelvis, or we can move the pelvis on the femur, as seen in the picture above.
If you can imagine what is occurring when the pelvis goes into an anterior pelvic tilt, we are in essence taking up a relative amount of hip flexion at the hip joint. And when we go into a posterior pelvic tilt, the opposite happens - we create more relative hip flexion or less corresponding hip extension.
This concept is important because, as we mentioned earlier, there is often not enough space in the front of the hip joint. If we are unable to maintain a good pelvic position or control our willingness to go into an anterior pelvic position, we theoretically close off the front of the hip joint. We reduce the amount of available hip flexion and potentially limit our ability to squat deep without impinging.
The FAD group didn't have this problem; while the FAI group with pain showed a bias toward an anterior pelvic tilt when squatting, even when compared to the healthy population group.
Back to our golden goose, the hip extensors. These muscles not only produce hip extension and control the head of the femur in the socket but, acting on the pelvis, they create and help maintain a posterior position of the pelvis — the trifecta.
And there you have it! As a recap: the FAD group had much stronger hip extensors than the other two groups. The authors summarized that this allowed the FAD group to maintain better joint congruency and pelvis position throughout the squatting motion. This translated to their ability to squat deeper and pain-free when compared to the FAI with pain group.
Get your hip extensors super strong! Over time you should find this is the long-term FAI solution you've been looking for. Happy squatting.
If you want to know more or receive the best updates on how to get out of FAI pain, email us at clientcare@myvitalsix.com or follow us on Instagram @vital_six. If you are in the Kansas City area text us 913.303.0032.
Citation: Catelli DS, Kowalski E, Beaulé PE, Smit K, Lamontagne M. Asymptomatic Participants With a Femoroacetabular Deformity Demonstrate Stronger Hip Extensors and Greater Pelvis Mobility During the Deep Squat Task. Orthop J Sports Med. 2018;6(7):2325967118782484. Published 2018 Jul 17. doi:10.1177/2325967118782484
