.png)
Hip pain can be a (literal) pain in the butt ...!
‘Hip pain’ is quite a broad term - some people will define their hip as the front hip bones or near the groin area, some the buttocks/upper posterior part of the pelvis, and some to the side where the thigh meets the hip.
There are many reasons why people may have ongoing hip pain, and as with many conditions, exercise is often the mainstay to improve strength and function. This puts Pilates teachers in a perfect position to help this group of people.
Of course you want to help! That’s why you do what you do. But - which exercises are best?
The answer is, it can vary depending on the problem!
The exercises we give should be based on what we see in front of us. I'm going to cover the following:
Things to consider
How does the client and their issue present?
How well your client can move and function?
What are they struggling with? What movement or position brings on their pain? eg: Walking? Side lying? Standing? End joint range?
How quickly is their problem aggravated?
How much pain are they in? I like to use the Visual Analogue Scale (VAS) of Pain out of 10:
0 = no pain
10 = Worst pain imaginable
Is it new or something they’ve had for a while?
Their foundational fitness and strength. This makes a difference!
Have they been assessed & cleared by a Physio or Doctor?
Once you know some of these answers, it will help you to formulate your plan.
It's worth bearing in mind that even for clients with a diagnosis, people can present very differently: One person with arthritis of the hip might be functioning with minor symptoms, but another person might be in agony.
I’ve seen Xray reports showing *severe* arthritis of a joint. Yet the client has full range of motion with only a reduction of strength and mild discomfort. Pretty damn good, & not what you would assume for someone with such a report.
Hence why it is always so important to consider your clients on a case by case situation. This tells us that it is likely that certain exercises could also work differently for each person, require tweaking, or perhaps even avoiding! Effective communication during and after their sessions is key to finding the right balance for them.
Ideally your client will have already seen a healthcare professional and had the ‘all clear’ to begin Pilates. BUT - perhaps they’ve been advised by a friend or relative to give Pilates a try first. Thankfully, strengthening the area around the hip is the mainstay for conservative management. So the good news is they have potential to improve with Pilates & time alone!
Depending on how your client responds to pain and movement will determine if they need a slower and gentler approach, OR, they might need holding back from certain activities/movements (we’ve all met those clients!).
What we want to achieve with Pilates is optimal function. If they have pain, we hope we can improve this, even if it’s just a notch or two on the VAS. It’s important to also know that maybe it won’t! Remember, pain is complex and multifactorial and there is not always a simple solution. But asking the client to keep a diary of symptoms (which might include pain out of 10, or a simple daily task and how they feel), really helps them and you to see progress.
There will be some conditions that cannot or will not improve with time and exercise, but exercise will help to prevent worsening pain and dysfunction. I always live by the saying “when it doubt, check it out!”.
As Pilates teachers, you must always work within your scope of practice. This means you are not there to diagnose, nor to work it out on your own, or ‘fix’ your client. However, you can use the knowledge you have of PIlates and which exercises apply to use as a strengthening tool to help our clients. Then if things are not improving, you know an onward referral is necessary!
Having a Physiotherapy degree & working directly with patients over several years has helped me immensely to get positive results for my clients with their Pilates journey, but I too will refer on when unsure, if a client is not improving - OR worse yet - getting worse!
I’ve listed my 5 top Pilates exercises using the Pilates apparatus that I use for my clients with a painful hip. I’ve included the ‘at home’ alternative for those reading who don’t have access to a Pilates studio, or for those wanting homework outside of studio time! (Yep, homework! The work is ongoing).
This is by no means an exhaustive list - I haven’t even included my LOVE for anything in side ly (or their alternatives) to work the pelvic stabilisers - but the list below works the areas all around the hip for general hip pain without getting too specific.
Common Conditions
Before we talk about exercise, let's take a moment to look at a few common conditions we may encounter as a Pilates teacher:
Lateral Hip Pain - now an umbrella term for what was once called Trochanteric Bursitis, and also includes Gluteal Tendonitis as this is where the gluteal tendons attach to the upper thigh bone. Often the two go hand in hand, but bursitis can also be secondary to other conditions such as Osteoarthritis.
Labral tear - the research to support that pain in the hip is coming from the torn labrum itself is poor. There are many people with a labral tear who are asymptomatic - and often a labral tear can be secondary to other issues, much like bursitis.
FAI: Femoroacetabular impingement - when bone overgrowth (spurs) — develop around the femoral head (ball) and/or along the acetabulum (socket). This bone growth prevents the joint from moving smoothly during activity. Over time, this can result in tears of the labrum and the breakdown of articular cartilage. (1)
Hip Dysplasia - where the hip socket (acetabulum) is too shallow. Some adults are unaware they have hip dysplasia as they experience few symptoms, others have symptoms since childhood. Often there is pain from secondary issues arising from the hip dysplasia (can be in the groin, outside of the hip, down the leg). It can be made worse by standing, walking or running, less commonly at rest. It can be associated with clicking, snapping or popping sensations. The exact cause of hip dysplasia is unknown but there may be a genetic component. Adult dysplasia can cause early arthritic changes and stress surrounding soft tissues.(2)
Osteoarthritis (OA) - the most common form of arthritis affecting millions of people worldwide, most frequently affecting the hands, hips, and knees. It occurs when the protective cartilage that cushions the ends of the bones wears down over time. OA can cause pain, stiffness, and swelling and therefore reduce function. Osteoarthritis symptoms can usually be managed, although the damage to joints can't be reversed. Staying active, maintaining a healthy weight and certain treatments might slow progression of the disease and help improve pain and joint function.(3)
Other Tendinopathy and Bursitis conditions (eg: Iliopsoas, hamstring, adductor tendinopathies).
