In this post, we'll be talking about hip flexors and how they've often been demonized as always being "tight". Oftentimes people experience pain, discomfort, or a lack of range of motion in the hips and immediately attribute it to the hip flexors being restricted. Our goal with this post is to provide a bit more context, determine if it is actually the hip flexors or not, and provide solutions for if it is or isn't. But first, it's important to determine what hip flexors are in the first place, and why the term tight is often used in relation to them.
Hip flexion occurs when you bring the top of your thigh up towards your stomach. There are a few muscles that participate in this action, namely the Iliopsoas (Iliacus + Psoas Major/Minor), Rectus Femoris, TFL, and sartorius. There are other muscles that also contribute to hip flexion, but these are typically seen as the major players of hip flexion.
First, let's define what "tight" means in this context. People often determine something is tight when there's discomfort, pain, or maybe even a lack of range of motion (ROM) or restrictions at a specific area of their body. Oftentimes they coin it as tightness because the area doesn't feel like it can move as much and sometimes can be relieved by stretching (even when it doesn't do anything productive in the long run). But this doesn’t actually describe the state of the muscle itself. Something can subjectively feel "tight" and be fully lengthened (overstretched). Something can be tight because it is in a shortened position and pulls you into a certain position. Or it can be tight because there is a trigger point present, instability, a recent injury causing splinting, etc. For the rest of this post, we will use "tight" to describe the hip flexors in being in a "shortened" position, which is what the goal of stretching the area would be to relieve, which is most often what the response to this sensation is regardless of what may be happening. Regardless of what may be the problem, oftentimes stretching or manual therapy is the go-to solution. These modalities are wonderful and can even help to mask the discomfort which can be beneficial in itself if it allows you to do an effective intervention pain-free, but much like a lock and key, we need to find the right key(intervention) for the lock (the root cause of the discomfort you are experiencing). Chances are if you are constantly stretching the front of your hip to no avail, your hip flexors are probably not "tight" or in a shortened position and you may actually be exacerbating the problem in the long term. But we can test for this by testing your capacity for hip extension. First, it may be advantageous to see how much active range of motion (AROM) you have in hip extension. You can lay face down, toes pointing to the ground and arms at your side. From here you will keep your knee straight and lift your whole leg off of the floor without moving or using your lower back. Image 1 Row 1 shows the correct way to perform it, while Image 2 Row 1 is the incorrect way, with an increased curve in the lumbar spine. We are looking for around 10 degrees of movement here. Next, we will check how much you have passively by doing another test called the Thomas Test. You will need a table or a high bench for this. But the pointy bones in your butt right at the edge of the table (Image 1 Row 2) and roll yourself back so you're lying face up with your knees in your chest with your butt towards the end of the table (Image 2 Row 2). From here keep your back flat against the table and lower one of your legs down so it is hanging off of the table, keeping the opposite leg in the same position. The main thing we are looking to see is where the knee is in relation to the greater trochanter (Bone on the side of your hip)(Image 3 Row 2). If the knee is above the greater trochanter (Image 4 Row 2), it could mean that the hip flexors are actually in a shortened "tight" position. If your knee is slightly above or even below the hip, but the knee is pointing straight out, that could mean that your Rectus Femoris (one of your quadriceps muscles) is in a shortened position (Image 5 Row 2).
Lastly, we will then look at the person's ability to maintain hip extension through movement. We will go into a split squat position (Image 1), testing both sides. If in this position, and while doing a few reps we find that the person needs to either create a large curve at the lower back (Image 2) OR has to bend at the torso and keep the back leg close to the front (Image 3), it could be another corroboration to our theory of someone having shortened hip flexors. If all of these tests come back negative, then we can be fairly confident that the problem may not necessarily be from hip flexors being short and tight, but rather from an inability to properly build Intra Abdominal Pressure (IAP)/brace the core through movement.
