Of all the different muscles that are important to stretch, the hip flexors come at the top of the list more often than not.  Hip flexors are stiff, short and overactive in a lot of people ranging from high level athletes to Jo Schmo’s working at their computer all day.

Athletes usually have pretty stiff hip flexors from running or skating.  On the other hand, desk jockeys sit all day, which shorten the hip flexors.  So hip flexors are a problematic area for a lot of people, whether you’re an athlete or not; this is why it’s important to stretch them regularly.

There are different types of hip flexor stretches that can be more or less appropriate for you, depending on your situation.  Let’s go over a couple of them.

1. First, and most importantly, the hip flexor stretch done wrong.

This is something that is seen way too often in people doing a hip flexor stretch; they just crank their hips forward as far as they can go until they feel something.  The problem with that is they don’t reverse the anterior pelvic tilt, which doesn’t even end up stretching the hip flexor muscles.  All they’re doing is overstretching the ligaments and front of the capsule making the joint unstable on top of not getting a stretch in their hip flexors.  No matter which hip flexor stretch you decide to perform, always make sure you maintain a posterior pelvic tilt; you should only have to shift forward slightly to feel a stretch.

2. The classic 1/2 kneeling hip flexor stretch on the ground.

This is the classic hip flexor stretch where you assume a 1/2 kneeling position, perform a posterior pelvic tilt, and slightly shift forward while squeezing your butt the whole time.  It is pretty basic, and a good way to teach someone who’s just starting how to perform a hip flexor stretch the right way (posterior tilt, squeeze the butt, etc).

3. The rectus femoris stretch.

Of all the different hip flexor muscles we have, the rectus femoris is one that is often problematic.  Since it crosses both the knee joint and the hip joint, flexing the knee while extending the hip will emphasize the stretch on the rectus femoris.

4. The box hip flexor stretch

The internal rotation of the femur on the back leg, the front foot being elevated, and the overhead reach all increase the stretch on the psoas.  The psoas is another problematic hip flexor, so getting some manual work done on it in combination with this stretch should help release it.

5. The back knee elevated hip flexor stretch

This is a variation of a hip flexor stretch for someone who presents with Femoroacetabular Impingement (FAI).  Most people with FAI can’t flex their hip past 90 degrees because of bony overgrowth either on the femoral head or on the acetabulum.  With a conventional hip flexor stretch, the front hip flexes at around 90 degrees and a little more, so this variation prevents any irritation of the hip.

There are plenty other variations of hip flexor stretches, but this should at least give you a basic understanding of what type of stretch to use when, when stretching the hip flexors.

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When assessing the active straight leg raise in the FMS, it’s not uncommon to find a side-to-side discrepancy.  Usually, following the FMS correctives will clear this imbalance within a couple of sessions.

Even though you might think that simply stretching the hamstring on the “tight” side is the answer, a lot of times it’s not.  Especially if you see the left side being the restricted one.

Let me explain.

If your pelvis is anteriorly rotated on one side, that puts your hamstring of that same side on constant stretch.

Notice on the left what happens to the hamstring when the pelvis is rotated forward.  It puts it on a constant stretch versus the image on the right where the pelvis is in a more neutral position.

If you take a person with an anteriorly rotated pelvis through the ASLR, the side of the rotated pelvis will create the illusion that the ASLR is asymmetrical, and you might think that the hamstring on that side is tight when in fact it’s probably longer; it’s just on stretch right off the bat when doing the ASLR which will make the leg stop sooner and it will look restricted.

If you don’t know that, you might hammer the hamstring flexibility exercises and the corrective drills until you get a symmetrical result.  But in fact, what you will have done is over lengthen and over stretch the hamstring on that side, while still having an asymmetrical pelvis, and THAT might cause further problem down the stretch.

And the reason why I mentioned the left side being more restricted than the right one, you may ask?

According to the PRI philosophy, every human being is asymmetrical in the same way because we are all built the same way; we all have a heart on the left and a liver on the right which affects the shape and the positioning of the diaphragms (yes, we have 2), and this impacts the orientation of the ribcage, the hips, and the shoulders.  Because of that, you often find the left pelvis being anteriorly rotated and the right one being posteriorly rotated.

People are affected to different degrees with this asymmetry, but if you find a discrepancy in the ASLR with the left side being significantly more restricted than the right, make sure you further assess to make sure where the problem truly originates.

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Hip capsule mobilizations can be an important part of the puzzle when addressing hip stiffness.   If traditional modalities such as self myofascial release and stretching don’t seem to be doing the trick, it might be indicative of hip capsule stiffness.

