How Researchers Studied Joint Injections for Pain 

In this study, 459 individuals received hip or knee injections in the researchers’ clinic. At the time of injection, researchers took an MRI of the affected joint. 

The study participants received 1 to 3 joint injections each with an average of 1.4 joint injections per participant.  The participants returned for follow up within 2 to 15 months after their last joint injection. On average, follow-ups occurred seven months after the last joint injection. 

When the patients returned for their follow-ups, researchers conducted an MRI to see if any change occurred to the affected joint.  The study found that 36 out of the 459 patients (8%) experienced an adverse outcome in the affected joint.

The Findings on Injections for Joint Pain 

The Four Adverse Effects from Joint Injections

The four adverse outcomes discovered in this study included the following: 

1. Accelerated osteoarthritis progression in 6% of patients; 

2. Subcrondral fractures in 0.9% of patients; 

3. Osteonecrosis in 0.7% of patients;  and

4. Joint destruction and bone loss in 0.7% of patients. 

Now what do those mean in plain English?  

Accelerated Osteoarthritis (“OA”)  - this was by far the most concerning negative outcome.  6% of all patients receiving injections in the study experienced accelerated OA.  The orthopedic community defines accelerated OA as a loss of joint space of more than 2 mm within 12 months. 

Subchondral Insufficiency Fracture (“SIF”)  - this outcome affected nearly 1%  of all study participants. The study indicates that if SIF is not diagnosed at an early stage, it can progress to articular surface collapse. If there is a collapse, orthopedic surgeons would likely recommend joint replacement. 

Osteonecrosis  - believed to be caused by reduced blood flow to the joints. The study indicates this lack of blood flow can cause bone plate collapse.  The collapse can increase chances of developing OA and more pain. Orthopedists would likely recommend joint replacement. 

Joint Destruction and Bone Loss - although this outcome occurred in less than 1% of patients, it’s the most scary.  This was identified as rapid bone loss that is worse than OA. 

Our Position on this Joint Injection Study

There are two primary reasons you might get a steroid injection for joint pain. 

1. The first is pain relief.
2. The second is to test whether the cause of pain is in the joint itself.  

Both of these reasons are dubious and we'll analyze each separately.  

Now we have a study that spells out, in overloaded medical language, the type of structural damage that’s possible.  OA, SIF, Osteonecrosis and bone loss? Based on the findings, the risk of ending up with any of these types of structural damage is slightly less than 9%.  

That is pretty high for a pain treatment that provides short term relief at best.  Maybe it makes more sense to focus on the underlying compensation that is causing the pain in the first place?

Steroid Injections are not a Reliable Test for Joint Damage

As for testing whether the pain is in the joint itself, this is just plain wrong.  In the last few years, we’ve published numerous articles going over the shoddy science supporting intra-articular injections as a diagnostic tool for FAI and other joint issues (Check it out here, here and here). 

So let’s put this all together.  An injection for joint pain is not a reliable test to measure the effectiveness of surgery.  And it can potentially make things much worse for the affected joint.  

There are not many things that are definitive in the world of science, especially medicine. This gets pretty close though. Using steroid injections to determine whether the pain is coming from the joint itself is not supported by science. 

Closing Thoughts 

There is only one reason to receive a steroid injection for joint pain that makes a little sense: You are looking for the possibility of short-term pain relief without any concern for the long-term effects or a long-term solution.  

Our team at Upright Health does not believe in joint injections and actively encourages clients to stay away from them.  However, if you’re steadfast on your decision, at least understand why you’re doing it and what the risks are. 

Remember: 

• Injections do not provide a long-term permanent solution to joint pain.
• Injections are not a useful diagnostic tool to determine whether pain is coming from some damage “in the joint.”  
• Injections can have serious side effects and are not as safe as commonly presumed.  

By using a steroid injection to temporarily relieve pain, you’re telling your brain that there is nothing wrong with the way your body functions.  So chronically shortened muscles or weak and atrophied muscle will remain dysfunctional (and cause you pain once the injection's effect wears off).  

Even worse, because we’re numbing our body’s natural feedback mechanism, we might engage in activities that place these muscles into even more dysfunction. The imbalanced muscles can send out signals of pain. They can also pull bones into problematic/unstable/painful positions. By the time the numbing agent wears off, it is no surprise that our pain comes back even worse and that there is a possibility for greater pain. 

