You have been treating your back for months. You have stretched it, rested it, maybe had it imaged, and it keeps coming back. Somewhere in there, nobody asked about your groin.
That is the gap where hip impingement lives. It is common and it responds well to treatment. It also spends a lot of time being mistaken for a lumbar problem, which means people do months of the wrong exercises for the wrong joint and then decide therapy doesn't work for them.
By The First Rehabilitation Team · Reviewed by Dr. Dave Kashuba, Ph.D.
What hip impingement actually is
The hip is a ball sitting in a socket. Femoroacetabular impingement (FAI, if you want the short form your surgeon will use) means the two do not clear each other cleanly through their full range, so they collide at the edges instead of gliding.
Cam and pincer: two shapes of the same problem
It comes in two shapes. In a cam lesion the ball is misshapen. Orthopedic surgeon Dr. Zach McVicker, MD, who joined Dr. Dave Kashuba on Episode 10 of our Pain 2 Power podcast, puts it this way: “instead of being round, it's more like an oval peg in a round hole.” In a pincer lesion the shape problem is on the socket side, which covers more of the ball than it should. Cam lesions turn up more often in men, pincer lesions more often in women, and pincer cases are the more technically demanding to repair. By the time they reach a surgeon the labrum is often calcified, and it has to be reconstructed rather than simply repaired.
The labrum, or why a small tear matters
Around the rim of the socket sits the labrum. Dr. McVicker compares it to a gasket between two pipes. It creates a suction seal that spreads your body weight across the whole dome of the joint with every step. When that seal fails, load stops being shared and starts concentrating on cartilage that was not designed for it. In his words, “if you lose that suction seal, you're going to lose the pressure, it starts increasing pressure on the cartilage in there.”
Think about what that means over a day. Every step you take loads that joint with the weight of everything above it. Spread across the dome, that's manageable. Concentrated on one edge, it wears fast.
| Problem | What is wrong with the shape | Who tends to get it | What he said about it |
|---|---|---|---|
| Cam lesion | The ball is misshapen, “an oval peg in a round hole” | More often men | Impingement, cam and pincer together, is the most common hip problem he sees |
| Pincer lesion | The socket covers too much of the ball | More often women | Technically harder; the labrum is often calcified and has to be reconstructed |
| Hip dysplasia | The socket is underdeveloped, so load sits on the edge of the cartilage | Classically gymnasts and dancers who trained hours a day while still growing | The second most common problem he treats; edge loading “ends up in arthritis 100% of the time” |
The symptoms people miss
Groin pain is the one to know. “I think that groin pain, number one, that's the most common symptom,” Dr. McVicker said. It is also the detail that separates a hip problem from a back problem in the clinic, because Dave's tell is where the pain travels: toward the groin rather than down the leg.
Around it cluster the symptoms that get attributed elsewhere:
- Low back pain that never quite responds to back treatment
- Pain over the SI joint, or aching toward the buttock
- Soreness on the outside of the hip
- For some people, pelvic floor dysfunction, because some of those muscles are affected by the hip
- Trouble with walking itself, which he described bluntly: people are “unable to walk. It stops them in their tracks.”
Pain shows up with anything that torques or pivots under load, which in Palm Beach County means golf, tennis and pickleball. Dave has seen this diagnosed for the first time in seventy-year-olds who are still on the court several days a week. It isn't only a young athlete's problem around here.
Two clues Dave watches for
One is the belt buckle. Watch where a man's belt buckle points. If it tips downward rather than sitting flat, just from the way the pelvis is aligned, the pelvis is already tilted, and hip pain is usually not far behind.
The other is for women, who Dave pointed out tend to have wider hips and more laxity in the joint. His advice on air was not to brush off back pain or groin pain, and to get it looked at rather than waiting it out.
Why a hip problem shows up as back pain
This is the part that confuses people, so go slowly here. Your hips and pelvis sit underneath everything else. Dr. McVicker tells patients the same thing every day: the hips and the pelvis are the foundation, “and everything is built off of that, the curve of your spine, everything.” Then the line that explains the referral pattern: “pelvis is a ring. If you're causing abnormal torque across it, it's going to create problems throughout.”
Put that in everyday terms. If the ring is being twisted from the hip end, the strain has to go somewhere, and the low back and the SI joint sit right next door. That's the logic behind looking at the hip when the back is what hurts, and it's why a back program alone can stall when the hip is the driver.
He called hip work a puzzle for that reason. “Sometimes you got to think outside the box with it,” he said. It also takes time to sort out. “It's very, very complicated. It's very intertwined. So kind of have to listen to people a little bit longer.” We'd say the same about a good evaluation on our side of the referral.