There are a ton of different methods out there that work wonders to help loosen up the posterior hip capsule, such as the Mulligan mobilizations.  The Mulligan concept uses different strategies in itself.  One of these strategy that works especially well involves distraction of the femoral head.

Mulligan mobilizations require the help of a qualified practitioner.  There is however a way to replicate the Mulligan concept with self mobilizations and the help of a super band to reap some of the benefits of the Mulligan mobilizations.

I learned this self posterior hip capsule mobilization from my buddy Anthony Vittese, whose a very smart physical therapist.

The goal is to have the band high up in your groin so it’s as close to the hip joint as possible and cause a bigger distraction.  It’s worth noting that you need a band that’s super stiff in order for the mobilization to be effective; I don’t think the use of tubing or theraband would do it.

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With the rising popularity of Dr. Stuart McGill and his work on the lumbar spine in the health and fitness community, people have started to understand that excessive lumbar motion leads to injuries.  The extent of his research (which he has been leading for years) have given all of us a better understanding of the spine, how it works, how it should move, and what leads to injuries.

This is a MUST read. Period.

Like many other things in the fitness business, it caused an overreaction.  We started avoiding movement at the lumbar spine at any cost.  We started to focus on the hips and the thoracic spine as the places to improve mobility, which I’m not going to say it’s a bad thing because that is exactly what most people need; more mobility in the t-spine and the hips.

This overreaction, though, caused us to ignore that there is a certain degree of movement that is normal to have at the lumbar spine.

As you can see in the chart, although the biggest potential for rotation is at the thoracic spine, the lumbar spine still have a couple of degrees of rotation.  The same thing applies for flexion and extension.

To better understand the reason to why we actually need range of motion at the lumbar spine I’ll refer to the pendulum theory that Charlie Weingroff introduced a little while ago.  To quote Charlie:

“So every joint has a core and it has a neutral that is decided just like a pendulum.  It has to know that the stiffness properties allows it to go all the way to the left, right, front, back, etc., so it can rest with no effort in the middle, the position of optimal force transfer.

The clinical application is that the spine’s neutral is a function of full flexion, full extension, full side bending, and full rotation. Then and only then does the core have it’s premiere chance to do as little work as possible for segmental stabilization, and the phasic lumbar muscles can pick up the bracing slack to handle huge loads and force transfers.

If you don’t have yoga-ish mobility, the middle is always off-center, and the local stabilizers (of any joint system) aren’t triggered ideally via the brain getting “wrong” feedback from the joint receptors (…)”

What this means is simply that if your body doesn’t have a proper “neutral”, everything is going to be affected, compensation takes over, and injuries eventually happen.

Even if the goal should always be to lift weights and reinforce proper movement pattern with a perfectly neutral spine, it doesn’t mean that you’re body shouldn’t “own” that range of motion at the lumbar spine.

My personal story is a pretty interesting one in this regard.  Since reading the work of Dr. McGill years ago I became a strong advocate in limiting motion at the lumbar spine.  When I say I was doing everything with a neutral spine, I mean everything: sitting, brushing my teeth, tying my shoes, and even putting socks on in the morning!  Have you ever tried putting socks on in the morning without allowing any sort of lumbar flexion? Trust me it’s not that easy!  But I was doing it!

Not quite like this, but that far off!

I was also getting pretty strong for my height and my body structure, I was deadlifting a decent amount of weight and I never allowed myself to have anything less than perfect form on every single rep I was doing.

About 2 years ago, I started to get a little less zealous about the whole neutral spine thing in my everyday life.  A couple of months later, I was brushing my teeth in the morning and as I was bending over to spit in the sink I felt a sharp pain go through my right lower back just above my right SI joint.  A couple hours later, I couldn’t bend over at all, and I mean not at all.  Even breaking at the hips slightly to grab a glass from the kitchen table was impossible.  The pain started to go away after 3-4 days, but my back bothered me for a couple of weeks.  And weirdly enough, a similar event happened about 8 months later.

It’s only when I learned about the SFMA, the pendulum theory and other philosophies along the same line that I realized that my lumbar spine wasn’t flexing at all, which was later confirmed to me by a good friend of mine who’s an enlightened physical therapist.

I’ve been working on my lumbar flexion more recently and making sure my toe touch, as per the SFMA, stays intact and turns out my back has been feeling much better.

That doesn’t mean I’m doing silly stuff like stiff-legged deadlift with a rounded back, or crunches and sit-ups, but I’m doing isolated mobility exercises that don’t involve any type of loading to make sure that my pendulum is in the right “neutral” position.