The only way we advocate getting out of pain is to learn your individual muscle imbalances and compensations. Learning how the body optimally functions and how your body deviates from that provides you with a roadmap for recovery - and more! 

This isn’t a quick fix. It requires time, experimentation, and persistence. 

Nothing of value in life comes easy or quick, so don’t be fooled by the “quick fix” promise of steroid injections for joint pain. 

How Researchers Built the Personalized Hip Therapy using Ineffective Training Programs​

PHT is a program of exercises that aim to improve hip function in those diagnosed with FAI.  A group of UK researchers created the PHT to establish the standard for conservative treatment for FAI. 

The purpose of PHT's creation was to compare it to hip surgery for FAI treatment. ​Since 2016, many medical journals published studies comparing the effectiveness of hip surgery to PHT in the treatment of FAI.

Researchers selected exercises based on a consensus from physiotherapists they interviewed. They then tested the protocol on patients with FAI. 

The researchers arrived at this consensus in two phases. In the first phase the researchers gathered evidence on published protocols and created a sort of “draft” exercise program. This program was then emailed to physiotherapists for suggestions on changes. Once 50% of the physiotherapists agreed upon a protocol, the researchers moved on to phase two. 

In phase two, researchers tested the draft protocol on a group of hip pain patients. Another group of patients received hip surgery for FAI. The physiotherapists completed case reports for each patient receiving the non-surgical FAI treatment. 

The physiotherapists then met at a conference to exchange ideas and make further changes to the protocol. At that point, the protocol became the Personalized Hip Therapy program. 

The Personalized Hip Therapy protocol for FAI is built on a sandy foundation

The researchers did not interview hip pain sufferers that resolved FAI symptoms without surgery. Instead, they relied on published protocols on conservative treatmentf for FAI. But there were no published protocols that worked!

This is like saying “none of us know how to solve this, so here’s the best group of exercises that we already know don’t work.” 

The researchers admitted this issue themselves: "[The PHT] was developed based on the experiences of clinicians treating patients . . . and not by targeting the deficiencies observed in patients with FAI syndrome.” 

It was impossible to create an effective non-surgical treatment method for FAI based on prior protocols. This is because no prior effective FAI protocols existed! The only way to approach non-surgical treatment for FAI is to alter the way we approach the issue.

Conservative treatment for FAI with PHT does not Include Major Hip Movements  

The PHT has turned out to be an underwhelming tool for hip pain at best. It overlooks a shocking number of muscles and movements for the hip joint. 

Let’s first focus on the movements and muscles that the PHT does explicitly target. 

The PHT targets the following hip muscles for strength: glutes, abs and the “lower limb in general.” 

Movements targeted with stretching include the following: hip external rotation and hip abduction. 

The protocol also mentions that stretching for the hip flexors may be necessary. 

And that’s it. 

It is impossible to list every muscle and movement pattern that may be responsible for hip pain. However, evaluation of a wide variety of muscles and movement patterns is a MUST. The PHT barely scratches the surface. 

The PHT ignores the following major muscles for strength: adductors, quadriceps, iliopsoas, hamstrings, obliques and TFL just to name a few.

Major movement patterns ignored include internal rotation, adduction, hip flexion, hip extension and combinations and different variations of these patterns (e.g. hip flexion with abduction, adduction with knee flexion, etc.).

In short, the PHT leaves out more than it includes! It's as if the consensus resulted in a short list of random muscles and movement patterns to improve. 

Even more troubling is that the PHT recommends certain strategies without justification.

For example, the PHT directs the hip flexors to be stretched but there is no mention of strengthening this muscle group. We understand that hip flexor “tightness” is a popular bogeyman for hip pain. However, “tightness” does not always mean a muscle is strong and needs to be stretched. You can read more about this here.

One of the biggest issues I’ve seen with many people struggling with chronic hip pain is weak hip flexors. This alone can provide significant pain relief and the PHT doesn’t even mention it.

Personalized Hip Therapy is Structured to give Hip Pain Patients little Chance for Success 

The PHT provides for at least 6 and at most 10 sessions with a physiotherapist over the course of 12 weeks. 

This begs an important question: Is it possible for someone with chronic hip pain to see progress within this time frame? 

If they follow the PHT, which only focuses on 2 muscles groups and two movement patterns, it is unlikely. 

