The hip joint is made up of the femoral head and the acetabulum. It is a very constrained ball and socket joint where the ball fits almost perfectly in the socket. Surrounding the socket is a fibrocartilage called the labrum. Some hip joints develop in life without good coverage of the cup and they are said to be dysplastic. Dysplasia can occur as one develops and the socket does not deepen but stays shallow. People with dysplasia can have earlier onset of arthritis as a result of the loss of coverage and increased contact forces that occur.
Muscles and ligaments attach the pelvis to the femur. The muscles of the hip can move the hip in all directions forward back and rotate it internally toward the midline or externally. The gluteus muscles are responsible for lifting the leg back and to the side or abducting the leg. Here is a view from the back.
Notice the Gluteus Medius and how, if it contracts, it is responsible for keeping the pelvis level when walking or running. If the maximus contracts it will pull the femur posteriorly or extend the hip joint. There are small rotators on the front and the back and then there is the iliopsoas or the filet mignon of people. It is the biggest hip flexor and can cause bursitis as it attaches to the femur. Tendonitis will also present as groin pain and pain with motion from overuse. The iliopsoas actually starts on the lumbar spine vertebrae and moves forward towards the hip joint. You can see why you need to extend the hip and back to get a great iliopsoas stretch.
The joint capsule is made of ligaments that hold the joint tightly. In order to operate on the hip and perform arthroscopy, the joint has to be entered and filled with fluid. We can then get a better picture for what is going on with our digital camera that is placed into the joint.
Labral or cartilage tears can occur through repetitive stress, traumatic events, or as a result of pathologic anatomy that can cause pain and pinching of the cartilage. Here you can see a tattered labrum that can pinch in the joint causing pain in the groin.
Repairing vs. trimming the labrum depends on certain factors like age and the condition of the labrum. A bone spur on the femoral head is called a CAM lesion and can be trimmed to prevent tearing of the labrum; a pincer lesion is on the cup side and can be trimmed also.
Things that we need to appreciate in the CrossFit world. When squatting, rotate your feet outwards the hips then rotate and allow more motion in deep flexion and prevent impingement. New clicking in the groin where something feels like it is mechanically moving in the joint is a sign of a labral tear. People can feel groin pain or pain along the side of the hip in what is called a C sign where you grab the outer side of the hip in the front and the back. Other conditions that can occur in the joint are loose bodies or arthritis. One can also develop chondral injuries or injury to the shiny smooth substance that cushions the ball or socket.
X-ray of arthritis shows the bone on bone from loss of cushion.
Here is a nice site for basic stretches that can keep the muscle around the hip and the capsule loose and flexible.
I tell my patients they can lift but they have to be careful with heavy weights. I let my patients squat and exercise again, long-distance running not a great idea. Happy to see you as a patient.
Hey Sean I just saw you on the Crossfit pod cast, I have a hip labral tear with cam and pincer impingement and have to go in for surgery I have been told that In a lot of cases the Surgery does not work to the level the athlete wants. I was just wondering what you know about this and how often people are able to fully return to sport after the surgery.
Hi Gareth, my partner does these for my group so he would have more knowledge of this. Of course, I can’t speak to your hip directly but he has had athletes return to full activities.
Hi Sean. I’m a UK CrossFitter and Master. Just read your excellent post in CF Masters and headed over here. I’ve been diagnosed with osteo-arthritis in my right hip. The options I was given were hip replacement (no running or jumping afterwards!) or an injection. I chose neither and the pain I get is hard to predict but generally builds up over time and has correlation to the volume of training I’m doing. I see managing the condition as my only real option.
Are the stretches, above, a good idea for me? Also, are there any supplements or dietary recommendations you would make? Thanks again for all the great info on here, Tom
Hi Tom I cant make specific recommendations for you as I have not examined you. Flexibility and keeping range of motion is important for hip arthritis. Also no dietary supplements have been shown to be superior to others for the cure or treatment of arthritis. Good luck with it, Sean
After having an MRI this week, I was just diagnosed with a full thickness labral tear in the anterior region of my hip labrum. Also, mild tendonitis in the gluteus medius was found. I am waiting for my appt next week to determined our orthopedic surgeons suggestions for the next steps.
I guess my question while I wait to meet with the surgeon is what do you think the liklihood of needing that anchor technique where they drill into your bone to drop the anchor holding the sutures? Looks kinda crazy…
That would be the technique if you have tried conservative management and it has not gotten better unfortunately.