Finally, 5 Pilates exercises for general hip strengthening
1. Standing Press Down Front on the Pilates/Wunda Chair.
Press the pedal with your powerhouse & glutes - whilst the magic works your standing leg A LOT - which strengthens your pelvic stabilisers!
Progress: Going Up Front
Regress: Seated Footwork 2 and 3
Home Equivalent: Single leg step up on the stairs - this works the leg on the step more and not really the free leg at all, so more like the progression on the Wunda Chair ‘Going Up Front’. If this is too challenging, try standing tall and lifting the knee straight up in front of the hip instead.
2. Standing Press Down Side on the Pilates/Wunda Chair.
Working the hip abductors and adductors with external rotation position of the hip. You might need to start with the pedal in a lower position or your client on a block/box so the hip is not too compressed if causing discomfort.
Progress Wunda: Going Up Side
Regress Wunda: Seated Footwork, or side sitting on top of chair push downs.
Home Equivalent: Single leg side step up on the stairs - as with above, this really works that step up leg and actually quite challenging!
Progress Home: Step up and down just tapping the floor leg only - so effectively single leg squats on the working leg on the step, without allowing the lower leg to take weight. 2) Add a band above the knees and keep pressing out with the floor leg. This will make you work both hips.
Regress Home: Stand on the floor with the hip in external rotation and lift knee up/down. OR: Stepping up onto a smaller step.
3) Bridge - Keeping the shoulders and back of the head down pressing down into your mat. Begin by lifting your pubic bone toward the belly button and carry on peeling the spine away from the floor. Hold for a breath or two, then lower down in reverse order.
This good old staple works the hip extensors: the hamstrings, gluteus maximus, as well as the paraspinal muscles. For some added oomph, I love to use a magic circle or resistance band above the knees to kick in the Gluteus Medius as well.
On the Wunda: Try to keep the pedal lifted as a challenge.
On a chair at home: You can add a band around the knees. You can also do this with feet against a wall, or with feet on the floor. Having the feet/legs elevated often reduces hamstring cramp (common in bridge!).
Progression on the Wunda Chair: Add very small pulses at the top range by pulling the pedal up/ down whilst maintaining your hip height…Hello Hamstrings!
Progression at home: Keep the hips elevated and pulse the legs outward (into a band or just on their own). Hello Glutes!
3a) Single Leg Bridge Progression: The same as above, just harder! Roll up as in number 3, then fold at the hip to lift the knee.
Make sure your clients can maintain their pelvic alignment. Ie, if they lift the leg and their hip drops downward toward the floor, often they aren’t quite ready for this progression.
4) Standing Hip Extension
- Using the Tower/Cadillac leg springs on hook 2
- Work the leg back into extension into a functional range without involving the lower back (Notice I’m leaning forward so as not to arch my back)
- this helps me to really feel it in my hamstrings and glutes. Great for the standing leg too - don’t be surprised when you hear your clients complain about that standing leg burn!
Home Alternative: Use a resistance band looped around both legs.
Progression: Heavier Spring/Band; Add holds/pulses.
Regression: Light Spring/Band/No band
5) Standing Hip Abduction
- Using the Tower/Cadillac leg springs on hook 2
- Both feet facing forward, lift the leg out to the side, leading with the side of the foot and toes forward.
- Work the hip in a functional range without leaning with your trunk to compensate. Another great one for the standing leg too!
Home Alternative: Use a resistance band looped around both legs.
Progression: Heavier Spring/Band; Add holds/pulses.
Regression: Light Spring/Band/No band.
I hope you get to try these with your clients and see some progress after a few weeks of repetition!
If their painful hip is NOT improving, exercise is causing worsening pain, it’s time for a referral. Sometimes, movements can aggravate a painful hip, particularly with things like a labral tear, FAI, OA where going into end range or compressive movements are provocative. Here are some things to remember:
Avoid end of range joint movements in a painful hip
Start lighter and smaller! Begin with a smaller range of motion, and tolerable load (spring/band tension).
Progress load in pain free range. Progressive load helps to improve muscle hypertrophy (size) and strengthens the muscles and tendons. Strengthening the surrounding soft tissue helps to support the painful joint.
SOME pain can be expected. Usually say no more than a 3/10 on the VAS (10 being the worst pain) is acceptable. This may include a short while after exercise.
If pain is > 3/10 that lasted days, then consider: Reducing load, reps, range.
- OR - possibly backing off from the specific area completely until it settles down
before you reintroduce work for that joint.
And always:
When in doubt - CHECK IT OU T!!!
Seek advice from a physiotherapist or refer them back to their doctor.
Do you have a client with hip pain? Did you find this blog useful? Please leave your comments below, I’d love to hear how your client is doing!
Sonia is a Musculoskeletal Physiotherapist and Pilates teacher from the UK. She also offers consultation services to Pilates teachers who are seeking support of a healthcare professional to help them with their clients who may have an injury or condition, or simply just for advice regarding best exercises to give. For further info and to book yourself a consultation, visit www.phyxx.co.uk
FAI definition - https://orthoinfo.aaos.org/en/diseases--conditions/femoroacetabular-impingement/
Hip Dysplasia - https://www.cht.nhs.uk/services/clinical-services/physiotherapy-outpatients/hip/hip-dysplasia
Osteoarthritis - https://www.mayoclinic.org/diseases-conditions/osteoarthritis/symptoms-causes/syc-20351925
Comments