Managing Hip Impingement: Making Progress with Strength Training

This post is part two of a series on hip impingement. Read Part 1: Managing Hip Impingement: My Injury and What Didn’t Help.

After almost two years of mystery nerve pain, finally receiving the correct diagnosis completely redirected the trajectory of my recovery.

Switching directions

To recap where I left you: after the hydrodissection, I had constant, burning pain in a line stretching through my low back, hip, thigh, and calf, tracing the path of the sciatic nerve. I was having difficulty sleeping, sitting, and working, and even mild activity such as bike commuting would flare the pain for days. I fell into a bit of a depression because I was forced to remain sedentary, increasing my anxiety and triggering an identity crisis. When Dr. Yen realized, upon re-evaluation (four months after the fateful procedure), that I presented signs of hip impingement—which manifests in poor hip alignment and collateral nerve compression—I was at first excited to have a diagnosis. No one prior had been able to definitively explain where my pain came from. However, a Google search quickly alarmed me. The internet, which always floats the most extreme examples to the top of your feed, told me that I’d need invasive surgery, would have to cease activities that caused pain (i.e., everything), and that my life would need to be severely modified.

Dr. Yen suggested that I continue physical therapy to attempt to manage my hip impingement without surgery and recommended Sarah Haran’s practice. Feeling like I was out of options and exhausted by the thought of initiating treatment with yet another provider, I reluctantly looked up her practice. Five days later, I arrived at Dr. Haran’s clinic for my appointment without much hope. I had been disappointed so many times by doctors and therapists who had assured me that I’d be running in no time, only to experience no change, or worse, more pain.

I’ll jump ahead to present day to say that I’m not yet completely healed. I still am not able to run or put in long days in the mountains, and my symptoms have not yet subsided to pre-hydrodissection status. However, within a month of being diagnosed with hip impingement, I improved enormously. My pain level is down and I have begun to reintroduce some of my normal activities.

Confirming the diagnosis

Dr. Haran started with an evaluation to see how my hips were moving and very easily confirmed the hip impingement diagnosis: my glutes were not only weak, but my brain had ceased to even recruit them during certain movements. This left my hip flexor group overworked, pulling my femur too far forward in the socket and causing inappropriate contact and pain between the femur head and my hip socket.

This hip imbalance had only directly caused me minor pain — pinching in the front of my hip during extreme hip flexion or steep uphill hikes — but it indirectly caused my nerve pain, as the misalignment of my hips allowed my sciatic nerve to be smashed by the piriformis muscle. This explained why the many previous isolated procedures and physical therapy directed at my glute and nerve had not worked. The epicenter of the pain was higher up in my hips, causing aftershocks of pain in other areas where local treatments were futile.

Dr. Haran explained that our plan would be to work on 1) relaxing my hip flexors, as they were overworked, weak, and strained and 2) strengthening my glutes and training my brain to actually recruit what should be a strong, stable muscle that bears the brunt of leg activity. These together would reset the position of my hips. Although my MRI had revealed* that I also have at least mild structural impingement, Dr. Haran believes that only extreme cases require surgery: almost nobody has perfectly symmetrical and structured bones, yet most people do not have hip pain. This suggests that hip impingement is usually manageable with proper muscular mechanics alone. However, since my primary symptom presented as nerve pain (not hip pain), Dr. Haran explained that we’d have to be careful to strengthen my glutes while avoiding aggravation of my nerve, which complicated my treatment plan. To begin this process, she prescribed various at-home exercises designed to relax my hip flexors and strengthen my psoas and glutes while avoiding large ranges of motions or positions that would flare my nerve pain.

 *Just a note that general MRIs are not appropriate to diagnose hip impingement or labral tears. These diagnoses require specific MRIs that are targeted to image your hip joints, and in the case of labral tears, hip injection with dye is needed. I happened to have a pelvic neurogram to image my nerves, and my doctor was able to notice both CAM and pincer impingement as a secondary observation. My hip impingement was formally diagnosed with functional tests, not imaging.

Importantly, Dr. Haran taught me that many of the exercises and stretches I’d been repeatedly prescribed actually exacerbate hip impingement symptoms. In fact, she said hip impingement is typically not managed well by physical therapists who do not specialize in hips (even if they are experts in other areas), and almost all of her patients come to her after months or years of being assigned unsuccessful and even harmful exercises.

