Overactive hip flexors

I've just seen a 21yr old female dance student (of Caribbean origin) who complains of slight ache around her right hip/hip flexors and a feeling that right hip often wants to 'bend inwards' (flex) when dancing.

• ROM - all full, slight ache in right hip flexors at eor hip flexion
• Strength - all fine except hip ext rotation, in prone, which is markedly reduced compared to all others, still very functional but a potential problem as a dancer.
• Hip flexors clearly very dominant on active hip extension and external rotation in prone, R & L.
• Well developed quads and glutes (?genetic due to origin) - played competitive football age 8-16 and danced for 10 yrs.
• History of knee pain due to patella sitting high due to tight quads - resolved by stretching quads (1 yr ago)
• Posture - Very slight pelvic rotation to right, all else normal.

I'm reasoning that she has overactive hip flexors but am not sure where to go with this - any suggestions? I've so far gone with relaxing hip flexors using a nobber and self-massage and ext hip rotator strengthening in prone with theraband. Does that sound OK? Any other suggestions? I don't have loads of experience and haven't seen this before. Thanks everyone :)

Important thing to check is psoas involvement. Get the patient to hold hand behind head and see if they can actively hip flex beyond 90 degrees and hold it there. Early fatigue or spasm may mean increased tone (overactivity) of hip flexors due to overuse/strain. The hip flexors although appearing tight, may simply be overactive or spasming due to weakness. If this is the case they would need to be re-strengthened especially above 90 degrees of hip flexion

You say you tested strength, how did you do this? Did you test hip flexion strength in supine? In supine get the patient to lift leg to 45 degrees, laterally rotate leg and resist against a steady push from you down and out at about 30 degrees. Weakness in the hip flexors usually means tightness of the sheath of the muscle, fascia. Lateral rotation weakness probably indicates piriformis tightness. The above 2 muscles (psoas and piriformis) are very common problems in dancers as there is a lot of work done into flexion and lateral rotation, ballet dancers in particular. Also you must realise that tightness of one muscle sheath often leads to weakness of the antagonistic muscle, so hip extension can be weak, tested in prone with knee flexion. If hip flexors are dominant as you say, then I wwould believe she has fascial shortening of the iliopsoas and other hip flexors. If her pain is in the hip flexor area, anterior, then it is likely a result of compensation for weak abductors, or a direct result of hip flexor tightness/weakness. Most pain occurs in an area where we compensate, very seldom in the original area of weakness/tightness. My suggestion would be to re-test strength using long levers and muscles in their inner range, so as to expose weakness easier. She is a dancer and can be relatively strong, but muscles do not lie, so put them in their weakest range and test. A muscle should be relatively strong in all ranges. Any tightness would require myofascial release approaches, as stretching will only maintain what is there. Exercising will also only lead to further tightness.

Knee pain is also an indication of hip muscle imbalance, where quads compensate for weak hip abductors/extensors, so she obviously has a history of hip imbalance before this condition. I would focus on restoring hip extension ROM. I test this in supine, one leg off the edge of the plinth, the other flexed and held in full flexion by the patient to neutralise the pelvis. The leg hanging off the plinth should drop well below the level of the plinth into about 40 or so degrees. If not, psoas is tight, thus weak.

Hi Folks,

Overactive hip flexors is a really common problem among dancers, as so much of what they do requires high leg extensions to the front, back and side. There may definitely be shortening and tightening of the Psoas and also overuse of Rectus Femoris, however it is important to work out why she is overusing these muscles. Many Ballet dancers mistakenly overuse quads instead of deep turnout muscles (eg. Quadratus Femoris).

Once you have checked for tightness with Thomas test (as Physiomitch suggested), it's well worth checking her range into external rotation with the leg in a neutral position. Compare her passive to active range in external rotation and find out what she feels she is using to move into that range. (It will probably be hip flexors!).

Checking her posterior hip for tightness you may find tightness in Post Glut Med, Piriformis, Obdurators.... This can push the hip slightly anteriorly in the joint and can irritate the anterior structures further. (massaging the front of the hip can sometimes aggravate the hip more!). If the posterior muscles are tight release these with soft tissue massage and trigger points and you may find that her hip catches less at the front when taken into the Quadrant position.

Once you've released the back of the hip try strengthening the external rotators in 4 point kneeling with the theraband tied to the ankle so that the quads remain relaxed and the spine is in a neutral position (+ core activated)... this can help you break the cycle of overuse.

If your dancer can start to feel her correct turnout muscles engage in a standing position (try a plie/small knee bend in a turned out position) then she can start to engage these more often and it will help to free up her hips... so much of it is about technique!! Finding a good Dance Physio to check her dance/ballet technique can really help solve these kinds of problems!!

Hope this helps :)

Thanks for all the suggestions thus far. I'm due to see her again next week so will add to and modify my investigations, try out the things suggested and hopefully make some progress! Will keep you updated.