If comprehensive training focuses on improving specific weaknesses, then it is much more likely.

A lifetime of poor movement habits takes more than three months to reverse. Giving people with hip pain realistic expectations is important.

From our experience, three months is a reasonable time frame to start seeing improvement. It’s reasonable in that time to see how a comprehensive movement practice can improve hip comfort.

But ALL hip pain will NOT be “cured” in such a short period.

And most people will not learn enough in only six or ten sessions. Certainly not if those sessions are only thirty minutes long. And with a physiotherapist who already believes that FAI can only be treated surgically.

Personalized Hip Therapy does not improve hip range of motion 

PHT prohibits painful hard end stretches. This is a good idea. The nervous system will not adopt a greater range of motion in a position when it senses extreme pain.

However, obtaining larger ranges of motion in essential hip movements is critical when regaining function in the hips.

The PHT advises against “vigorous stretching” and “painful hard end stretches.” This likely causes therapists to avoid improving ranges of motion in certain positions. This, in effect, paralyzes the patient from ever making significant progress. 

Pain in the end range of a stretch means the body does not like this position. But that does not mean it is not capable of becoming more resilient in that position. It is crucial that people with hip pain explore these painful positions to determine how they can overcome the restriction.

If you avoid every position that triggers discomfort, then what’s the point of the therapy in the first place? Avoidance is a guaranteed method of making zero progress. 

If one stretch is difficult, may be a less intense stretch will help to progress into it. Maybe strengthening the main muscles involved will make the stretch easier.

Maybe working on another movement pattern will open the stretch more.  The fact that a stretch or a position is painful is actually a great opportunity to use it as an assessment. Finding ways to perform the movement in a pain-free way brings you one step closer to being pain-free in your daily life. 

There are nuances to stretching that everyone must become aware of to gain hip mobility. The PHT throws proper flexibility training for the hips into the trash, and leaves hip pain sufferers with nothing useful!

The Ideal Conservative Treatment for FAI

The ideal conservative treatment for FAI would include all three of the following elements:

1. (1) Assessments that identify individual movement dysfunctions; 
2. (2) A reference guide of exercises to improve each basic movement pattern, including progressions; and
3. (3) Guidance from an experienced trainer that is familiar with common difficulties.

The first task in any movement protocol is to test the functioning of basic movements. For the hip joint itself, assessments can include: flexion, extension, external rotation, internal rotation, abduction, adduction, and combinations of all those motions. Other assessments can include full body movements such as hip hinging and squatting to test the ability of the muscles to handle loading. 

Then, the protocol must identify techniques and exercises to improve restricted movement patterns. There would also be progressions for each exercise. This way,  there is continuous improvement in key movement patterns. 

Unfortunately, creating a fool-proof protocol without human error is impossible. The human body is not a perfectly predictable machine. People with hip pain often need modifications and unique strategies to work around challenges. 

The FAI Fix, for example, includes over 80 different exercises. It also includes assessments and guidance on how to deal with various challenges. It works for many people, but we know that it’s not 100% foolproof. Sometimes more specific coaching and coaxing is necessary to make positive changes.

We’ve had users of the FAI Fix work with us when they want more guidance, and we’ve seen how many variables can go wrong. Sometimes the problem is poor form. Sometimes it’s fear of a certain position. Other times it's the upper body that is causing compensations in the lower body. The possibilities are endless.

There are many possible obstacles in healing your own hips. But they are surmountable if you put time, attention, and intention into solving your own issues.

It can be a time-consuming and frustrating process. That’s why it can be helpful to work with an experienced trainer or physical therapist. It is important to find someone with the right mindset and who is familiar with the various hurdles of movement training.

Conclusion 

An adaptive protocol is in a much better position to compete with hip surgery than PHT for improving hip pain. Focusing on the root cause of the hip pain - improper movement patterns - should be the basis of conservative treatment.

Unfortunately in the medical literature, that approach doesn’t exist. The best option right now is PHT, and that is a woefully inadequate protocol for solving hip pain.

FAI patients deserve a more comprehensive, nuanced non-surgical treatment. Otherwise, studies comparing hip surgery and conservative treatment for FAI are not helpful. The results between the two treatment methods will be minimal at best.

To become better at hip movement, you need to practice . . . hip movement! This is a process that is individualized. It's a process that requires time and customization and does not fit well into the mold of modern medical studies.

