Editor's note: The below are intended to be general recommendations for yoga practitioners and teachers. They are not a replacement for the personal advice of a health professional. Yoga teachers should remain within their scope of practice: This means not attempting to diagnose, treat, or offer medical advice to students.
Femoroacetabular impingement (FAI), or hip impingement, is a problem that’s both structural and mechanical, having to do with both our bones and how they move. Those with it may feel a pinching sensation or discomfort at the front of their hips during or after yoga practice, and may have some difficulty bringing their thighs and torso very close together. FAI is implicated in joint degeneration; if unaddressed, it can lead to joint problems down the road like osteoarthritis.
For those susceptible to FAI, a great irony is that the practice of yoga, so often valued for its ability to improve flexibility and joint health, has the potential to lead to declines in both. Fortunately, making some changes to our yoga practices and our movement strategies can help relieve discomfort and possibly prevent further hip damage.
Physical therapists Shanté Cofield, better known as “The Movement Maestro,” and Ariele Foster, founder of YogaAnatomyAcademy.com and creator of the online course "Way of the Happy Hips," weigh in about how to reconfigure our yoga practices and repattern our movements to alleviate the “pinch.”
A good first step may be noticing which poses aggravate our hip symptoms. “Our hips are more comfortable in positions with more slack, ‘open packed’ positions,” Foster says, referring to positions that allow for spaciousness in joints. However, as she points out, many positions are “closed packed,” in which there is the least space between bony surfaces. “Yoga twists often involve deep hip flexion, hip adduction, and some hip internal rotation. The combo of those three actions is when the ligaments are the most taut, and repetitively spending time in these positions can contribute to FAI and related conditions.”
Yoga poses that are closed packed and require flexion, adduction, and internal rotation of the hips include marichyasana C (Marichi’s twist), parivrtta utkatasana (revolved chair pose), parivrtta trikonasana (revolved triangle pose), as well as twists from anjaneyasana (low lunge) and crescent lunge. Drawing a knee toward the opposite elbow from plank, or drawing a leg across the body while lying supine in supta padangusthasana (hand to big toe pose) are also closed packed positions.
Many yoga positions are “closed packed,” which may cause difficulties for those with FAI.
Simply flexing the hips repeatedly or for long periods might be uncomfortable, too. Despite being a vital part of the vocabulary of human movement, squats are singled out by some researchers as particularly problematic for many whose hips are susceptible to FAI. Common poses requiring hip flexion include utkatasana (chair pose), malasana (squat), and paschimottanasana (seated forward fold) and other forward folds, and humble warrior. Even gentle poses like balasana (child’s pose), apanasana (knees to chest pose), or supta padangusthasana (reclined hand to big toe pose) may prompt a pinch at the hips. Foster adds that even sitting in chairs is probably a major contributor to FAI symptoms.
In addition to steering clear of any of the aforementioned poses if they cause discomfort, those of us with FAI may want to skip any poses in which we feel bones bumping against each other—the front of our hips coming into contact with our thighbones—by not going as far or as deep: We can try increasing the angle between our legs and our trunk to stay out of the problematic zone. For instance, staying up higher in utkatasana to keep the thighs and the spine farther apart may make our hips more comfortable.
Widening the angle between thighs and torso might be enough to make a pose more comfortable.
Poses that allow the hips to be in more open positions, among them, hip extension—the position of the hips in backbends—may feel good, but those who have had FAI symptoms for some time may find that their hip flexors are irritated and their hips object to these poses, too. “Your hip flexors hold a grudge,” Cofield says. “When your hip flexors are unhappy, extension can hurt, flexion can hurt.”
We can skip or modify any poses that are uncomfortable, closed packed or not. While some yogis may persist in slightly uncomfortable poses with the hope that they will eventually become comfortable, Cofield says that “Pushing through the pain is not the answer. It will only make things worse. The longer you try to push through it, the longer it will take these symptoms to resolve.”
We can skip or modify any poses that are uncomfortable, closed packed or not.