Do you ever assess for lumbar range of motion?  You might be surprised at what you’ll find.

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Static stretching is an important part of any training program to help improve or maintain elasticity in muscles and range of motion around the joints.  Depending on the sport you play, some stretching might be more important than others.  In other words your post-workout stretching circuit might be different depending on what sport you play.

Hockey players, for example, usually have pretty stiff hip flexors (especially the TFL), posterior hip muscles (glutes, piriformis, etc), and posterior neck muscles due to the way they skate.  These will be areas that you’ll want to focus on in their stretching circuit.

Here is the post-workout stretching circuit that we use at Endeavor with most of our hockey players at the end of every session:

1. Lateral Hamstring w/ Band

2. Prone Glute

3. Lying Knee-to-Knee

4. Rectus Femoris w/ Internal Rotation

5. 90 Degree Pec

6. Cross-Body Lat

7. Diagonal Neck

Notice how their is no groin, or adductor stretches.  The reason is that it’s an area that hockey players are already overly flexible in.  In fact, they need a little more tightness in the groin/adductors area, and more tissue elasticity in the posterior hip muscles.

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Baseball is one of the sports that puts the most stress on your joints, especially if you’re a pitcher; the throwing shoulder is under tremendous stress.  With the crazy velocities at which you throw a baseball, and with the volume of pitching that accumulates over the years, by the time a pitcher gets to the professional level, he probably has a lot of overuse damage to it (soft tissue restriction, ligament laxity, partial labral damage, etc).

Last Saturday I played in a fund raising dodge ball tournament in Philadelphia.  Having not played dodge ball since middle school, and not being a natural thrower (my main sports growing up were hockey and basketball) made me a little worried about my dodge ball performance.  As expected I sucked pretty bad, but at least I stole the show with my purple cobra entrance before every game…

A little less glorious when you get hit in the face 30 seconds later, though!

If you’re wondering where I’m going with this, here it is: I was so freakin’ sore the next day it was unreal!  My whole shoulder and arm, starting from the attachment of my rhomboids on my spine going all the down to my fingers, were as sore as I’ve ever been in my upper extremity.  Rhomboids, levator scapula, rotator cuff, biceps, and all of my forearm muscles were completely smoked.

Is that a coincidence that these muscles all have fascial connections?

That just made me realize all the stiffness and soft-tissue restrictions that can build up in a baseball pitcher’s arm when he throws around 100 pitches every time is on the mound.  Of course there are some adaptations taking place; the body becomes more efficient at it as you build up your arm strength, stamina and improve your technique, and you don’t get sore (like I did playing dodge ball) every outing.  But it still makes you think about all the stress that the shoulder and arm are taking on a weekly basis.  And when young baseball pitchers throw with their high school team in the spring, play summer league and fall ball on top of that, the accumulated stress on your arm builds up pretty fast.

That’s why taking care of your pitching arm, using injury prevention strategies, and having an smart (and planned) training program are going to be important factors in the longevity and durability of your arm over time.  Soft-tissue work on the rhomboids, levator scapula, rotator cuff, biceps, and forearm muscles is going to be an important part of that ‘arm care’ program.

Try and not cry the first time you dig a lacrosse ball in your rotator cuff muscles

If I got stiff and extremely sore in these muscles by playing 6 games of dodge ball (realistically ~10 throws per game), I can guarantee you that any baseball pitcher will build up severe restrictions in those same muscles over time, whether they feel it or not.

Do your dedicated self soft-tissue work on a daily basis, go see a qualified active release therapist on a regularly (once a month, as a bare minimum- but College and professional players probably need more) and you’ll increase your chance of staying pain and injury free, and give yourself the best chance to perform at the highest level.

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There are bunch of different injuries that occur in every sport.  If you look carefully at the injuries in each sport you’ll notice that there are injuries that are common in each one of them.  In fact, you could probably identify 3-4 different injuries in a given sport that you keep hearing about from athletes.  Hockey, like every sport, has its common injuries.  Before we go any further in this injury prevention discussion, it’s important to acknowledge that there are 2 different types of injuries:

1. Trauma injuries (e.g. shoulder dislocations, concussions, etc) that usually happen with some type of contact.  These injuries are not really preventable (the only thing you can really do is beef up the surrounding muscles to limit the effect of the impact).
2. Overuse/Under-recovery injuries (e.g. tendinopathy, muscle strains, etc) .  These injuries are largely preventable and can become pretty much completely absent if taken care of the right way.

Unfortunately, nothing you can do to prevent that.