If you’re weak in hip flexion, you need to practice hip flexion. If you have limited hip internal rotation, you need to practice becoming better at hip internal rotation. The PHT misses this basic concept and so many more.

I hope this article gives you the information you may need when deciding on whether surgery for FAI is right for you. I encourage you to continue troubleshooting your hips through movement. Leave hip surgery and Personalized Hip Therapy on the shelf to gather dust in the meantime.

Maybe your bed is super old. 

Maybe you're 99% sure that your current bed is contributing to your back pain, hip pain, or shoulder pain. 

As you start navigating the many options of beds, you realize that you have to choose a mattress firmness. Soft vs. firm? Medium? 

What's the difference?! 

This video will explain how to choose the right mattress firmness for your particular style of sleeping. And it'll cover key aspects to consider if you have back pain, shoulder pain, or hip pain. 

This video is based on years of experience with different beds contributing to or causing me all kinds of aches and pains. 

I also talk about how much money I'm willing to spend on a mattress and why history seems to indicate that being as cheap as possible about a bed is probably your best bet. 

Hip mobility and deep squats

Let's talk about what your hips are capable of. 

Hip joints are where the leg bones meet your pelvis. You can watch this video for a quick and simplified tour of hip anatomy.

There is an infinite number of different angles and positions you can put your legs in relative to your pelvis. That means that there’s a lot of ways you can move your hips.

When you watch a small baby learn to crawl, walk, run, and climb, you will notice that the hips are capable of a lot of movements. Babies can sit in all kinds of interesting configurations and even go into the splits with enviable ease. 

Proof? Check out my son doing some interesting hip movements here.

But adults, especially in Western chair-based societies can’t. Many modern Westerners can’t even sit in a remotely deep squat. 

Why is that? 

There’s a very vocal camp that claims that Westerners can't squat deep because of bone shapes. Many European hip joints, they claim, are not built to squat deep. The bones simply smash into one another before reaching full depth.

This sounds very convincing, especially if you hear someone with a medical or doctorate degree say it. 

But there's a problem.

Has anyone done a detailed study on a large group of people showing that the bone shapes create a clear limitation to your ability to squat deep?

Not that I’ve found. 

If you can find one that shows a strong correlation between hip bone shapes and hip mobility, I'd love to see it. There's tons of building evidence that shows "pathologic" bone shapes aren't even related to hip pain or hip mobility issues (see this study on femoroacetabular impingement, for a clear example).

And there's a rich history of orthopedic medicine over-promising, under-delivering, and destroying people's spines, shoulders, and knees in the name of quick fixes. 

And this perspective also doesn’t explain why you can easily find Asians who grew up in Western countries who also cannot squat deep. 

Or why babies of European descent CAN squat deep...and why they eventually lose it. 

Or why you can gradually train people to be able to squat deep  -- even if they are of European lineage...

Always Think Muscles.

That's a mantra around here. This video breaks down the reasons why for you. You don't HAVE TO watch it, but it's a good quick primer on why it's just not worth entertaining the "bones" idea. 

The real reason why you can't squat deep

The answer for why you can't squat deep has to do with how you train your body. 

"No!" you say. "That's too simple!"

Yup. 

It is that simple.

"Then why aren't all the doctors and PTs saying that it's just a training problem?" you may be asking.

I think there are two main reasons the "bone shapes" theory is gaining traction is because

1. It means you have to put in a bunch of work to fix your squat and many people don't want to hear that
2. It absolves professional healthcare "providers" of their guilt for being unable to help you fix your squat with quick and satisfying solutions. 

A third hidden reason is that it feels really great for a doctor to be able to say, "Oh, some people just can't squat deep because they have misshapen bones that only someone with extensive years-long training can shave away in a specialized surgery that only a few thousand people in the world know how to do."  Most doctors have the best of intentions, and wanting to feel good about what they know and how much they can help others with their knowledge is just a natural, positive, human thing.

The point is, it's a lot easier for average people to buy into, "it's your bones and you can't change the squat depth" than "you can change it but it's going to take some work on a daily basis for months or years."

If you're sitting there thinking "I'm not willing to put in months or years of work on this," then you may as well accept the bone theory. 

If you're a stiff person with stiff hips who wants to get less stiff and get deeper in your squat...

And if you really want to improve your squat depth and are willing to work for it and want to learn exercises that will help you improve your squat depth...