In my case, almost every provider I had worked with had prescribed intense hip flexor stretches and yoga, where I’d continuously try to coax my hips into positions that I now know are inhibited by my bone structure, not inflexible muscles. She told me to completely stop stretching my hip flexors. Her philosophy is that hip flexors become tight and painful because they are overused and weak, and that not every painful muscle needs to be stretched. I quickly abandoned my routine front leg stretches and decided to quit yoga, which I had been practicing as a replacement for my other lost activities. To be clear, I’m not advocating that everyone with hip impingement abandon yoga if they love it — but you will have to modify or eliminate positions that trigger pain.

At the time of this first appointment, I was still experiencing near-constant pain, and for some reason my historically unproblematic left leg also began to flare in a sciatic nerve pattern. With the initial (unexplained) irritation caused by the hydrodissection followed by four months of constant (and incorrect) physical therapy, I think my nerves and surrounding tissue were caught in a positive feedback loop of inflammation and pain, never having the chance to relax, rest, and decrease swelling. My nerves themselves (and their feedback pathways to my brain) were extremely overstimulated: I had been starting to feel not only the burning and periodically electric pain, but the nerves in my legs had begun to vibrate, hum, and twitch involuntarily, which added to my anxiety as I felt that I possibly had a more serious neurologic problem. Mentally, I was extremely anxious and hyper-aware of any nerve sensations, causing me to both notice and expect constant pain. Every time I experienced a pain flare, I would fall into a negative spiral, knowing that my progress was once again set back.

Week one

I began the exercises, not expecting any positive changes, and returned for a follow-up appointment a week later where she fine-tuned my exercises. I still felt rather depressed and skeptical that I’d get better, but I did feel somewhat hopeful about Dr. Haran. After years of frustration at the vague hypotheses about the origin of my pain, it was clear that I definitely had hip impingement. Her blog posts exactly described my experiences, and I felt hopeful that this new treatment plan wouldn’t simply be another iteration of unsuccessful regimens. Dr. Haran actually mentioned this mental phenomenon. She explained that since her practice has successfully treated a high volume of hip patients, she and her other therapist, Dr. Beth Ansley, operate very confidently, which begets trust from patients. I hadn’t conceptualized my newfound optimism in this way, but it made sense. I believed her.

Week two

About two weeks after the initial appointment, I realized that my leg hadn’t been hurting constantly. I was actually shocked. I hadn’t expected any improvement, so I hadn’t immediately noticed the subtle improvement. Additionally, the constant nerve vibrations, twinges, and muscle twitching had stopped, as had the newly onset left leg nerve pain. This first small win boosted my morale and relaxed me, slightly, about the whole predicament.

I also started acupuncture and structural body work massage with two additional providers. Although I’m quite the skeptical scientist and am wary of any more spiritual, less evidence-backed alternative medicine (there is scientific basis for acupuncture), I understood that my pain was not an isolated issue and that it required holistic bodywork. I was so anguished about my inability to exercise or do what I loved that my pain monopolized my mental and emotional focus, and I knew I needed to physically and mentally relax. My incremental physical improvement coupled with the support and positivity of three incredible providers began to give me hope that I might be able to recover.

Week four

My weekly appointments were extended to every two weeks and eventually monthly. After one month of hip impingement-focused treatment, I had progressed more than I had in almost two years. By this point (three appointments deep), my pain was less constant and some days were even pain-free. Dr. Haran noted that my hip flexors reacted more appropriately, as my glutes had begun to carry out their share of the work. I resumed bike commuting a couple times a week (10 miles round-trip), and although I still felt some pain, it was manageable. I had continued acupuncture and massage at the same frequency as physical therapy appointments, and much of this work focused on relaxing other parts of my body, as the opposing half had tightened as compensation for my weak, dysfunctional right side. My massage therapist worked to break down the fascia around my glute, hamstring, and IT band, working to free the nerve and muscle from the connective tissue.

Cupping leaves a mark, but it’s been helpful in loosening stuck muscles and fascia

She also treated me with a lot of cupping on both my glute and hamstring area as well as my back, as whole body imbalances had either caused my pain in the first place or had developed as a result of it — probably both. Although paying for three out-of-pocket providers on a regular basis was extremely financially taxing, I felt that the money was worthwhile if I could, for a short time, aggressively attack my injury from all directions with an interdisciplinary approach. The improvements encouraged me that the money was well spent. My health and mobility are invaluable to me, and I’m grateful that with some financial prioritization, I was able to manage these expenses on a graduate student stipend.

