The hip complex is often a source of running injury and inefficiency. The cause of a running injury is often found in an area distant from the actual pain of the injury, and many running injuries are misdiagnosed due to the failure of not looking at the whole body and how it moves or doesn’t move. Failing to evaluate the hips of a runner often results in unsuccessful running injury treatment. Research has shown a correlation between gluteus medius weakness and iliotibial band pain (Fredericson et al.i). Taking a closer look at the running stride (through 2D high speed video running analysis) has objectively shown us how hip weakness can lead to overuse injuries in the knee, lower leg, ankle, foot, and low back as well.

The complexity of the relationship between the hip and pelvis while running deserves explanation. A delicate balance exists between the muscle length and muscle strength of the hip flexor and hip extensor muscle groups. When this balance is compromised (through pelvic level asymmetries, weakness, muscle tightness, joint stiffness) compensations subconsciously step in to enable us to run. These compensations, however, predispose runners to overuse injuries. Because each running stride results in a force 2.5 to 5 times greater than our body weight, subtle postural and strength asymmetries must be identified and addressed to effectively prevent or treat running injuries. An efficient, pain-free running stride begins with flexing the hip, but is complimented by hip extension of the opposite leg. While hip flexion initiates the running stride, hip extension provides the power needed to propel us forward efficiently. A delicate but crucial balance of postural symmetry (right and left sides of the pelvis), joint mobility (prolonged sitting shortens hip flexor musculature which may limit necessary hip extension), and strength (gluteal, hip, quadriceps, hamstrings, lower abdominals) must all be sufficiently present to allow the hips of a person to run mile after mile without pain or compensations.

It is important to understand the role our modern lifestyle plays in running injuries. Modern day humans sit way too much. Our ancestors did not experience the high incidence of running injuries we do because they were on their feet and constantly moving to support their subsistence lifestyle. Our hip flexors become tight and shortened with prolonged sitting. Our pelvis tips anteriorly with prolonged sitting, and the hip joints become compressed. The forward tilt of the pelvis due to tight hip flexors increases compression in the lumbar spine and inhibits the lower abdominals in their attempt to stabilize our core. Our gluts are overstretched and become dormant while our hamstring muscles shorten, making it difficulty for our gluts to extend our hips. Basically, our modern-day lifestyle predisposes our hips to dysfunction and necessitates proactive action on our part to make sure we are as mobile and strong as possible.

Addressing hip dysfunction (tightness, overuse, weakness) is not as simple as stretching your hip flexors. A thorough examination of a runner’s movement patterns, strength, and a video running analysis will collectively reveal the role the hips play in a particular running injury. Manual therapy is an important diagnostic and treatment technique to restore necessary hip joint motion and to release excessive muscle tension secondary to compensatory muscle use. Targeted strengthening exercises, muscle energy techniques, active stretching instruction, myofascial release techniques, and dry needling are among the skilled treatment techniques performed by physical therapists which can lead to tremendous results.

So the next time you are out running the trails or roads, take a minute to appreciate the reciprocal, efficient work being done by your hip flexor and hip extensor muscle groups with each stride.
John Fiore, PT
Sapphire Physical Therapy

i Fredericson M, Cookingham CL, et al. Hip Abductor Weakness in Distance Runners with Iliotibial Band Syndrome. Clin J Sport Med. 2000; 10(3): 169-175.

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