WATCH the following video.

It provides you with three simple exercises to help you get deeper into your squat. 

Key Point: if you're stiff, stop blaming your bones.

It’s important to keep your focus on what you can control: your muscles. 

If you’ve grown up in a modern Western society, you rarely need to squat deep. You rarely take your hip joints into novel ranges of motion like a baby. You rarely sit on the floor. You never do anything that even remotely approaches the splits. You have been told to bend at your knees instead of your hips by the doctor for decades. 

When you exercise, you walk, run, or swim...all these activities move your hips in a very limited range of motion. These activities do not make squatting deep easier. 

When you sit in a chair, you train your hip muscles to freeze the hip joints into a shallow squatted position. 

When you lift weights or play tennis or golf, your hip joints stay in limited ranges as well. 

The point is, most people’s hips are always stuck in the same limited positions. And the muscles need time to relearn how to go to positions they aren’t familiar with. 

Deep hip muscles that most people never learn to stretch properly...THOSE need attention before you can make any claims about how bones affect you. It's not just about doing random yoga classes twice a week. It can sometimes require daily work ... multiple times a day.

And, yes, I do mean that you can make progress even if tests you see PTs and trainers online yammering about say you can't squat deep. 

Again, they're just giving you an excuse for 1) why they fail to produce deep squats in people they train (when the problem is they likely aren't programming properly) and 2) for you to say, "meh, I can just live with this." 

If you get caught up in the idea that “my bones” are the problem, you give up prematurely and will be unable to make any progress whatsoever. 

It's a process. The journey for every person will look different. Be willing to experiment, and explore. Be consistent and persistent. 

We'll be updating this post with future videos to help you with a deep squat. In the meantime, one of my personal friends and super duper mobility monk Shane Dowd over at GotROM.com has a comprehensive program to help you squat deeper. 

If getting a deep squat is important enough to you that you'd be willing to spend money (and time, don't forget the time - oh, the time!) check it out. 

What about flexible people who can't squat deep? 

There are people out there who cannot squat deep, despite being able to do the splits and touch their toes and generally do all kinds of bendy things.

We've seen these people (almost always women who've done ballet, yoga, gymnastics, some other form of dance) as our clients and in our live workshops...and they, too, can squat deep. 

The problem isn't that they aren't flexible enough. That's clear. 

And the fact that they can put their feet to their faces tells you that the BONES aren't stopping their range of motion.

So if you're a flexible person who can't squat deep, you can tell the P.T. who says it's your bones fault to go stick his thumb up the anterior side of his coccyx.

What is missing is STRENGTH. Strength to control the position and to feel like you can actually get yourself up and out! 

How do you build that strength? 

I'm glad you asked. 

These two videos give you several ideas to help you build squat strength and control so you can squat deep.  

Deep Squat Summary

To summarize our approach to squat depth: 

1. Always Think Muscles - you're wasting your time and energy looking for excuses for your poor squat mobility.
2. Put in time and effort consistently - Work on your flexibility daily and don't sabotage it with other activities that will ruin your flexibility (e.g. heavy deadlifts, barbell squats, and high volume sprinting/running will almost definitely be keeping your hips tight). 
3. Make lifestyle changes. Sit in different positions. Don't lock into a chair all day. Move around. Fidget. Practice. Practice. Practice.

That's it. Simple. Does this mean you may have to change things in your life? Maybe. Does it mean you'll have to experiment and explore? Definitely. 

Will it take time? 

Yes.

And the sooner you start, the sooner you'll achieve your deep squat. 

Progressing

Give your chosen corrective exercises up to 2 weeks to show lasting results. If, after 2 weeks, you sense you're still milking benefits out of said exercises... then continue doing so for as long as you see fit.

However if, after 2 weeks, either:

• you sense you got what you needed from said correctives, and are ready to move on
• you don’t sense any obvious lasting changes

Then revisit the corrective exercise articles [1][2]. And focus on a different 1-3 exercises for the following 2 weeks.

The bottom line?

Be mindful, consistent, and patient.

Deadlifts Programming

Recall that deadlifting is a skill. Corrective exercise is preparation for said skill. And to master said skill, you must (at some point) directly practice the skill itself.

So whether CONCURRENTLY with your corrective exercise work, or only AFTER you feel you’ve reached a baseline of readiness... begin practicing deadlifting too.

