// Hip flexor strains – glutes may be the answer!

The common complaint of ‘pain at the front of the hip’ can have a deceptive origin says physiotherapist Tim Keeley.

In our physiotherapy clinics, we are seeing lots of patients with hip flexor strains. Based on this, I’m guessing that personal trainers are also experiencing a prevalence of clients reporting pain at the front of the hip. Interestingly, in almost all cases of hip flexor strains that we see, the cause of the problem is not at the front of the hip, but in the posterior hip muscles – usually the gluteals. Fully rehabilitating a hip flexor strain involves treating the underlying cause, and to do this the therapist must look at the back of the hip for answers. The following pointers will help you get clients back on the right track.

Hip muscles

The hip is a ball and socket joint which requires many little muscles for stability, and large muscles for bigger movements. The large hip flexor muscle group, Iliopsoas, is commonly injured in people who run or partake in sports or exercise without following a well-designed progressive program. This is the muscle that helps pull the thigh forward during running, sprinting or moving up steps. It needs to work with its ‘antagonist’, the gluteus maximus, to help move the thigh, and the hip stabilisers to maintain pelvic alignment and the ideal working environment.

Muscle imbalances and the ‘lazy bum’

Many people have no idea that one gluteal is often weaker than the other, that they have a ‘lazy’ bum and gluteal muscles which don’t work as they should. These incorrect muscle patterns can be caused by previous pain and injuries, long periods of one-sided sport, or strong dominance on one side of the body. Like being right handed, you can also be right footed and have a ‘right glute’. It’s only after an injury, however, that most people will get assessed and the root of the problem discovered and addressed.

Even one-sided pain following a back injury, pregnancy or surgery can ‘switch off’ the gluteals and deep hip stabilisers. This, in turn, means most of the gluteals don’t work to the optimum and lag behind – what is often called ‘delayed firing’. A runner with one side which is not stablising (called a ‘lack of lateral stability’) may also cause injury to other parts of their hip joint including the labrum, as well as the lower back, knee and leg muscles. Injuries such as patellofemoral pain, shin splints and runner’s knee can then arise.

Prone leg raise

Outside vs treadmill running

If you run on a treadmill, the road is ‘moving’, meaning the hip does not need to be pushed forward as much, because the leg is taken back by the movement of the belt. This means there is an imbalance between the hip flexor and the glutes, which can cause overuse of the hip flexor.

Running outside, on the other hand, encourages correct muscle use which can help prevent hip flexor injuries and maintain proper use of the hip stabilisers and power movers. The more the hip is in flexion (e.g. on hills), the more your gluteus maximus muscle will fire.

Physio treatment and muscle rehab

The best treatment is prevention. If a client is continually getting light strains in the hip, they should get assessed by a physiotherapist to see if their hip stabilisers and glutes are activating and firing correctly. If imbalances are found, the physio can teach them how to switch the appropriate muscles back on via a series of simple exercises targeting low level firing patterns, before progressing to more difficult strengthening exercises. This will be done in conjunction with deep core muscle re-training, which is always necessary to help prevent major strains and tears. If the client does get an injury, however, the treatment follows a similar trajectory, while also addressing the injured area.

Rehab exercise example

A great exercise to get clients started is the ‘prone leg lift’. This is a reasonably advanced exercise, so if your client can’t get a controlled glute contraction they should continue to work with their physiotherapist until they can do so. It’s also important that you don’t use this exercise as your client’s only form of correction.

Technique: Lie on your front with a rolled towel under your head. Place your right hand on your right buttock. Firstly, draw in your inner core and maintain your breathing, using your pelvic floor correctly to around 30 per cent (if you are unsure consult your physio). Make sure you continue to breathe through your lower rib cage and never hold your breath. Keeping your leg straight, think about raising your leg, focusing on your glutes that you have your hand on. Don’t lift it yet, but try to imagine you are lifting a heavy leg with your buttock (Note: Don't simply clench your glutes – this is cheating!). If you feel a contraction and get some ‘tone’ in your buttock, hold for 10 seconds and then gently raise your leg in the air about 10cm, maintaining the contraction without losing your core stability or arching your lower back. Lower and repeat 20 to 30 times.

This is a difficult exercise, and for this reason your client should always be guided by yourself or a physiotherapist initially. This will ensure correct technique and prevent them from adopting a bad pattern and compensating with other larger and global muscles, which can make the injury worse.

There are many more progressions to help clients get the perfect firing backside and stay free of hip flexor strains, but this is a great starting point.

Tim Keeley, B.Phty
Tim has over 12 years experience in the physiotherapy and fitness industries. A rehabilitation expert, clinical educator and convention presenter, he is also the director of Physio Fitness Australia, operating four clinics across Sydney. For more information go to www.physiofitness.com.au or call 1300 233 300.


As part of a superb line-up of presenters, Tim will be sharing his physio know-how in FILEX 2011’s inaugural Physiotherapy & Exercise strand. Choose from:

• Strength essentials for lower back problems (B1H)
• ACL reconstruction rehab: program essentials (C1G)

For program information click the links above or check out the Physiotherapy & Exercise and the Personal Training strands in your FILEX brochure. Visit www.filex.com.au to view the entire brochure and register online.