Yoga and Your Hips: Deciphering Femoroacetabular Impingement and Hip Labral Tears

You may have this condition, and not even know it. In cadaver studies, 93-96% of (careful) hip dissections show hip labral tears (full disclosure: the average cadaver age was 78, but read on).

The labrum is a fibrous lip of cartilage that deepens your hip sockets the way a maternity waistband hugs a pregnant belly (and makes pants less likely to fall down). The labrum has been shown to stabilize the hip in the socket in a similar fashion to the aforementioned pants.

Labral tears fall on a Venn Diagram of hip aches and pains that frequently overlap with “Femoroacetabular Impingement”, also known as FAI (see my own drawing below). FAI usually affects younger to middle age population (as opposed to clear-cut osteoarthritis that is most often diagnosed in older adults) and some authors have associated a physical (hatha) yoga practice with FAI. 

Correlation doesn’t equal causation, and I’ve been sitting on this blog post concept for a long time — I think some clarity on the topic of hip injuries and yoga is overdue.

What is Femoroacetabular Impingement?

FAI is notable because it is considered a cause of premature osteoarthritis, i.e. is on the continuum of degenerative joint disease. Your femur is your thigh bone, the largest and strongest bone in your body. The acetabulum is the socket in which the “ball” or head at the top of the femur rests. Together they form the hip joint, or very specifically, the femeroacetabular joint.

The pinching or impingement of FAI is the thigh bone pressing against the socket, the acetabulum. Other bony prominences of the pelvis can also cause hip impingement.  This may be developmental or congenital, or stem from repetitive extreme ranges of motion. Compression of soft tissue between bone is also possible, and the labrum may be trapped between the thigh bone and acetabulum or the thigh bone and another portion of the pelvis.

The person in pain can’t decipher which one is happening without diagnostic imaging, like an xray or an MRI. Anterior or groin pain is a key symptom of FAI, and almost certainly involves abnormal hip joint mechanics. Pain may show up posteriorly or come on only a certain range (usually full flexion – for example, knee to chest – with internal rotation taking the heel out to the side and knee to opposite shoulder). Instead of pain, there may simply be limited range of motion, typically from the femur having abnormal contact with the socket.

(FYI, many people have a non-symptomatic labral tear).

A diagnosis of Femoroacetabular Impingement is not particularly helpful in isolation. It doesn’t doom you to surgery.  I’d recommend vetting out what might have caused it, and whether you have any of the following conditions that are close relatives of FAI:

  • Iliospoas (or psoas) or general hip flexor tendinopathy: Your main hip flexor (anterior muscles that bring your thighs closer to your chest, such as when climbing stairs) is a muscle called psoas, which shares a common tendon with iliacus. (Tendon is how muscle attaches to bone).
  • Ligament sprain (mild or full tear) at or around the joint, including other pelvic ligaments
  • Acetabular labrum tear (FYI, there is also a labrum in your shoulder)
  • Early hip osteoarthritis (the most common form of arthritis — mainly affecting cartilage at joints), mild cartilage wear and tear, often localized
  • Moderate or severe hip osteoarthritis – widespread or severe, may include bone spurs and even bone on bone contact
  • Other conditions

Western science’s understanding of FAI and labral tears is evolving, but we know that both are much more widespread than previously thought. They may even account for some of cases of back pain due, SI joint pain, or even pelvic pain, the pain referring from the hip.

Labral tears are very likely under-diagnosed, and are estimated to be the cause of hip or groin pain in athletes up to 55% of the time.

How Femoroacetabular Impingement appears in my mind: inherently interwoven with a variety of causes and conditions that also cause hip pain and dysfunction. This is my own drawing :).

How Femoroacetabular Impingement appears in my mind: inherently interwoven with a variety of causes and conditions that also cause hip pain and dysfunction. This is my own drawing :).

What causes FAI?

This is the juicy part I want to emphasize: anyone for almost any reason can get FAI. FAI and labral tears are frequently associated with an active lifestyle, and athletic pursuits, but also have genetic (or epigenetic) contributions.

Labral tears are most frequently at the front of the hip and often are associated with sudden twisting or pivoting motions. Can hatha yoga cause them? Possibly: a rapid transition from ardha chandrasana (Half Moon Pose) to revolved Half Moon Pose could be a cause, but would be much more likely if the hip joint was stuck or unstable initially.