How we tell the hip from the back
At the evaluation we ask where it hurts and when, then we test. How far does the hip flex and rotate, and does a particular position reproduce the groin pain? How does your pelvis behave when you stand on one leg? Does pain travel down the leg, which points us toward the spine, or into the groin? Dave offers free consultations for exactly this sorting question, and as he put it on the show, it tells him “whether to send you to Zach or send you to go see a back doctor or an orthopedic that specializes in something else.”
Hip impingement treatment in North Palm Beach: what therapy does
Most painful hips we evaluate have one thing in common: a weak gluteus medius, the muscle on the side of the hip that keeps your pelvis level while you stand on one leg. Every step you take is briefly a single leg stance, so when that muscle gives up, the joint absorbs what the muscle should have.
The first exercise
The exercise Dave starts nearly everyone on is a sit to stand with a resistance band looped just above the knees. The band matters. A sore hip makes you shift your weight onto the good leg, and you will do it for weeks without noticing. Dave's explanation on air: “if you have a hip problem, you have asymmetrical weight shift on one more than the other. So if you add a theraband and you do the same exercises, it stabilizes and makes you equalize.” The movement retrains the pattern instead of reinforcing it.
Building the program
From there the program builds: standing leg abductions holding the back of a chair, kicking away from the midline; clams to strengthen the external rotators, which are weak in almost everybody because nothing in daily life asks for them; a side lying leg raise; and a prone cobra with the pelvis staying down on the floor to open the front of the hip. One piece of practical advice from Dave that belongs with any floor exercise: make sure you can get back up before you get down there. All five are written out with sets and reps in the hip section of our home exercise library.
Changing how you load the hip
Load management does the rest. Stop sitting with your legs crossed, and break up repetitive bending. Modify the task rather than abandoning it. And rather than giving up golf, change the swing so it stops driving torque through the hip. “There's ways to change your golf swing and modify your swing,” Dave said, and for a lot of our patients that conversation matters more than any single exercise, because eighteen holes three mornings a week is a lot of rotation.
When it is time for a surgeon
Therapy is where this should start, and for many people it is where it ends. The reason we do not wait indefinitely is that a torn labral seal keeps letting the joint grind at itself.
Hip dysplasia raises the stakes. There the socket is underdeveloped, so the load concentrates at the edge of the cartilage rather than spreading across it. Dr. McVicker's assessment was direct: that edge loading “ends up in arthritis 100% of the time.” Labral tears come early, and the surrounding soft tissue takes a beating. Gymnasts, dancers and long distance runners are the classic histories.
Modern hip arthroscopy is small work, done through a few poke holes with a camera, and it preserves the joint you were born with. Dr. McVicker described the recovery as much less painful than a total hip, though return to sport takes somewhat longer. That is the argument for looking early rather than waiting for the conversation to become about replacement. As Dr. McVicker noted, a replacement can feel close to normal, “but it's not your own hip. You don't have the proprioception” that your native joint provides. That positional sense is what keeps you from missteps, and missteps are what turn into falls.
He also told the story of high school athletes who had been told their careers were over, and who went on to play college sports after treatment and rehab. Dr. McVicker practices with the Paley Orthopedic and Spine Institute in Jupiter and West Palm Beach, and he is one of the surgeons Dave sends hip patients to when a joint needs more than therapy can give it. For the full conversation, read our Episode 10 recap with Dr. McVicker.
And if the hip is past saving
Some hips get to the point where the arthritis has already won, and replacement is the right call. That is not a failure. Orthopedic surgeon Dr. Michael Leighton, MD, who joined us for Episode 12, called total hip replacement “the best operation that's done in orthopedics.”
His recovery priorities were simple and in order: “it's first about getting motion back. Second, obviously allowing the wound to heal.” Many of the old dislocation precautions that used to keep people in traction are mostly gone now, though he still wants patients to avoid the most provocative positions early on. He had kind words for the therapy side of that: “providing them with guardrails like the physical therapists frequently do are really very helpful.” Our post-surgical rehabilitation follows your surgeon's protocol exactly, from the first visit back on your feet through walking without help.
Start with an evaluation
If your back pain has never fully explained itself, or the ache sits in your groin when you get up from a chair, an evaluation is the fastest way to find out which joint is actually responsible. We will look at how your hip moves, how your pelvis behaves under load, and how much work that gluteus medius is really doing, then build the program from what we find. In most cases Florida lets you start a physical therapy evaluation without a referral, and our front desk checks your benefits first.
Call 561-624-4263 or request an appointment. You can read more about our approach to hip pain and back pain, see how we structure physical therapy, browse the physical therapy questions in our FAQ, or hear the full conversation on the Pain 2 Power podcast.
This article is general information, not medical advice. Every situation is different, so please consult a qualified professional about yours.