First, let's give some background: Our core is a hub of force transfer. Whether it be from an intrinsic force we are trying to transfer outward, or something external being brought internally, forces will almost always travel through the core to be transferred somewhere else or to be resisted. For this to be most efficient, managing IAP is crucial. IAP is the pressure that is built up in our abdomen and is increased when we go through inhalation. As we inhale, our diaphragm descends, decreasing the volume in the abdominal cavity and increasing the amount of pressure in the abdominal cavity. With inhalation, certain muscles are also being eccentrically loaded, most notably our "core" musculature. Oftentimes people have "dysfunctional" breathing patterns, flared ribcages, and lack of pelvic control, which can all set the stage for excessive force being put onto structures and muscles. This can show itself as having pain or discomfort on the anterior part of the hip, which we will see through looking at something called the conjoint tendon, and the two muscles that form it. The Transverus Abdominus (TVA) and the Internal Abdominal Oblique (IAO) are two important intrinsic core muscles that are responsible for lumbar spine stabilization, pelvis, and ribcage positioning and stability, forceful exhalation, and transferring force to and from the limbs. The TVA, along with the psoas, interdigitate with the diaphragm, making them inexplicably connected. As we inhale, the TVA and IAO are eccentrically loaded, as they oppose the diaphragm in action, putting them in a position to be more able to contract and often time stabilize. The TVA and IAO also come together to form the conjoint tendon which runs down towards the pubis. This tendon is fascially connected to the iliopsoas complex.
This fascial connection between the conjoint tendon and the iliopsoas can be used to help describe how proper hip flexion occurs when we are moving off of a stable and stacked core. Oftentimes people have poor breathing mechanics, flared ribcages, and anteriorly tilted pelvises, which set the stage for a poor build-up of IAP. When that happens, we can't get a full inhale, can't build sufficient IAP, can't properly load our core musculature which allows our hip flexors to move off of a stable core, possibly causing some sensations of discomfort through the front of the hip due to a lack of force being buffered centrally. Now, let's get back to core bracing. Core bracing involves using our breath to manage intra-abdominal pressure (IAP). As our diaphragm descends on inhalation, the volume in our abdominal cavity decreases, and pressure inside it increases, creating a closed container of pressure that our musculature can use to act on to stabilize the spine, transfer force to and from the appendages, and resist movement. On inhalation, the TVA and IAO are both eccentrically loaded, as they functionally oppose the diaphragm by being forceful exhalers. Being that these muscles form this tendon, once they are loaded on inhalation with an increased IAP, it sets the stage for hip flexion to commence, utilizing the pressure and tension built up to produce force. If we tend to fall into positions where we have flared ribs, an anteriorly tilted pelvis, and an inability to get a full inhalation, we won't be able to load these musculatures as efficiently, create sufficient IAP, and thus not allow our hip flexors to produce force in as efficient a manner as possible. If this happens, it is possible that we will have pain, discomfort, or tightness in our hip from improper loading or from our body sensing instability, causing it to reflexively tighten to limit movement.
From here on out we will talk about strategies for both scenarios - one for true hip flexor tightness, and one for improving core bracing and positioning. If 2/3 of the previous tests come back positive, this would leave us to believe that the hip flexors may be hypertonic, limiting the potential for a full excursion through hip flexion and extension. If we have limited hip extension, here are a few strategies that we can use to help regain that ROM.
Inhibit the hip flexors: If you are/have a manual therapist on hand, doing some sort of manual therapy to the Quads/Hip flexors can help decrease tone in those muscles and help set the stage for the hip extensors to produce force (Images 1&2). Working the TFL and even the lateral border of the Iliacus muscle can all be fairly easily achieved with a foam roller, lacrosse ball, or your own thumb. To target the TFL and Iliacus, find the pointy bone on the front of your hip called the ASIS. To get the TFL, go to the outside of the ASIS and press on the muscle that is there (Image 3). Turn your leg in and out to work it a little deeper. To find the Iliacus, go to that same bone, but instead, fall on the inside surface of it (Image 4). If you drop in half an inch, you will feel the belly of your Iliacus. Press it against the inside of the bone and flex and extend your hip.
