Brian Schiff’s Blog

Improving proximal hip stability and reducing frontal plane collapse is critical for protecting the knee. Poor frontal plane control often contributes to anterior knee pain, IT band syndrome, shin splints, plantar fasciitis and other injuries. This exercise is an advance progression of the standing pallof press, and it is very effective for enhancing single leg strength as well as hip/core stability.

Click here to read my full column on this exercise in PFP Magazine.

Femoroacetabular impingement (FAI) is now a common term in orthopedics. When I first started practicing physical therapy the term did not exist. As a matter of fact, I was told my hip had a bone spur in the early 2000’s, and I am sure it would now be classified as FAI. If you are unfamiliar with it, click here to read a prior post on the basics of it.

Today, as clinicians we face the tough task of helping patients overcome hip pain related to overuse injuries, acute strains, osteoarthritis, myofascial pain, etc. One of the biggest challenges is definitively identifying the etiology of hip pain. Hip pain can be extra-articular (outside the joint) or intra-articular in nature (in the joint). Consider this retrospective study published in AJSM in 2015 by Naal et al. on sonographic presence of groin hernias and adductor tendinopathy with FAI.

Differential diagnoses when ruling in/out FAI include:

• Adductor (groin) strain
• Rectus femoris strain or avulsion
• Iliopsoas tendinitis
• Athletic pubalgia
• Trochanter pain/bursitis
• Femoral neck stress fracture
• Osteitis pubis
• Cancer
• Genitourinary issues
• Low back pain

The list above is certainly not all inclusive. The key to obtaining a more accurate diagnosis involves taking a thorough history, performing a comprehensive exam, and getting appropriate imaging. Click here to learn about a paper on the diagnostic validity of tests to predict intra-articular hip pathology. Soft tissue pain related to muscle strains should improve with rest and treatment, whereas joint pain related to FAI is usually consistently painful or worse with increased repetitive activities such as running, dancing, twisting, jumping, cutting, etc.

Patients with FAI will often cup their hip and make what is referred to as the “C sign” when describing where they feel the pain.

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This exercise is intended for advanced users who want or need to increase shoulder, core and hip stability, while also seeking to improve hip disassociation. The core must function in an anti-extension and anti-rotation fashion throughout which is a safe and effective way to target those muscles while also providing a demanding strengthening exercise for the upper body and hips.

With that said, sufficient upper body strength is a must for this exercise.  Clients with wrist pain/weakness or elbow and shoulder pathology should only perform this exercise provided they have are symptom free and have moved through the following progressions. In many cases, it is best to start with tall planking and leg lift progressions on the floor before trying this exercise.

The video below will review the exercise in one of my latest columns for PFP Magazine.

Many athletes and clients I work with lack adequate pillar and shoulder stability. Whether this is related to acquired laxity, inherent instability or simply a lack of proper muscular control, I think it is important to assess baseline stability in anyone performing overhead lifts, ballistic upper body training and in overhead athletes.

In my clinic, I work with lots of baseball players, swimmers and volleyball players. Most females tend to struggle with hyper mobility (loose shoulder joints) whereas many of my males tend to have soft tissue tightness and in some cases limited internal rotation (GIRD). Both males and females tend to have a need to improve dynamic shoulder and pillar (core) stability to reduce injury risk and optimize mechanics.

The following exercise is one I use to both assess anti-rotational control/stability as well as train the body to resist torsional forces. In the video below, you can see how to assess your baseline strength and stability.

This exercise is very effective in working improving glenohumeral and scapular stability as well as enhancing shoulder, torso and hip stability. In my opinion, athletes with poor stability in this assessment should not perform unilateral Olympic lifting or ballistic overhead training as they may lack the necessary neuromuscular control to execute the proper movement pattern.

One of the more challenging issues I see in the clinic is pain in the upper hamstring region. Proximal hamstring tendinopathy, referred to medically as tendinosis, is common in runners and athletes. With that said, arriving at this diagnosis can also be challenging as proximal hamstring pain can also be caused by sciatica or referred pain from the low back region. A thorough clinical exam and good history will be able to definitively help diagnose the cause.

Chronic hamstring pain can occur as a result of a previous acute tear, or due to ongoing tendinitis that is aggravated by repetitive activity. Running, biking, rowing and even prolonged sitting can aggravate the hamstring tendons where they attach to the ischial tuberosity. There is also an ischial bursa that cushions this region that can become chronically inflamed. It is a common problem for distance runners and athletes involved in sprinting, hurdles, or cutting . Typical signs and symptoms include a deep, local pain in the buttocks/upper hamstring region that worsens with running, squatting, lunging and sitting.

Differential diagnoses include:

• Sciatic nerve irritation (may be a co-morbidity in some cases)
• Ischiofemoral impingement
• Apophysitis or avulsion in adolescents
• Deep gluteal muscle tear
• Stress fracture (posterior pubic bone or ischial ramus)
• Partial or complete rupture

Proximal hamstring tendinopathy is rarely painful during activities that do not involve elastic energy transfer or compression, such as walking on even ground, standing or lying down. Tears are typically accompanied by extreme hip flexion and knee extension during an acute injury (usually hear an audible pop).  In some cases, chronic pain may also be accompanied by an exaggerated pain response, referred to as central sensitization where the central nervous system conveys an amplified neural signal resulting in pain hypersensitivity.

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