Sports Injury Unpacked: Hip Flexor Tear

Despite the irony – physiotherapists can also acquire an injury. In this blog article I’ll dissect an injury that I obtained during this past footballing (or soccer) season. I will focus on how the injury occurred, the multiple factors that lead to the injury, how I managed the tear initially and the rehab I underwent to return to my sport.

“Oo that’s not good”

It was a sunny Saturday afternoon, and I was rushing from finish work to make it to fields before my game started. I managed to arrive 20 minutes before kick off which allowed a very brief 15 minute warm-up which was slightly less than half of the usual amount of time I would spend warming up. I was just finishing up the last of my dynamic hip flexor/hamstring stretch before entering the pitch (last of all the players) to kick off.

15-20 minutes into the first half I felt great, I felt fit, my touch was good and I had already set up a goal. At the 20 minute mark I attempted to thread a through ball through to the left winger with the outside of my foot – just as the ball left my foot and my hip was about 90-100 degrees of flexion – I felt it. It was an abnormal feeling – and one I hadn’t felt before. It felt similar to when I had “tweaked” a muscle in the past however this time it felt different – and felt more like a rip. Pain was surprisingly low at this point, I knew I had done something bad but I continued to jog for another minute or so. Once I got the ball again and attempted to change direction – I knew I was done, and gently pushed the ball over the sideline and limped to the bench. After testing the hip out at various speeds it was clear that I could jog with a slight limp pain-free but as soon as I increased my speed to 75% the pain was too high and while I could pass with the inside of my foot, striking the ball was far too painful.  A striker with no pace and an inability to shoot or cross the ball was of little use – so from that point onward I began the long process of rehabilitation.

There were signs

In the passing weeks while I was unable to train or play, I reflected on my injury. Having never sustained an injury of this significance I wondered what lead to it occurring and concluded the following:

1. Sudden spike in load

   • Majority of training sessions for the season had involved some fitness via jogging or shuttle running, passing drills, dribbling drills and small sided games with very small goals.
   • In the week leading up to that game our sessions changed completely. On the tuesday we spent an entire training session shooting at a full size goal – with majority of shots being taken from 15-30 yards out and almost all of them taken with my right leg. It was the first time we had done such a high amount of shots this season. The next day I felt an unusual imbalance of DOMs – with my right quad feeling sore and my left relatively unaffected. At this point I thought nothing of it and went to training thursday.
   • Thursday’s session had a higher attendance, so my coach had a focus of fitness for the session. A series of HIIT involving squats and jump squats followed by 10 x  50m sprints at 100% was easily the most intense session I had had all season and the first time we had done a series of sprinting at max effort. 2 DAYS LATER was matchday and the day I tore my psoas.

2. Poor conditioning

   • If I had better prepared and conditioned my body via shooting, sprinting and high intensity work during preseason  – my body would have been able to tolerate the sudden spike in load.

3. Lack of strength training

   • Research has shown that strength training in soccer players reduces their risk of injury – I wrote a blog on the topic HERE >>>
   • My lack of gym membership and infrequency of workouts at home is another factor that contributed to my injury.
   • If I had been working on improving the strength and capacity of my hip flexors, quads, hamstrings and core then again, my body would have handled the increased load without compromising my psoas major.

4. Lack of a warm-up

   • Another key factor that played a role in my injury was my rushed and inadequate warm up. This was another ingredient that may have perhaps made my hip flexor prone to injury

5. Susceptible due to my pelvic posture

   • I have a significant anterior pelvic tilt in my pelvis (and therefore an increased lumbar lordosis). This is primarily due to overactive and shortened hip flexors (such as the psoas)
   • I may have been susceptible to a psoas tear due to my psoas being shortened

   

The power of rest

Following the injury I made sure that I was icing my hip and taking prescription NSAIDs each day. I was also spending some time massaging it and got some of my POGO colleagues to release some of the tension.