I have a labrial tear I was diagnosed with 3 yrs ago. I started cf 1.5 yrs ago and started having pain in the “c” area you have described, as well as in the groin. I went for PT, and he told me to basically stop all cf movements, as my hips are very weak and I am overcompensating with other muscles. After resting a week, I only feel worse. I saw an orthopedist this morning who took new X-rays (no MRI yet), and found that I have hip displasia. He said there is no reason to stop cf, because the tear would have happened anyway, and if it got worst, that would have happened anyway as well. He said basically, I am destined for early ones arthritis, which is probably the pain I feel now, and the only thing I can possibly do is preventative surgery to help save my hip from early replacement. I am just wondering what your thoughts are on this. He said I can a any movement that does not give me pain. I am thinking squats below parallel are still not a good idea right now, being my hips are too weak and unstable to hold me I. Good form (according to my chiropractor and PT). What are your thoughts?
Most likely diagnoses are arthritis or labral tear. Agree with avoiding things that you know hurt it or that you feel later. Don’t push through pain and get it reevaluated if it is still hurting.
Hello–I came across your blog after seeing some of your posts on the CF boards. I’m a CrossFitter (and part-time coach) in DC who has been dealing with some hip issues and just scheduled hip arthroscopy to repair (or possibly reconstruct) a torn labrum and to fix Cam/pincer FAI. The pain I’ve been having seems to be coming from an ossifying labrum rubbing against my cam impingement.
Anyway, I would love to get the thoughts of a CrossFitting ortho as it has been hard to get some realistic opinions from anyone who really understands what I’m going to be facing.
Any chance you would be willing to share some realistic thoughts on recovery and when I will be able to get back to the squatting/lifting/kipping, and everything else I love so much?
PS I met your wife at the games and some other CFNE folks–sat and watched some of the masters competition with them!
Thanks so much–alissa
Hi Alissa, recovery and prognosis is often related to what is in there to begin with. If there is arthritis and exposed areas of bone then that sometimes can delay or slow the recovery process. Sometimes if there is arthritis then the pain from that can persist and inhibit further activities. If not, then the repair and shaving can take 5 to 7 months to recover from and get back to squatting. There are always modifications along the way and after surgery that can be done as well. Good luck with it, Sean
I have recently been diagnosed with AVN and currently participate in CrossFit. The doctor who originally diagnosed me immediately wanted to do bone decompression and when I told him I would like to hold off he told me that he wants me to use crutches all the time until I follow up in three months and no lower extremity workouts. The second opinion I had told me not to do bone decompression as it weakens the bone and ultimately I would need a hip replacement anyway so continue exercising with modified WOD’s and just wait it out. He said it was idiopathic and he has seen cases where it reverses. He also said it was not definitive AVN and could possibly be changes in my bone structure due to my young age (35). One of the coaches at my box is also a physical therapist and wants me to do osteogenic exercises in hopes to reverse it. I plan on getting a third opinion just because these docs opinions and treatment plans are so different. Do you have any suggestions or have you worked with AVN patients? Just trying to gather as much info as possible as this does not appear to be widely known……
Yes I have worked with AVN, it’s a complex issue that can go either way, I have seen things improve and I have seen them go on to hip replacement. Decompression can be performed as long as it has not collapsed. As far as you personally I would have to see your studies and examine you to make a better more informed statement.
Sounds like a labral tear to me, disarticulation of hip would be a stretch ni my opinion. You should see someone about a hip labral tear, orthopedist who does hip arthroscopy. Take care.
I have been an athlete and active CrossFitter for nearly four years, and I LOVE to squat. With that said, I recently started experiencing an uncomfortable “clunking” sensation in my right hip when squatting below parallel (in the groin/hip flexor area). I potentially also have bilateral hip dysplasia (mom also has this, recently had hip replaced at age 63), viewed in an Xray after a back injury in 2011.
The Clunk began with a pain in the same hip flexor/groin area (2 ½ weeks ago, after a heavy back squat session) which has since subsided, replaced by this nagging Clunk. It began as a big Clunk, and has now subsided to a small clunk. It happens whether under load or not, whether moving slow or fast, whether air squat, wall ball, thruster or heavy squat. While not painful, it gave me pause, so stopped going below parallel, and figured I’d modify for a while and rest the joint.
Finally, after 2½ weeks, I saw my chiropractor, who informed me that I should never squat below parallel again, and that further squatting could result in a disarticulation of my hip (not appealing). Understandably, I’m pretty upset and freaked out, but also definitely seeking a 2nd opinion, and preferably from a fellow CrossFitter!