Half-Kneeling stretch/Couchstretch: The leg that is being stretched is the down leg. Get your knee under your hip, engage your back toes on the ground, keep your ribs down and pull your butt down towards the back of your knee (Image 1). To increase the intensity of the stretch, shift your whole body forward (Image 2) while keeping your ribs and pelvis in line with each other. Images 3 and 4 show common faults while in this position. Keep your torso tall and don't arch excessively in your lower back. Image 5 shows a more advanced version of the stretch where you use a bench or a high box to put your foot on instead of having it be on the ground. The same principles apply as above.
Facilitate Hip Extensors: Now we want to activate our hip extensors. These do the opposite movement of what the hip flexors do. Now that we have inhibited the hip flexors, we want to give some permanence to the new length we achieved by getting our hip extensors to activate. This will also further help to decrease tightness in the hip flexors by a process called Reciprocal Inhibition. First, we want to start with the hamstrings. The hamstrings are the primary muscle in gait that bring the hip from flexion into extension. They also help set the stage for the pelvis by posteriorly tilting/maintaining a neutral pelvic position. Image 1 Shows a hamstring glute bridge on a bench. These will all be held for around 8 deep breaths w/ slow exhales through pursed lips. Go into a 90/90 position as shown with your feet up on a bench. Reach your arms up to the ceiling, bringing your upper back into the ground, while also keeping the lower back on the ground as well. From here apply heel pressure into the bench bringing your knees to the ceiling. Hover off of the ground so that your lower back is still on the ground. You can then progress this to the floor if the bench is too easy (Image 2). Next, we will get the glutes involved. Starting with the same cues as above you will hover off of the floor using your hamstrings. Once there, begin to bring the bottom of your glutes to the back of your knee, squeezing the glutes to do so bringing the hips towards the ceiling (Image 3). You should feel your glutes light up like a Christmas tree. Lastly, to add a layer of difficulty, we will do them single-legged. First, we will just tap one leg on and off of the bench for the duration of the breaths and then switch legs (Image 4). After that, we will hold the leg straight out instead of tapping (Image 5). For both of the single-legged versions, try not to rotate through the hips or torso. Load that one leg as much as you can and keep things in line as if you had 2 legs down.
Load and Go: Now that we have the sensorimotor competencies of what it is like to feel our hip extensors, it's time to load them and create long-lasting effects. We will look at the sled push, Dumbbell RDL, and Glute-focused hyperextension.
Sled Push: When done right, this is a great drill to train hip extension. We want to start in a position where our arms are locked out strong and our torso falls between the arms, as shown in Image 1 Row 1. When pushing the sled, you want to push off of your toes and fully straighten out the back leg so that you can draw a straight line from your hip to your foot. Also, be sure to land on your toes on the front foot to allow for a continuous toe-off for the next stride. Common mistakes in the sled push are starting with your arms completely bent (Image 2 Row 1), being too rounded through the back and not extending your pushing leg enough (Image 3 Row 1), or arching too much through the lower back and bending the neck up too much (Not shown).
DB RDL: The DB RDL is another great way to train hip extension and can be loaded up a substantial amount. Hold the dumbbells at your side, make sure that your ribs are down and that you aren't arching through your lower back. Imagine bringing your pubic area towards your chest (don't flex your lower back too much) (Image 1 Row 2). From there, slightly bend the knees and push your hips back like you are going to open a door with your butt and lower the weights down to the ground, not moving the spine at all and keeping the knees in the same position as we started (Image 2 & 3 Row 2). Stand back up by pushing through the floor and squeezing your glutes bringing your hips forward again. A common mistake with the RDL is overarching at the lower back to "feel the hamstrings more" (Image 1 & 2 Row 3). This puts the hamstrings in a bad position to produce force and loses their function of controlling the pelvis in space by keeping it under the ribs. Another common mistake is to do a stiff-legged RDL, which is a different exercise altogether (Image 3 Row 3). This includes keeping the knees as straight as possible instead of letting them bend a little.