As a physio, when I get an acute presentation similar to my own, I advise they rest it and avoid training/playing their sport until the pain and inflam settles. However, I only truly understood the power of rest 2 weeks after the injury occurred. I went down to play a social 10v10 match with a few mates. The hip felt okay for the majority of the time I played, I was avoiding sprinting and attempted to avoid shooting, but 2-3 times I did shoot and it felt a little uncomfortable. The next morning I woke up and my hip felt like it was back to square one – I was getting pain on stairs, getting into the car and isometrics in minimal hip flexion. After that, I had complete rest, no training, surfing, running, kicking for 2-3 weeks. It felt like forever but looking back, I wish I started the rest period from the day I injured as I might’ve returned to playing 1-2 weeks sooner than I did.

Following my aggravation of the injury 2 weeks later. I organised an ultrasound to determine the exact location/severity. It showed I had a 15mm partial thickness tear of my psoas major – a hip flexor.

Rehab

During the initial 3-4 weeks, I spent time avoiding sprinting, kicking and change of direction. Ice, NSAIDs and massages were used as well as a slow introduction of isometric contractions in low end ranges. I used pain as my guide for all rehab stages, and “listened to my hip” when determining when to progress/regress my exercises, what % effort to use or know when I had done enough repetitions.

As pain improved, I began to contract the muscle through range without resistance and began to contract isometrically in medium ranges.

1. Isometric holds in mid range

This was followed by resistance through low-mid range at increasing reps. I also used sliders to help with hip mobility and activation through range.

2. Resisted hip flexion

3. Hip extension/flexion on slider

4. Hip flexion hovers (start with small hovers then move to larger ones ie 0-45 degrees)

Return to training

Upon my return to training, I made sure that I avoiding powerful shooting (e.g. top of foot), crossing and driven passes. I was also avoiding top end sprinting. Essentially, I limited myself to only side foot passes/shots and running to a max of 75% pace.

In terms of dosage, my first session back was limited to 45 minutes (usually 90 mins) and avoiding game-like scenarios. After the initial session if I pulled up fine the next day then I would increase my dose the next session to 60 mins, then 75 until the full 90 minutes.

In my final two sessions prior to my planned return to a full game I started to involve sprinting and kicking a ball with force. With both of these exercises I ensured I would check for pain following the action and that night/next morning to see if I put too much load through the muscle.

My first match back

After 8 weeks of rehabilitation and painfully watching my team play without me on the sidelines – it was time for my return. My team were in the race for fourth and needed a win today (against the current 3rd place team) to be in with a shot.

During my return to training prior to the game, I knew I was lacking match fitness as drills that I managed prior to my injury was causing me a great deal of huffing and puffing. For this reason I started the match on the bench, which allowed me to spend more time warming up my hip. After 15 minutes I went on playing centre attacking mid, something I did not have the fitness for at all. I switched back to striker after 15 minutes until halftime.I had second breather on the bench at the start of the second half, coming on with 30 minutes to go. With 10 minutes to go, I made a run and was played in on the counter to face the keeper on the left hand side, I opened up my body and curled the ball onto the bottom right post and into the net to make it 2-1 and keep our finals dream alive.

As you can imagine, the celebration was exuberant. Scoring the winning goal in the last 10 to stay within reach of the top four. After 8 weeks of being sidelined with the most significant injury I’d ever had – it was truly the best feeling ever and made every bit of rehab and pain worth it.

Hip hurt but lesson learnt

My injury, though frustratingly long, taught me a lot in regards to what it is like to be on the other side of the treatment table. It taught me the power of rest, using pain as your guide through rehab and that if you are diligent, if you do the work and if you’re patient – then you can do anything on your return to the sport or exercise you love.

 

 

Alec Lablache
POGO Physiotherapist

Featured in the Top 50 Physical Therapy Blog  

Book an Appointment with Alec here.

References:

Posture Direct. (2019). How to fix your hyperlordosis. Retrieved from http://posturedirect.com/fix-hyperlordosis-arched-back/