How do you fix trigger points with FAI?

You’ve been told you’ve got hip impingement. You don’t want surgery. You’ve started learning how to exercise your hips and to do massage work on yourself. Now you’ve discovered TRIGGER POINTS!

Someone posed this question on a Facebook support group for people who are suffering with femoroacetabular impingement (FAI):

I do have a question about muscles that need strengthening (as glutes) but that are painful because full of trigger points…same for muscles that need stretching but are full of trigger points. What do you suggest in such cases? I know that muscles with painful trigger points shouldn’t be stretched or strengthened, you should first get rid of the trigger points otherwise they get worse. But then, if they can’t be strengthened too much or stretched, how do we get rid of imbalances? It’s something that hapoened to many of us, working with painful muscles can make things worsen, so even simple strengthening sometimes is a no go, I have lagged behind in my rehab because of this, the continuous setbacks due to working with muscles that had trigger points…and I still have this problem. Even massaging or relaxing with myofascial release doesn’t get rid of them completely, so do you still recommend the exercises in your channel if let’s say, gluteus medius, is painful and flares up?

To provide some context: our general contention is that hip mobility issues are NOT a result of bone shapes. You can gradually and drastically improve the function and range of motion of the hip by training the muscles properly. The X-ray and MRI signs of femoral acetabular impingement are entirely or very close to entirely irrelevant.

As I’ve noted in previous posts, the radiologic findings have not been shown to correlate to pain or even range of motion deficits, so it doesn't make sense to attribute range of motion deficits to bone shapes.

To reprogram the muscles to work correctly, however, is literally a pain in the butt, as this woman notes in her question. Trigger points can flare up when you stretch and strengthen muscles.

There are two parts to this answer on trigger points and FAI...

First, the philosophical part of trigger points

Ask yourself: Is it a safer bet to manage the trigger points while doing exercises for the rest of your life...

...OR is it a safer bet to cut into your skin, peel back some muscles, shave off a piece of your bone, possibly remove or tack down a piece of labrum, and then stitch you back up for a recovery that could last an indefinite period of time with rehab exercises for the rest of your life?

Option 1 means you keep all your original equipment, which means forward progress would be limited only by normal human potential. If you are able to rehab your muscles, you’ll also be able to develop strength and mobility beyond what you probably think is possible.

What does that mean? The upper limit of hip mobility is demonstrated by gymnasts, acrobats, olympic weight lifters, hockey goalies (my favorite), etc. They are humans. They train. They bring their muscles to a level of coordination and strength that is incredible. Still, they are human, and what they have achieved is a result of training and work. They illustrate the upper limits of your potential should you choose option 1. If you put in the work and discipline, it is actually conceivable to move your hips exceptionally well over time.

Option 2 means you are hoping the surgery does provide relief AND that the surgery does not in anyway drastically affect your future physical potential.

Having read stories of unsuccessful FAI surgeries, I personally never thought option 2 was a safe bet for either the former or the latter.

Even if you get pain relief, you are sidelined for months if not longer, and you are then put on a lifetime of exercises designed to keep you above a minimum acceptable level of function. You are warned not to “overdo” it. Your potential is forever crimped by the feeling that if you do just a little too much, your hip may fail you.

This begs the question: what is happening anatomically that you can “overdo it” post surgery? Why would there be any problem if you have surgically removed the problem?

Again, the health of the muscles play a key role, even if you DO get surgery.

A brief aside on the results of FAI surgery

I have a client who feels his FAI surgery has left lasting damage, and I have read plenty of stories out there from people who feel the same. I’ve also personally met many people with stories of continuing or increased or displaced pain after surgery. So option 2 is shaky to me in terms of short term and long term outcomes, so I would never place my hope there personally.

That said, I would be lying if I claimed I never thought about hip surgery for myself. I thought many, many times about how I might really need surgery for the grinding, popping, and weakness. But knowing that surgeries are FAR from guaranteed to help, I always put it out of my head quickly and kept forging ahead.

Second, the very practical approach to dealing with trigger points and FAI.

While I was rehabbing my hips, my right glute max, glute medius, and piriformis (and its 5 deep rotator friends) would keep me up in bed with cramping and aching. Some days, I’d actually get pain in my right knee as well.

After I thought, “maybe I need surgery,” I’d try to deal with the problem as best I could. If my butt felt tight, I’d sit on a lacrosse ball, massaging out the trigger points. Then I’d get right back to doing my glute strengthening exercises.

When my right knee started hurting (it had been clicking and popping for literally years), I tried stretching my quads, foam rolling my quads, massaging my quads…and that didn’t help. Then I just thought, “what the hell? Maybe my glute could be responsible for this?” and I got back on that lacrosse ball. As if by magic, my knee stopped hurting. In hindsight, it seems reasonable to think that tightness in the glutes and in the deep hip lateral rotators could cause strain at the knee.

A constant torque of lateral rotation into the femur would put strain on the knee joint and the soft tissues that stabilize it. Once I identified the pattern for my body, I always knew what to do when the knee started hurting.

Any time a problem would crop up, I’d release the trigger point and keep moving forward. It didn’t matter where it was. My inner thigh felt too taut? Release, stretch, repeat (actually there are very good reasons to be smashing and stretching the inner thighs).

I would do glute exercises every day, multiple times a day, and if it seemed like my butt was overworked, I’d release it with a ball or foam roller, take a little rest if it felt necessary, and get back to it.

Setting expectations with your FAI trigger points

I have clients with various hip and shoulder and back problems — some with trigger points at the heart of the problem, some with weakness at the root of the pain. 

Sometimes within the first 30 minutes of doing some massage work, we see huge improvement (e.g. pain completely gone). Sometimes we see an up and down curve of improvement.

Sometimes massage work actually makes pain WORSE. This is a case where "tight muscles" are actually WEAK muscles.

Progress with FAI is rarely linear or instant, but over time muscles learn and motor control improves. You just need to learn how your body works and what your body needs to feel good to move forward.

A summary of FAI trigger points…

It’s important to realize that a trigger point is not a sign that your body is broken. It’s just a naturally occurring phenomenon that you can do something about and that you should proactively approach. As you release those points, they stop occurring as often.

You’re training your body to become comfortable with a new level of muscle activity and a new resting length of specific muscles. As with anything, there is a learning curve.

Your body will resist change. That’s natural. But if you take the long view and maintain your course, your body WILL learn to adapt.