Knowing that there is little we can do to prevent trauma injuries, we’ll focus on the preventable injuries.  Appropriate training and recovery methods can almost always prevent those injuries.  If we want to help prevent those injuries, we need to know what they are in the first place.   In hockey players, the common preventable injuries are:

• Adductor/Hip flexor strains
• Hip labral tear
• Sports hernias

If you are a hockey player or train hockey players, you’ll know that these injuries are VERY common among the hockey community.  The nature of the sport and the large amount of stress placed on the hips can explain in part why those injuries occur.  But it’s also important to understand that common doesn’t mean that it’s OK and that we shouldn’t do anything to prevent them.

To prevent the injury, you need to understand the injury mechanism.  In hockey the hip abductors (glutes) get a lot stress from the skating motion.  Conversely, the adductors and hip flexors are elongated with every stride of the skating motion.  That certainly creates imbalances across the hip musculature; some muscles get weak, some muscles build up a lot of adhesions and trigger points and some muscles are just overused.  Re-establishing that muscle balance in your training program is crucial to keep your athletes healthy.

Getting some soft-tissue work done on your glutes and adductors, stretching your glutes, strengthening your adductors in a shortened position and re-establishing neutral pelvic position (getting out of anterior tilt, which is way too common among hockey players) are just a couple of examples of strategies to help restore muscle balance across the hips for hockey players.

Kevin Neeld has a full chapter in his book Ultimate Hockey Training dedicated to those common hockey injuries and how to prevent them.  If you haven’t already, I strongly suggest you pick up a copy of his book.

Injury prevention strategies are an important part of a strength and conditioning program.  How important is it to get bigger, faster, stronger and more powerful if you’re sidelined with a preventable injury?  Not that important I would think…

But when including injury prevention strategies in your program or the ones of your athletes, you can face a couple challenges, mainly:

• how exactly to program those injury prevention strategies in your training
• how to not completely turn your training program into a rehab program
• not make your athletes feel like patients
• how to maintain a training effect while still working on injury prevention

Not Exactly how you want to make your athletes feel like

These are legitimate concerns in my opinion because there is a fine line between too much and too little corrective exercises.  And it’s also not easy to know where to include them in your program so you still end up with an optimal result, both from from an exercise prescription and a time management perspective.  Here are a couple of tips to help you program your corrective exercises better into your own program or the ones of your athletes.

1. Your warm up.  There is a decent amount of injury prevention strategies that can be included in your warm up, especially if they’re mobility exercises.  A warm up is the perfect time to work on soft-tissue restriction and mobility to improve range of motion.  And you’re going to use your lifting to reinforce that new found mobility with appropriate lifting exercises.

Your warm up should be a little more specific than that…

2. Your cool down.  Soft-tissue work and static stretching are great to include at the end of your training session.  It will promote recovery and limit the possible range of motion loss from tight muscles.

3. Fillers.  This is probably my favorite way to include injury prevention strategies in a training program.  Fillers are basically a corrective exercise that you include between sets of a lifting exercise.  It can help reinforce a movement pattern of your main lifting exercise, it can be a stability exercise or it can be a mobility exercise that doesn’t affect the part(s) of your body you’re training.  The reason I like fillers so much is because from a time efficiency perspective, it really doesn’t get any better.  It saves time so yo don’t have to do all of that corrective work at the beginning or at the end of your training, which would make your session time longer by at least 10-20 minutes.  It also makes your training more productive; you spend less time (if at all, when programed thoroughly) waiting and doing nothing between your sets of your main exercises.  This is something very common among most gym enthusiasts; they spend an awful lot of time doing nothing (most of the time talking, and losing focus) between their working sets.  No wonder why most people hate going to the gym and lifting weights!  I would hate training too if I had to wait 1-2 minutes between every single set of every exercise I’m doing; this is boring as hell!  Putting fillers in between your sets makes you move more, reduces your down time between sets, and makes you feel like your training was much more productive and that you got a lot more done in the same amount of time.  And you took care of the injury prevention side of things on top of that!

Here’s what a hypothetical upper body day could look like with the use of filler sets if we wanted to include shoulder injury prevention strategies (filler exercises are highlighted in green) :

Notice that you’d still get a decent training effect from the rest of the exercises while simultaneously working on lower trap and serratus anterior activation, t-spine mobility, breathing patterns and anterior chain muscles extensibility, which all play an important role in injury prevention for the shoulders.

As I mentioned above, fillers can be a tremendous addition in your training program.  Give it a shot and play around with your corrective exercises that you want to include in your program.  As long as your filler exercise doesn’t interfere with your main exercise, you should be fine.  But you might need some time to play around and find good combinations that will work for you.