Yogis intent on keeping their spines long, and maintaining the gentle inward curve of their lower back, may do this by overdoing the anterior—forward—tilt of their pelvis. Tilting the pelvis anteriorly while sitting—or practicing yoga poses—is “almost certainly” more likely, according to Foster, to lead to FAI than would tilting the pelvis posteriorly, especially if that anterior tilt becomes habitual. “A chronic position of anterior pelvic tilt could contribute to FAI due to faster bony contact between the front rim of the socket and the femoral neck,” Foster says.
Forward folding while working to anteriorly tilt the pelvis may aggravate FAI.
Additionally, in an effort to keep their lower backs “flat,” some yogis may think maintaining an anterior pelvic tilt when going into forward fold is virtuous. “Constantly ‘folding from the hips’ or maintaining the position—or spirit—of a backbend when in a forward fold” creates faster bony contact, Foster explains.
It’s important for yogis to recognize that at a certain point in a forward fold, the pelvis does need to move into a posterior tilt. (When the legs are straight, this may happen when the thighs and the spine create a 90-degree angle, but the degree at which the pelvic tilt must change varies from individual to individual.) When moving from dandasana (staff pose), to paschimottanasana, the top of the pelvis must be allowed to move backward and the lower back to round.
For those whose FAI symptoms are flaring up, staying up higher, out of the “pinch,” is essential.
We can undo the habit of tilting our pelvises only anteriorly and allow ourselves to get good at tilting our pelvises posteriorly, too. We can work to find a more balanced pelvic tilt in poses like mountain and chair, and notice, when forward folding, when the pelvis wants to change its tilt: Let that change happen. We can even work toward a more nuanced understanding of how the two halves of the pelvis can each tilt in different ways with this practice.
“FAI is not a hip problem. It is a hip symptom because of a core stability problem,” Cofield asserts. “We need to use our core to stabilize us in all positions. When we’re unable to do that effectively or efficiently, we’ll steal from other joints.”
Cofield agrees that excessive, chronic anterior tilt can play a role in FAI—and attributes that tilt to the core muscle imbalances. “If someone has an excessive anterior pelvic tilt, that can throw off the balance of that entire group,” she says. “When you do some of these movements, you may tend toward using your hips to gain the stability that you don’t have from your midsection.” In essence, according to her, we move into a closed packed position, because “Bone on bone feels more stable”—that less-than-ideal movement strategy is one that does for us what our core isn’t doing.
This does not mean the core is necessarily weak; our core muscles may have the capacity to fire, but according to Cofield, we may have “a lack of reflexive stability”: Those muscles may for some reason not be firing when or how we need them to. Supporting her assertion that FAI is a core issue, some research is beginning to point to the benefits of core-strengthening physical therapy practices.
Cofield emphasizes the wholeness of the core: “We need your entire core—your diaphragm, your pelvic floor, anything at the front of your body—rectus abdominis, transverse abdominis, obliques, your back musculature—we need all of that. It’s a matter of, are all these working together and appropriately at the perfect time?”
Sitting in a chair, in Cofield’s view, may be problematic for those with FAI primarily because it underutilizes your core: “When you are chair-sitting, you’re not really using your core the way you would have to if you were sitting unsupported on the floor.”
To begin to retrain the core, Cofield suggests first working on our backs (supine) to do some repatterning. There we can cultivate a diaphragmatic breath (as opposed to a breath that just moves the chest or the belly), encouraging the expansion of the full circumference of the lower ribs. Then, still lying down, we can grab onto something behind our heads—the legs of a table, or a strap looped around a pole—and try to pull it toward us to engage our cores. If that is going well, Cofield suggests that we move our legs one at a time, in and out, to and fro—“Your legs are really long, so they’re like dumbbells for your core”—while still breathing normally and avoiding adverse indications like pain or clicking.
“Generally a focus on glute- and deep hip-rotator strengthening is key [for those with FAI],” says Foster, pointing to research showing that those who have FAI tend to be weaker in the hip flexors and extensors. They may also have weakness in the muscles that rotate and adduct and abduct the hips. “Research shows that nearly all hip muscle groups have been found to be weaker in those with symptomatic FAI.”