Glute-Focused Hyperextension: You can do this on a 45-degree hyperextension, or on a GHR as shown in Row 4. Position yourself on the implement so that you are comfortable and so that not too much tension is going through the knee. Squeeze your glutes as if you were going to bring them to the back of your knees (Image 1 Row 4). Hold that position and let your torso bend forward with control (Image 2 Row 4). Bring yourself up using your glutes, squeezing your hips into the implement. A common mistake on this is to arch your lower back and to use that to move you through space (Image 3 & 4 Row 4). Have your back be neutral and have the movement come from the hips instead.
Next, we will talk about breathing, building IAP, and bracing. When teaching this to people, I like to talk about 3 things.
Setting the stage for success: Learning what a stacked ribcage over a neutral pelvis looks and feels like
360 breathing and how to expand the lower ribs and increase IAP
Musculature contraction on top of a stacked ribcage and built up IAP
Setting the stage for success Building IAP and being able to produce and resist force will go a lot further if we have a basic understanding of what it feels like to keep your ribcage stacked over your neutral pelvis and maintain it through movement. Why is this important? Your diaphragm works best when your ribs are stacked over a neutral pelvis. When there is a drastic change of position, it changes the resting length of the diaphragm, as well as the trajectory of the diaphragm when it contracts, potentially limiting its excursion through inhalation and exhalation. It also changes the resting length of other stabilizing musculature, puts excessive force on certain joints, decreases the efficiency of force transfer, etc. To help get into this position, try and shift some weight back onto your heels. Imagine that there is a point where your ribs meet your abdomen and another one on your pubic area. Try and gently bring those points together. Sinch your ribs into your abdomen and tuck your butt under your ribs like you are holding a credit card in between your butt cheeks. This will help you find a neutral ribcage and pelvic position. We don't want to be excessively curled under in either the ribs or the pelvis. Common postural things that we see are people who have an excessive arch through their lower back (Image 2), have their chest up really high (proud chest) (Image 3), or a combination of both (Image 4).
A good way to help feel this in action is to do a curl-up. Lay on your back with your knees bent. Your lower back should be able to fit your hand under it between the ground. From here put your arms at your side, breathe in, contract your core like you are going to protect your some from being hit in the gut, and bring your hands towards your heels by raising your upper back off of the ground. The tension that is built doing it must be maintained through the set. When you come back down don't let up and relax.
Now that we understand what it means to have our ribcage stacked over our pelvis, let's talk about breathing while in this position. When it comes to taking in a breath, we want to think about doing 360 breathing. This means that when we breathe, we want to expand circumferentially through our ribcage and abdomen. A really simple way to feel this would be to take your hands and clasp them around the sides of your lower ribs (Image 1). Apply inward pressure with them to provide resistance for your breathing. Take a inhale through your nose and separate your hands (Image 2) and then exhale through pursed lips all of the air out. You can also get a resistance band, wrap it around you and inhale (Image 3), trying to expand the band to provide a bit more resistance circumferentially (Image 4). With practice, as you inhale through your nose you should be able to feel everything expand in a full inhalation.
Once we have this down, next we will look at getting a musculature contraction on top of that breath, and using exhalation to control how much pressure we have built up in conjunction with that contraction. A major part of managing a brace is being able to use your breath as a means of controlling how much pressure you want built-up/turning that pressure into force output. This includes being able to take breaths with a fully engaged core. We will go over a few progressions of exercises, from easy to difficult, that will help you 1) Feel your core contract 2) Practice breathing with a contracted core, and 3) Manage pressure with exhalation through pursed lips. With the following exercises, we want to make them as difficult as they should be. We will be working from the most regressed positions to the most progressed positions, often increasing in difficulty. In order to make sure our effort matches the difficulty of the movement, we should remember that we don't want to put the same effort into creating a brace as we would with a max weight squat with our supine 90/90 position. We will be able to modify the level of difficulty with the control of our breath through pursed lips, and the level of muscular engagement we allow for each exercise. Supine 90/90 + band as progression
The first one that we will look at is a supine 90/90 position. For this, we want to create a small space between our lower back and the floor and raise our knees to be stacked over our hips, and reach our hands up to the ceiling, like we are going to touch it. From here we will breathe in through our lower lateral ribs, engage our core by sinching our ribs down, and exhale. As we go through our breaths we will breathe in on a contracted core.