Week eight

By this point, time between appointments increased, creating a more manageable appointment schedule. At each one, Dr. Haran or Dr. Ansley would evaluate me, perform some manual massage or cupping, and create new exercises for me. I would then spend a month strength training with my new homework. I had now attempted a few mountain biking excursions—nothing too extreme, but I could manage a few hours of moderate biking without much pain. Even though I would experience some familiar nerve soreness the day following activity, I noticed that the pain retreated much more quickly than it would have two months prior. Instead of a four-day flare, I would feel much better after 24 hours.

Because I started to trust that the nerve pain would subside quickly, I stopped obsessing over pain twinges, which greatly improved my mood and allowed my injury to take up less of my mental energy. While true hiking with elevation gain was still too much, I could at least take my dog on longer trail walks, up to five miles. Admittedly, I’m used to much more strenuous mountain treks and “better” scenery and still felt disappointed about the alpine adventures I was missing, but I realized how even a simple trail walk boosted my morale significantly. I actively began to appreciate any amount of outdoor exercise I could tolerate, in any form, which is a lesson I am continuously attempting to practice.

Finally “hiking” with my dog again

Week twelve

I am now three months out from my first appointment with Dr. Haran, and although I’m not yet fully recovered, the progress is undeniable. I have completely resumed my daily bike commutes around hilly Seattle, and while I sometimes experience mild nerve pain on the bike, it never persists. I also managed a mountain bike trip where we spent three days biking fairly strenuous routes. Honestly, I panicked as my leg began to flare a bit by the end of the second day, but spending the third day resting in the hot springs completely revived me. I was able to put in a full day of biking the following day, demonstrating that I am now able to recover quickly. I am hoping to soon get back to multi-day backcountry trips on the bike, but am attempting to reintroduce activity gradually, where I “quit while I’m ahead,” before I actually experience pain.

It’s now almost ski season here in Washington, and last weekend I attempted my first ski tour since before the hydrodissection. Ski touring is essentially hiking uphill with a relatively heavy ski attached to your foot, so I was nervous that not only would the uphill trigger my nerve compression, but that the upward motion required by my hip flexors would reignite the old front hip pain. To be honest, I was afraid to try to ski. I’d been feeling relatively positive about my progress and was wary of the mental crash that would occur if, ten minutes in, my nerve began to throb. I managed a three mile ascent (and descent!) on skis, and although I had to bail before reaching the top, I was satisfied that I not only was able to do some amount of uphill, but that I’ve fine-tuned exactly which level of activity I can handle without resetting my symptoms or triggering extreme soreness the next day. I’m going to continue to reintroduce activity using what Dr. Haran calls a red-yellow-green light pain scale: green is great, yellow is permissible, and red is too much.

Overjoyed to be skiing uphill again

Small setbacks are frustrating. The biking excursion was manageable, yet 20 minutes on the elliptical caused soreness for days. I emailed Dr. Haran, distraught, and she reminded me that even though my recovery trajectory is upward, I will still experience smaller, intermittent backwards motion. I’m trying to remember this as I reintroduce activities. I think I’ve still got a lot of strengthening to do and running will probably be the last sport to add back into the rotation, as it was, initially, the most aggravating motion for my nerve. Although after two years I sometimes struggle to believe I’ll ever run again, I don’t see why, after continuing to strengthen and stabilize my hips, legs, and core, I won’t be able to return to my favorite sport.

I will check back in with the Salty community in a month or two and update my progress.

If anyone has experience with hip impingement, advice, or questions, let me know!

Note: I have no incentive to promote Dr. Sarah Haran except that she and her practice have helped me when no one else could, and I just want to highlight the type of treatment/provider that has worked for my hip problems. She is located in Seattle, but if you live elsewhere and have hip problems, check out the Arrow PT website. Their blog is incredibly informative and she also does remote consultations and treatment. If video conference appointments isn’t your style, I would at least contact her as she could likely recommend a specialist in your area.

I’m a scientist, environmental activist, and mountain athlete pursuing a PhD in Seattle. As a long-time runner who is currently unable to run due to injury, I’m documenting my ongoing rehab to correct hip impingement and journey to get back on the trails.

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