“Strengthen everything,” states Cofield. “It’s never wrong to be strong.”
Cofield recommends several hip- and glute-strengthening movements for those with FAI: “bridges, weighted bridges, deadlifts, rack pulls, kettlebell swings, monster walks [band around ankles and walking sideways], band-resisted marching.” She specifies, “It is just a matter of applying a graded approach to these things.” In other words, start slow, then work your way up to more intensity, never bringing the legs and chest so close that there is any “pinch.”
For a more detailed practice, the leg- and hip-activating sequence shown here is designed to strengthen the abductors, hip rotators, and glutes, though you may need to skip any poses that call for an uncomfortable degree of hip flexion.
Foster, while cautioning that we are entering more speculative territory, says, “One theorized cause [of FAI] is time spent in end-range position of the hips.” If this is true, an FAI-mitigating strategy might be to show restraint in approaching extreme poses and extremes of range-of-hip motion.
The belief among some yoga practitioners that “Feeling a stretch is always a positive” is mistaken, according to Foster, and Cofield cautions that a desire to push their flexibility could take students past the point where their joints are most stable. Of yoga practitioners who rely on their hyperflexibility, Cofield says, “They just go there passively and kind of hang out. And what happens if you’re not using your muscles to help support you? You start using your joints.”
To Cofield, the ability to be active and stable in poses is more important than how far we can go in them: “Deeper is not better. It’s not about how deep and far you can go; it’s about, ‘Are you strong in that position?’” She asks us to ask ourselves: “Can you actively get in and out of it—using your own muscles instead of your hands to get your body into that position? If you have to use your arms, you don’t really own that position.”
For instance, could we lift a foot into tree pose, move our legs toward our chests in supine pigeon, position our legs for pigeon, all without the help of our hands? Furthermore, could we get out of those poses without the help of our hands? Doing so would require—and signal—our strength in those poses. While holding those poses, we could promote our stability by imagining resisting a tap from a hand—or a strong gust of wind—that’s trying to knock us over.
However, even if we can maintain control in the depths of poses, we may still benefit from a measure of moderation. Cofield says, “We’re not really designed to go into super-end-range positions. Even if you are strengthening, stabilizing at these end ranges, understand that no one is meant to live at extremes. You can visit them, absolutely, but don’t live there.”
To be on the safe side, those of us with FAI may wish to be mindful in our approach to extremes, valuing active, controlled movement over passive drops into deep stretches that tax our hips.
The general advice above may give us fertile grounds for exploration and improving how our hips feel in our yoga practices—though perhaps not overnight. Cofield counsels patience. “Symptom resolution can take a long time because those with FAI have likely been moving in this way [the way that causes problems for them] for a while,” she says.
To facilitate faster improvements, it may be worth a visit to a physical therapist. “I would strongly suggest working closely with a physical therapist that has some expertise in hip stability in a one-on-one capacity,” advises Foster, adding, “We see the dentist every six months. Why not see a physical therapist preventatively, too?”
Cofield says that FAI “isn’t something you can work through. You have to work around it.” She tells her clients, “We’re going to take a pause,” language that may feel less prohibitive and permanent than telling them to “stop” a movement or an activity. “We’re going to take a pause, and we’re going to work around this, do things that don’t hurt us,” she counsels them, “and let that area calm down, and then strengthen.”
It may be valuable to take such a pause with the activities of daily life, too. Irritating positions or movements for those with FAI can include leaning forward, pivoting, and getting in and out of a car. Do our hips dislike any of these movements, or are they not big fans of sitting on low couches or in bucket seats, or getting up from the floor? Perhaps bending over children or pets, gardening, yardwork, or house cleaning triggers our symptoms?
If we back off the activities that bother our hips until they are calmer, we could then revisit those activities with the mindfulness yoga helps us cultivate: going slower, maintaining the muscular control that helps keep our joints supported and spacious, noticing the way we are tilting our pelvis, perhaps keeping a greater distance between our torso and our thighs. This broadening of our awareness to encompass new possibilities for our movements may help us, little by little, to get rid of the pinch.