We will then add a band to the mix. Tack a light band off on something above your head that is stable and hold the band with your hands in the same position discussed above. This will provide some resistance for us and will require our serratus and obliques to engage to stabilize our torso from being pushed into extension from the band. Same cues as above to maintain position (Image 1).
Deadbug: For this exercise, we will start off in the same position as we did for the supine 90/90. From there, we will, without changing torso or spinal position, control one leg down and the opposite arm down. Be sure to not let the back arch as you're controlling it down. This will be the first movement we do that will challenge your ability to truly manage IAP. After you take your breath and contract on top of it, use pursed lips and exhale, further engaging your core as you lower your limbs down. When you bring it back up, do it with power and control, further breathing out more air. Re-breathe and do the opposite sides. As you progress you can hold your exhale for more than one rep. To add some for the upper body, you can use a band like in Image 1.
Hollow Hold: We will start in a 90/90 position again. From there, we will lower both legs and both arms towards the ground, being sure to not let ourselves arch through the back (Image 2). Use the same cues of breathing and bracing as you control your legs down. Hold this position for as many DEEP breaths as you can before you feel your form give. It may only be for 4, but eventually working up to around 10 will be easy. Keep your legs straight and ribs sinched into your core and remember to breathe during it.
Bear Hold/Alternating hands/Legs/Both
Bear Hold: For this next one we will go into quadruped position. Stack your shoulders over your wrists and your hips over your knees. Be sure to engage your toes into the ground (Image 1). Push your palms into the floor and retract your upper back to the ceiling and position your lower back in a way where you aren't too flat or overarched. A tennis ball should be able to gently sit there. From breath, brace your core, lift yourself up, and hover your knees right above the floor (Image 2). Hold this for deep breaths, making sure that we don't lose our muscular contraction and that we are fully exhaling. To progress this movement, we can alternately lift our legs (Image 3), lift our arms (Image 4), and then lift opposite arm and leg at the same time (Image 5). When doing this, we want to fully load the supporting limb and try and limit any deviation of your Center of Mass too much. Try and stay in the same position as you started in as best as you can. This is VERY tough.
Side Plank/Copenhagen Plank
Side Plank: Lay on your side as shown in Image 1. Be sure to not shrug your elbow that is propping you up into your ears, and don't have it be too far out in front of you. Lift your hips off of the floor, reach your top hand up to the ceiling so that your torso is suspended in the air by your feet and forearm (Image 2). When here, be sure to push into the ground with your forearm and bring the top ribs to the ceiling. Breathe into your top ribs through your nose, and then exhale through pursed lips, not letting yourself dip down to the floor. As you exhale feel the bottom ribs come together, engaging your obliques. Hold this position and do it for breaths. If you feel that your torso or pelvis is rotated too much to the ceiling or to the floor, correct it by imagining a wall in front of you and you were trying to be parallel to it.
Copenhagen Plank. This is a plank variation where instead of your feet being on the floor, your top foot is on a bench and your bottom one hangs down. We will set up similar to the plank, but instead with our top leg on a bench. To make it easier at first, start with having your knee be the contact point on the bench (Image 3). When lifting your body up in the air, be sure to apply downward pressure from the top hip, and upward pressure with the forearm on the ground. Bring the top ribs to the ceiling just like in the plank. Support yourself with your top legs adductors and bottom forearms side obliques. If this is too tough, you can keep the bottom leg on the floor to help support you at first. If it becomes too easy, go further out so your contact point is on your foot/ankle (Image 4). If you start to feel inside knee pain, you are probably not pressing into the bench right with your leg. Make sure that you are engaging from the inside of the hip, and not the inside of the knee. Imagine if you were going to try and bring your foot across your body as if you were drawing a line in the sand with your foot. Have it come from the hip.