Training Days

Choose the deadlift variati​​on that allows you to express proper deadlift form.

Warm up however you like, before lifting your "work weight" of the day.

If you’re an absolute beginner, then I’d recommend choosing a “work weight” that is:

• light enough to NOT require more than 3 minutes of rest between each set
• light enough to allow you to perform at least 3 high-quality reps per set
• heavy enough to NOT allow you to perform more than 10 high-quality reps per set

3 sets of 5-8 reps (of said weight), twice a week, is a good place to start for most people -- increasing the work weight by 0-5% each week.

Though, to be clear, there is nothing magical about the above number suggestions. They are a means to an end. Like taking medicine, they describe a dosage to encourage your body towards change. Over time you can experiment with different set/rep schemes to further optimize your dose.

And what if you're already running a deadlift strength program that's been working for you? Well then, just keep doing that!

The bottom line?

You don’t need the “perfect program” (as if there is such a thing) to make progress. Though you do need to get started.

Here's a template to help you do just that.

In this lesson, we’ll cover why bending over and reaching down (with a neutral spine) requires access to adequate:

• shoulder flexion
• hip flexion
• hip horizontal adduction
• midfoot rotation

Shoulder Flexion

Hip Flexion

Hip Horizontal Adduction

Midfoot Rotation

So which of these pose explorations did you find most enlightening to your limitations? Take note of this (as well as your previous insights) as you move onto the next article.

In this lesson, we’ll cover why forming a neutral spine requires access to adequate:

• hip extension
• shoulder extension
• rib rotation

Hip Extension

Shoulder Extension

Rib Rotation

So which of these pose explorations did you find most enlightening to your limitations? Take note of this for later, as you move onto the next article.

Neutral spine... neutral spine... neutral spine.

But... what if you currently lack the spine control to FORM a "neutral spine"?

What if you lack the hip control to MAINTAIN a "neutral spine" (as you bend over)?

Do you expect any of the above to change via deadlifting, alone... where you can compensate in countless ways to pick the weight up?

Sure, you can take your chances on that. But I'm guessing if you're here, you're looking for a more precise way to fine-tune your deadlift technique.

Notice any relationships?

Enter "deadlift correctives".

You see, proper deadlift form is comprised of a combination of joint positions.

For example:

At the bottom position of a proper deadlift, you're combining a neutral spine... with a deep hip bend.

Now, if you struggle to combine these joint positions (neutral spine + a deep hip bend) during a deadlift... why not train this, using a different exercise that's easier to manage?

That way...

You can practice mastering whatever combination of joint positions you currently struggle with most... WITHOUT getting distracted by having to manage all the other pieces of the deadlift.

Notice any patterns?

The bottom line?

To be ABLE to possess proper deadlift form... you must be ABLE to articulate EVERY joint into EVERY position that occurs in proper deadlift form.

If you’re missing access to any one of these “deadlift-specific” joint positions... then this can be difficult to change, using the deadlift as your ONLY tool.

Two different shoulder positions. Two different spine positions.

In the following lessons [1]
[2], I discuss key poses that emphasize joint positions found in proper deadlift form.

Through exploring and mastering these poses, you’ll:

• improve your access to the individual joint positions that occur in proper deadlift form
  (to improve your deadlift form)
• improve your understanding of proper deadlift mechanics
  (to make better informed decisions in your deadlift practice)

Comparison of hip angles affecting spine curvature

Why?

Because deadlifting using MINIMAL hip bending inhibits your powerful “hip muscles” (which reduces how much you're able to lift). And greatly increases your likelihood of injury (due to the altered workload on your “spine muscles”).

It goes to reason then that, although having SOME amount of unintentional spine rounding in a deadlift may not bring about the end of the world... the more proficient you are at being ABLE to perform a deadlift by holding a TRULY “neutral” spine curvature... the better.

If we can agree on this premise, then we can start breaking down the deadlift into what constitutes “proper form” and “proper muscles used”. And we can move on to how to take concrete steps in obtaining this “proper deadlift form”.

Learn to perform the (L) photo... before you explore the (R) photo.

HOW TO PRACTICE "PROPER DEADLIFT FORM"

Essentially, the deadlift is a series of questions.

1. Can I form a neutral spine?
2. Can I take my neutral spine with me, as I bend over and reach down?
3. Can I take my neutral spine with me, as I stand up and pull back?