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If you haven’t heard about the benefits of foam rolling to improve soft-tissue quality, you have probably been living under a rock for the past 5-10 years.  Even with all the benefits of foam rolling though, sometimes it’s just not enough to take care of your soft-tissue quality.

There are a couple reason why foam rolling might not be enough:

1. The trigger point is too hard to reach with a foam roller

2. The pressure applied by the foam roller is not enough to effectively target the trigger point

3. The trigger point area is just too stubborn and won’t go away

Let’s go into a little more details for each of those 3 reasons and see the possible alternatives:

1. Sometimes, you’ll want to foam roll an area of your body that’s not exposed as much as your quads and upper back for example.  Getting to smaller areas, close to the joints and the mid-line of the body can be a difficult task.  A couple example could be the pecs, the high adductors, the long head of the triceps, the plantar fascia, the levator scapula and upper trap among others.  These areas are located in spots where it is difficult to access with a foam roller.  A good alternative would be to use a smaller surface like a medicine ball or a lacrosse ball.  The lacrosse ball works particularly well on the pecs and the plantar fascia, and the medicine ball work really well for the high adductors.

2.  When you’ve been foam rolling for a decent amount of time (usually 6 months or more), you’ll find that the traditional foam roller will not work your trigger points as hard as you would like (a.k.a. it doesn’t hurt anymore).  There are a couple different ways to solve this problem.  The first one would be to move to a denser foam roller; they sell rollers of different densities, with the foam roller plus (a PVC pipe warpped around a thin layer of foam) being the hardest one.  If you feel really tough, or if even the foam roller plus doesn’t do anything for you, you can try a straight PVC pipe (which ends up being really cheap if you just get it a your local hardware store) or the rumble roller.  I have yet to try the rumble roller, but I have had great comments on it.

Are you game?

Using a smaller, denser surface like a lacrosse ball might be appropriate in this situation as well.  You’ll have more pressure applied on a smaller surface, which will increase the pain factor for sure!

3. That happens very often that all self soft-tissue tools won’t work to get rid of a trigger point.  In this case the only option left is to consult a qualified massage therapist that will work your trigger points more in depth.  An ART or Graston certified practitioner is recommended, as I feel it 2 of the most efficient soft-tissue methods available.  A couple of visits might be necessary to get rid of your tight spots.  And if you’re a high level athlete that imposes a lot of stress on his body, I would even recommend that you go see one on a regular basis, at least once a month; that will help keep you healthy in the long run.

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I wrote on Tuesday that you may not have to stretch your hip flexors, even if they feel “tight”.  I also showed how easy it is to screw up a hip flexor stretch.  If you missed it, make sure to read it HERE.  But how does someone knows if he needs to stretch his hip flexors if we can’t rely on the fact that they feel “tight”?  Those who are familiar with muscle testing a bit will say to use the Thomas test (or one of its variations) to assess hip flexor length.  The Thomas test is a commonly used test among strength coaches, physical therapist and other rehab/training professionals.  Here is what it looks like:

 
By letting one leg hang down, you can usually know if the person has short/stiff hip flexors if the knee of the down leg hangs higher than the hip.  In the case of a shortness in the rectus femoris the knee will also stay extended over 90 degrees of flexion.  A positive Thomas test (knee staying above hip level) usually is good indications that your hip flexors are short or stiff, but as I mentioned before it might mean that the problem is neurological, and stretching your hip flexors won’t solve the problem.  To add to the confusion, a negative Thomas test (knee dropping all the way down) doesn’t mean that your hip flexors aren’t short/stiff.  It could mean that your anterior capsule and ligaments are overstretched.  One way to prevent this is to make sure that you stretch your hip flexors the right way, like I mentioned in my last post.  But how do you know if it’s a capsule/ligaments issue or not?

Using the adduction drop test in conjunction to the Thomas test might be a good option.  Here’s what it looks like:

The adduction drop test is something I picked up from the Postural Restoration Institute.  They commonly use this test to identify what is called a left AIC (Anterior-Interior Chain) pattern, which implicates that most human beings are stuck in external rotation and abduction, and hip flexion in the left hip.  The combination of a positive adduction drop test and a positive Thomas test usually points in the direction of a left AIC pattern because of the lack of hip extension and adduction on the left side.

We can also use the combination of these two tests to identify anterior capsule and/or ligament laxity.  A positive adduction drop test and a negative Thomas test would be indication of anterior laxity in the hip capsule and/or ligaments.

Assessing before you prescribe a hip flexor stretch and making sure it is performed correctly if you need to prescribe it are the two keys here.

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