Split Stance Paloff w/ Rotation
For this, we can use either a cable machine with a U handle or a resistance band tacked off on something (Shown below). Grab the band with both hands and face 90 degrees from the attachment point. From here go into a stationary split squat position with your front leg being the leg on the opposite side from where the band is attached. Lower yourself in the split squat position, push the band directly out in front of your sternum (Don't forget our cues to keep the point on the front of your chest close to the pubic area and vice versa). Breathe, brace down, and rotate your torso away from the attachment point (If you are attached on the R, turn your torso to the left going past your forward leg). Maintaining your contraction and brace, return back to your start position with control and re-breathe.
For this exercise, remember to move from your core and not with your arms. Feel your obliques as you turn your torso and maintain your core brace.
Hanging Leg Raise
When doing a hanging leg raise you can use elbow straps that hang from the bar or hang from your hands. The benefit of hanging from the bar is that you can focus on your ribcage and pelvic positioning without worrying about grip and shoulder blade strength. You can also use the straps to further lock the scapulae down, providing an easier way to retract your ribcage during the exercise. Eventually, working to do it hanging from your hands will be a good way to challenge shoulder ROM, stability, and grip strength. To get into your starting position, get onto the bar in either the straps or with your hands. When hanging, bring your scapula down towards your back pocket, effectively pulling yourself a little higher in the air as if you were doing a scap pull-up. Torque your hand against the bar using your shoulders, bringing your pinky into the bar and your thumb into the bar. This will help engage your lats and rotator cuff to help stabilize the shoulder. Brace your ribs down by exhaling and keep your pelvis tucked. You should feel your core engagement here. This starting position may be enough for right now. Stay there, maintain your muscular contraction, and breathe (Image 1). Image 2 shows hanging with no engagement, excessive shrugging in the shoulders, and an arch in the lower back.
To do the leg raise, you can either keep your knees bent (easier- Image 2) or straighten them out (harder - Image 3). Bring your knees up to your chest or your toes towards the ceiling after you have already braced your core. On the way down, don't let your back bend. Keep the position all the way down.
Last but not least we have the ab wheel. If you don't have access to a wheel you can use a barbell with plates on it, or even a rag on a wood floor could do. Anything that you can hold on to with your hands and slide around should suffice. Start on your knees with your hands on whatever implement you have. Keep your toes engaged in the ground. Start with the implement close to you, pushing your palms into it, keeping the ribs down, and your butt tucked to neutral. Push the implement out in front of you in a way that will let your torso come closer to the floor and your arms going above your head. When lowering yourself down, don't let your ribs flar up or your back arch. Keep the starting position the whole way through. To come back up, use your lats to pull the implement back to starting and your core to help control you back to where you started. If you notice you are losing position, stop that set and rest for the next one. Remember to breathe and brace.
Once we can perform these movements to a high level, we can be fairly confident that we have the proper skills to manage a brace through dynamic movements. These movements should allow you to feel your core muscularly contract, give you practice with managing IAP with coordinated breathing, and teach the basic principles of maintaining general positioning of the ribcage and pelvis. These are tools and not the end all be all by any means. In most sports/movement endeavors you will be required to get out of these positions because sport and movement are very dynamic. But having a home base is important to come back to so when we need to fully extend to catch a snatch, fend off defenders on the field, or throw a 90mph strike, we can come back to the reliable positions that allow us to re-stabilize and produce sufficient force to get our tasks done. We hope that you enjoyed this content and find it useful. Remember, this is not medical advice and if you are experiencing pain or discomfort, or need a better eye for assessment, consult your coach, pain management practitioner, or doctor.