And that's proper deadlift form in a nutshell.

Every coaching cue you've heard of (such as "push your hips back" or "brace your abs")... are merely heuristics to help you say "yes" to those three questions. 

• Can I form a neutral spine?
• Can I take my neutral spine with me, as I bend over and reach down?
• Can I take my neutral spine with me, as I stand up and pull back?

Why am I emphasizing this?

Because it's important that you ultimately understand the "why" behind a cue... and not just ​blindly follow cues that work well for other people with different bodies.

Internalize the three questions above... as you use the following deadlift tutorials to find the coaching cues that work best for YOU.

If you were able to execute the deadlift form as described above… then great! You can skip to the article on constructing your routine, so you can learn how to progress from here.

If you had trouble executing the deadlift form as described above... (or wish to do so using a different apparatus/ROM, that you currently have trouble with)... then move onto the next article.

After weeks of experimentation on myself, I discovered that it wasn’t only what strategies I used that mattered but the order in which I used them. Once I began using the step-by-step protocol discussed in this article, I noticed a dramatic improvement in my chronic hip pain.  

I started using this same protocol with clients who also had positive results.  That said, it's important for every individual to adjust the protocol based on their needs.  This is not a one-size-fits-all approach and it's important to find a routine that works for you. This is one approach that has worked fantastically for me. 

Why does Your TFL hurt?

Unfortunately, the TFL doesn’t like doing double duty during hip abduction and eventually it can begin to tense up, ache and become painful. It’s like when your coworker doesn’t do his job, and you end up having to cover for him over and over again.The same situation can occur in hip flexion or internal rotation as well if the primary movers of these muscle actions are dysfunctional. 

It means the TFL is always doing more than it should in some motions. 

Another reason your TFL may be painful is weakness.  If the TFL itself is extremely weak and unable to optimally contract when it is recruited in various movement patterns, it can result in a constant sense of “tightness.” If that sounds like you, you may want to read this article. 

A final other reason could be an imbalance between the TFL and muscles all around the hip (like the adductors). We’ll save that for another article or video one day. 

How to Use This Tutorial: Improve Function to Improve Pain 

Our ultimate goal here is to ease your TFL pain. To do that, we’re going to think about muscles. Always Think Muscles. 

This is an important concept to grasp because there can be one movement pattern that your hip is dysfunctional in or there can be three.  Until you optimize each movement pattern and achieve correct muscle balance, there is a risk that your TFL will be achy. The goal of this tutorial is to provide guidance on how to determine which of your movement patterns are dysfunctional and how to improve them. 

The recommended way to use this tutorial is to identify which movement patterns you are weak in and then tailor your training to these findings.

Practically speaking, I suggest everyone perform the “TFL warm-up” from Step 1 below and then add specific exercises from Step 2 to optimize dysfunctional movement patterns. 

You may only need to improve one movement pattern or you may need to improve all three of the suggested movement patterns.  It really depends on you and it is highly individualized. The only way to know is to attempt each group of exercises to see if they are challenging for you.  If they are challenging, then you need them. The harder an exercise is, the more you need it! 

It is also important to note that the below warm-up and movement patterns are not an exhaustive list on how TFL pain can be improved. 

This is one routine that has worked for me and my clients, but there are a lot of other options. The important thing is to understand the principles at play.  

If you find other helpful exercises or methods to improve your TFL pain, by all means include those exercises in your training protocol and use the recommendations here as a way to help you think about how you implement those exercises into your training.

Step 1 – TFL Warm-Up

The Banded Hip Circles and Softball on TFL are two great drills to warm up the hip if you’re struggling with TFL pain.  You can also use this as a part of a warm-up before your normal workouts or other dynamic activities. 

Banded Hip Circles

A  chronically shortened TFL can cause instability and restricted movement of the femur in the hip joint. The way in which we establish stability and smooth movement in the hip joint is by introducing optimal muscle balance around the hips. 

However, I've  found that this can sometimes be difficult to do by simply strengthening the weak muscles because of how immobile and stubborn the hip joint can become. This is why I  recommend starting with gentle banded distraction drills to mobilize the hip joint before performing any activation drills.

Softball on TFL 

Once we’ve mobilized the hip joint a little bit, let’s reduce some of the excess tension in the TFL.  The most helpful tool I’ve found to really get into the TFL is a softball. This may be quite painful at first and you may not be able to get much body weight on the softball in the beginning.  All this means is that you need it even more so stick with it! 