Sorry for the long post. I’m trying to stay optimistic! I welcome any response you may give. Thank you Dr. Sean!
A few days ago I noticed a pinch feeling in my right hip flexor as I was warming up doing squats holding a kettle bell. I decided to lay off it and forgot about it until 2 days later when I noticed the pain again warming up with med ball squats. I then realized that I also felt this pain when lifting my right leg and resting it on a higher object (think Captain Morgan.) It has been 5 days and the pain is still present despite laying off of it, icing, and only working out once this week with modified movements. The pain is not severe, but I don’t want to injure myself further. Before this pain I had been squatting a lot more often and did sprints last week. Any idea what this could be and how I should take care of it?
Hi krystle, hopefully just a hip flexor tendonitis as you started something new this can happen. Activity modification for 2 to 3 weeks Then let me know, if u want to come in. Sean
Sean- I’ve been feeling a sharp little pain in my right hip flexor area the past couple days. I didn’t notice anything “happen” but on Saturday I was warming up and did a squat with a kettle bell in hand and first felt the pain. I decided to lay off it and then on Monday I had forgotten about it and squatted during warm up with a medicine ball and felt it again. I also feel the pain if I lift the right leg up to rest it on something. I don’t feel it during air squats. I’m going to continue to lay off of it. What do you think it could be and what should I be doing to care for it?
Good question, there are studies showing that younger people wear out their liners faster than older, presumed to be related to activity level. The liner is the plastic that is between the socket and the cup. There are no definitive studies saying that increased activity increases the wear rate. Most joint replacement surgeons agree that running is more likely than not to accelerate the wear of the liner. So it is rare for a surgeon to endorse running after joint replacement. The risk is entirely up to you. In my opinion, Crossfitting can certainly be done. Running long distances like marathon just does not make sense to me after a joint replacement. Shorter distances are ok in my opinion and certainly cross fitting with modifications
Thanks. I probably should have mentioned that both hips are metal-on-metal. When the first one was replaced, the surgeon tried several liners, but thought the best fit was none. The surgeon who did the latest replacement said that since the first one was doing well, there was no need to change. I was a good candidate for metal-on-metal. I agree with you about running, that’s one area I haven’t been able to master. Runs longer than a 5K cause a lot of discomfort. Fortunately the coaches only have us attempt that distance once or twice a year. I can also opt for a shorter distance and finish with rowing.
Once of my karate instructors had both hips replaced as a child. He has not had a revision and it has been 20+ years. While he doesn’t run, he was proof to me that being fit might help in the long run.
I just had my right hip replaced in Feb. I had the left one replaced in 2004. I am 50 years old and started crossfit in 2011. They had to be replaced due to a vascular necrosis. None of the doctors or healthcare providers are cross fitters. They are trying to persuade me to stop cross fitting. Their belief is that the implants will fail much more quickly. Is there any evidence cross fitting will be detrimental? I plan to return after I clear my hip precautions and scale the WODs. My coaches are all very well aware of my situation and worked with me last year. What are your thoughts?
Pretty much anything that hurts while you are doing it or right after, so there should be some experimentation. Good luck.
Hi Dr. Rockett,
I’ve really enjoyed and found great use from your blog. I’m having a hip issues that has started recently, and from all the symptoms that I have read about, it sounds like burcitis. It is my left outer area of the hip. I seem to have movement just fine when bending my legs, however, if I stand straight up, keeping my left leg straight and raising it, at approximately 1 ft. or less off the ground, I get a very sharp pain in the outer area of the hip. Stretching certainly helps, but I’m avoiding squats, box jumps, etc.. (anything with hard impact on the hips).
My question is if this is Burcitis, does it go away on it’s own usually, or does that type of injury require surgery/invasive therapy, etc..?
Thanks so much.
Chad, That sounds like an abductor tendonitis. The abductor muscles come down from the pelvis and attach on the outer aspect of the hip. Although a bursitis and abductor tendonitis can be very similar in their symptoms and their examination, both can get better with modification and a bursitis sometimes benefits from a cortisone injection.
Thanks so much for the advice! I’m going in for a visit with my physician next week. In the meantime, should I stay away from certain movements? I have alot of pain doing situps, so I’m not doing those.
This is really useful information, thanks for sharing it Sean! Since so much of what we do in CrossFit involves hips, its almost impossible to push through WODs with a hip injury, and things can go from bad to really bad very quickly. If anyone has a labral tear and wants to talk about what surgery is like, rehab, getting back into CrossFit, etc, feel free to email me at firstname.lastname@example.org. Been there 2x, and happy to share my learning.