However, this is crucial to point out when vetting cause vs. correlation: more than 3/4 of hip labral tears have no clear cause. The presumptive cause in these cases is repetitive activity. There are repetitive styles of hatha yoga, and teachers with formulaic or repetitive class plans, but hatha yoga itself is vast and quite far from repetitive.

For context, a random smattering of recent patients that I’ve treated with hip labral tears include:

  • a Bikram yoga teacher and competitor
  • a horseback rider who tried to avoid a fall by hanging on tight with the affected leg
  • capoeira practitioner (a capoerista)

Sports commonly associated with hip labral tears include: hockey, soccer, cycling and ballet. Ballet is often lumped together with yoga asana (they are not the same) and other styles of dance (also not the same) in popular media articles on this subject, which I think is an unfair comparison, though I understand the linkage.

But just being alive and moving may cause these conditions.

For example:

  • Unstable pelvis due to relaxin hormone (high levels during pregnancy and breastfeeding, but also at particular phases of a woman’s menstrual cycle)
  • Repetitive movements, i.e. hip flexion in cycling, or driving a manual transmission, or getting onto and off of a tall bed in the same way daily
  • Extreme end range of motion, including sitting cross legged on the floor with young children
  • Anteriorly tilted pelvis or structural abnormalities – hip dysplasia or excess bone growth
  • Labral tears may possibly even be a natural part of aging / passage of time (although not the case of pain in young folks)

Treatment is usually multi-pronged and may range from “conservative” (noninvasive) to major surgery.

On the conservative side, treatment may include:

  • Eliminating aggravating and painful movements, like full flexion with internal rotation
  • Avoiding sharp quick turning motions when your weight is all on one leg (unless training for a specific sport with a physical therapist, biomechanist or highly trained coach)
  • Physical therapy = I’m biased, but this is My Favorite :). And, it works! A skilled physical therapist will take you through strengthening your hip rotators, mobilizing the femoral head in socket, stabilizing your pelvis, examining core strength and gait and so much more.
  • Corrective exercises (which may include yoga poses), usually prescribed by a physical therapist, but possibly by another skilled medical practitioner

Did Yoga Cause my FAI, hip pain or Labral Tear?

It is certainly possible that a yoga practice contributes to hip pain, FAI, osteoarthritis or labral tears. However, you – the yoga practitioner – may have developed these issues anyway – either from pre-disposition (more on this in a future post) or from a distinct physical activity that yoga replaced in your life.

Yoga may also save you from FAI (and its ilk) by 1) increasing your bodily awareness and alerting you to what doesn’t feel ok and 2) from widening your general spectrum of movements and even 3) from its therapeutic qualities (a vague statement, I’m not stating that all yoga is therapeutic).

How do I prevent FAI or a Hip Labral Tears?

I don’t have a magic wand to prevent these hip pathologies, however, a few gems:

First Rule:

As a rule, don’t get into a rut with your yoga practice. Let’s say forward folds are easy for you: do the opposite (a concept from Patanjali’s Sutras known as pratipaksha bhavanam). Use your practice to go into the places that are limited, not to show off your extreme range. Say no to frequent splits (hanumanasana) and passive end-range wildness like foot behind the head pose (eka – or dua – pada sirsasana).

garudasana (eagle pose) to hasta padangustasana (standing hand to foot pose) to ardha chandrasana (half moon pose). Forgive the inaccuracies - this is my own drawing.

garudasana (eagle pose) to hasta padangustasana (standing hand to foot pose) to ardha chandrasana (half moon pose). Forgive the inaccuracies – this is my own drawing.

Second rule:

Juice up your transitions. The spaces between the poses and the time getting into the poses are *just* as important as the pose itself.

Pump up the grace all over the place!

Want to try moving from garudasana to hasta padangustasana to ardha chandrasana? I may not teach it, I may not even recommend it for most, but I am not going to stop you. The solid weight evidence isn’t there to point fingers at this as a cause any more than cycling or sitting — if practiced cautiously. To practitioners and teachers alike: please proceed slowly with a level of care and precision in the transitions at least as much as you would give to the poses.

Have you experienced hip pain? Or a diagnosis of femoroacetabular impingement or hip labral tears? Are you a yoga teacher who has stopped teaching or practicing long sequences on one foot / one side? I’d love to hear from you in the comments below.

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