Make sure you’re not just doing this passively and really try to “chase the pain” so that you’re releasing some tension and allowing the muscle to relax.   This can also be a good way to evaluate the progress you’re making since less tension in the muscle usually means less pain and discomfort. 

Step 2 - Movement Pattern Optimization 

This step takes a look at movement pattern issues. 

Hip Internal Rotation 

A common pattern I’ve seen with individuals who have TFL pain is that they also have extremely limited hip internal rotation. 

90 90 Mobility Drill with No Hands - Test for Restriction 

The 90 90 mobility drill is an easy test to evaluate your internal rotation. 

If you had trouble with that test, then here are some things you can work on.

Prone Hip Internal Rotation with Strap 

A great way to improve internal rotation is by implementing the contract-relax technique to develop more range of motion.  All you need for the below exercise is a yoga strap or a belt that can wrapped around your foot.

After you have performed the Prone Hip IR exercise, go back to to the 90 90 mobility drill to see if there is less restriction in the movement.  

90 90 transitions with hands

The 90 90 mobility drill is a great test for internal rotation but also a great mobility drill to enter and exit those deeper ranges of motion. If you are still having trouble without using your hands, try the following regression. with your hands to help you. 

Hip Flexion 

Another movement pattern that is commonly dysfunctional in those with TFL pain is hip flexion.  A great way to evaluate your hip flexion muscle function is by testing your high hip flexor muscle activity in the seated position.  

The seated hip flexion sequence can function as both a test and beginner exercise to reintroduce proper hip flexion muscle engagement.   Perform the following exercise and notice if you can feel the high hip flexors begin to contract as you flex your hip and extend your knee.  

Seated Knee Flexion and Extension

If you had trouble recruiting the  hip flexors in this position or your muscles become fatigued before finishing the prescribed volume, work on this exercise for a couple weeks until it becomes easy.  Remember, you’re not just passively lifting your leg. you are bringing awareness to your hip flexors and ensuring that you feel a contraction in the correct place. 

Once you’ve mastered the seated position, you can begin progressing to more challenging hip flexion exercises.

In the following video, you'll find some more exercises that you can experiment with as you become stronger.

V-sit leg lifts - Intermediate/Advanced

As you get better at hip flexion, you can start to play with different angles of hip abduction and internal rotation. The V-sit leg lifts are a brutally difficult test for your hip flexors. 

Hip Abduction and the TFL

The last movement pattern is hip abduction and I intentionally placed it last because it is usually the most difficult pattern to disassociate an overactive TFL from.  In my own experience, any type of hip abduction exercise would exacerbate my TFL pain.

It wasn’t until I began using the TFL Warmup that I felt confident enough to begin retraining this movement pattern. 

Having said that, this is an essential hip movement to get proper control over. Move through the progressions listed below slowly and don’t try to obtain too much range of motion too quickly.  Respect your current limits and ask the body for a little more range each workout. Perform the TFL Warm Up before any hip abduction exercises so your hip is nice and loose before seeking more range of motion in hip abduction. 

Work on each of the below exercises until they become easy, and then move on to the next harder exercise

Beginner -  The Fire Hydrant / 4-point Hip Abduction

Intermediate -  Side-lying leg lifts with resistance 

Intermediate/Advanced - Butterfly Abduction 

Closing thoughts on TFL pain and hip pain

If you’ve been consistently using the TFL Warm Up and improving your weak movement patterns then hopefully you’re beginning to notice improvement in your TFL pain.  You may start noticing that certain movements or exercises are more helpful than others.  

I like to tell my clients that finding out an exercise is not helpful is just as important - if not more important - than finding out an exercise is helpful.

Start filtering out the stuff that doesn’t work and continuing to improve the stuff that does.  

Once your TFL is feeling better and more functional, remember to keep training your hips! Pain is a sign that things are getting out of balance. So if you allow your hip muscles to get out of whack, the pain can come back. And it probably will. 

Ultimately, you’ll want to keep progressing and challenging yourself in the movement patterns that you have the most difficulty with. 

This tutorial provides some great ideas on how to get started, but eventually you’ll want to include more variety and difficulty to continue optimizing the all the movement patterns your hips are capable of. And there are A LOT of movement patterns they are capable of!