Strategies to deal with anterior hip pain and discomfort in the bottom of the squat

Hello,
I am looking for some advice or experience for the following condition.

Backstory:

I have this recurring issue of hip pain when reversing at the bottom of the squat. I’ve been dealing with this on and off for about 2.5 years now, and I think it has hindered my squat progress. It was bad enough 2 years ago that I didn’t squat often or only light for some months, but eventually it got somewhat better. But I only really got back to proper training when I started purposefully allowing a little pelvic tilt at the bottom, not trying to keep the lumbar fully neutral, leading me to believe the issue may be hip flexor- and pelvis stabilization-related. This movement pattern didn’t give me problems, but I do fear it ingrained a squat morning pattern in me, which I’ve been trying to get rid of for almost a year now.

Current State:

  1. The level of discomfort is variable across days and weeks. I also think it has moved between left and right hip throughout the years, but I’m not entirely sure and now its bilarteral. Some sessions are worse than others, but the pain is never fully absent during normal squats.
  2. I can even feel twinges of it on the leg press, but less severe
  3. The pain is not so bad that I couldn’t power through, but bad enough to distract me, increase RPE significantly, and reduce my confidence a lot.
  4. I don’t have pain in daily life due to this issue
  5. The pain appears to be related to the load unsurprisingly, and pain-free loads are probably below 70% of 1RM
  6. The pain is less or absent when doing paused or pin squats, it really seems to be the rapid reversal at the bottom of a normal squat that triggers it
  7. I can sometimes feel the discomfort throughout the day after the session. It doesn’t affect my daily life, but it can take hours or until the next day until it has fully dissipated
  8. The pain is not really reproducible any way other than squatting. I could sometimes trigger it with rear-foot elevated split squats, placing the hip under a loaded stretch, but last time I tried this, I was suddenly pain-free, but it still occurred during squats. Maybe the two are unrelated. What I’ve tried
  9. Incorporating movements to strengthen the hip flexors. Some form of leg raise in neutral and shortened hip position, split squats with one hip in a stretched position and actively pushing through that leg, I also no reverse nordics once a week.
  10. My training already includes pause and pin squats
  11. Not training at all for a week (not for this reason, but I can just say it has not changed anything)
  12. Cueing myself to keep knees out in the bottom of the squat more, as I sometimes felt this was easing the problem, but turned out to not be realiable. Also trained the abductors isometrically for a few weeks. The only thing I have not done, is just not attempting to do regular squats at all for a while, as I assume someone may suggest. Would avoiding this specific squat variation, or training it really only at loads that are completely pain-free be the best way forward? Just loading them to “tolerable” as I am currently doing does not seem to help.

Is it in any way useful trying to understand the exact cause of the problem, or should I just focus on getting the movement I want to do back to a pain-free state?

Does anyone have experience with this specific issue or could offer some more objective assessment of my situation?

Does anyone have experience with this specific issue or could offer some more objective assessment of my situation?

Unfortunately it is not possible to provide a confident, “objective” assessment via the forum; but if you are interested in a more detailed, individualized consultation, our rehab team would be happy to help.

Would avoiding this specific squat variation, or training it really only at loads that are completely pain-free be the best way forward? Just loading them to “tolerable” as I am currently doing does not seem to help.

Sometimes when people have been struggling with the same issue for a long time, it can indeed be a viable strategy to temporarily swap out a particular sensitive movement for alternatives. However, given that there are loading ranges that you can use pain-free (assuming this includes “pain-free” both during the session and afterwards), this may not be entirely necessary.

Is it in any way useful trying to understand the exact cause of the problem, or should I just focus on getting the movement I want to do back to a pain-free state?

I do not think that identifying a single exact cause is often possible in these types of scenarios. I think that many of the general principles discussed in our pain in training article are applicable here. You’ve done the first step of training at lower intensities and found it to be tolerable or even pain-free. However, I did not see much about other movement variations or any other programming details. For example, the use of unilateral exercises such as split squats/bulgarians, cossack squats/lateral lunges, single-leg RDLs, etc. can all be useful in the context of knee, hip, and low back pain rehabilitation. There are sample programming approaches described in that linked article, but we don’t have enough information about you here to lay out an individualized training plan, but that would be the kind of thing our team specializes in when working with folks.

Ultimately, the combination of lower absolute intensity (and potentially relative intensity, i.e. staying further from failure), increased movement variation (including bilateral and unilateral movements), and adjusting the overall training volume/frequency based on your tolerance and recovery, would be a wise approach. From there, the weights will naturally trend upwards as recovery/adaptation occurs (in other words, do not view it as needing to increase the weight in order to induce adaptation. This is discussed in further detail here).

Thank you for these thoughts.
I have started to replace the squatting slots by either squats at much lower intensities and/or slow tempo and I will also go down in volume. Furthermore I’ve resolved to give some love to rear-foot elevated split squats, probably I will swap these in for one of the squatting slots. There are usually 3 per week, 2 for normal squats and 1 paused variation, so I have some budget to allocate.

What is not really clear to me from the articles is how I can prescribe myself a progression and how to know when to pull back. For lack of a better idea, my plan is to do sets of 10 and bump the load by 5kgs each week, which would have me arrive at normal loading in about 8 weeks time. In the grand scheme of things, my symptoms are not that severe, I can do the target movement after all. But as this has been a long recurring problem, maybe I should take it even more slowly?

My GP referred me to an orthopedic doctor and would not prescribe physio otherwise, she even mentioned “imaging” (possibly not as a real recommendation though and I doubt the ortho doc will go to that length). Would any kind of imaging be indicated for an injury like this? The GP gave me the impression that because I have had this for years that an ortho assessment would be necessary, but I am uncertain if just the duration of the injury would change the management at all.

See the section in the article titled “Progression and Expectation Management” for guidance on this.

Hard to say via the forum; this would need more detailed conversation.

I thought maybe it’s informative for some to get an update here.

I haven’t made much progress on this issue, I tried to manage it with my coach by continuing to squat to tolerance, and that worked (without improvement or worsening of symptoms) for a while, but eventually it got worse and we removed squatting entirely, as the aggravation persisted throughout the day or days after the session.
I also did get an MRI, even though I am aware that it likely would not change management and the radiologist was of the opinion that there were both bilateral small labral tears (probably asymptomatic) as well as rec fem tendon irritation, which at least seems like a plausible diagnosis. I have to flex the knee in order to be able to provoke the hip pain, so I had been wondering if it could be rectus-femoris-related. This is also supposedly bilateral, and more pronounced on one side.

The ortho tried to sell me on their shockwave therapy treatment, is there any evidence that this is a useful therapy?

Regardless, I have accepted not squatting for a time and attempting to make do with other leg movements to let the area rest up and my kniesiophobia and frustration retreat for a while.

Two months later I have done no squatting, and only done leg press, some extensions, lunges. Leg pressing tended to be mildly discomforting, but much better than squatting, and my symptoms throughout the day disappeared completely. So I hoped I was finally making some progress.

Then I tried out some squats again, and even during warmups, I was transported back to the same state from half a year ago. And depending on the weight, I can tolerate it, but it’s not comfortable, and some discomfort persists after the workout. It is disheartening to find that neither tolerable exposure, not regression from the offending movement seems to make a difference for me.

I am thus unsure what to do next. Regress further and remove leg pressing and just do leg extensions for instance? Strangely those have fewer problems, even though the rectus femoris contribution is much larger.

Given what you have written so far, and the evolution (or lack thereof) of symptoms this is a point where I would recommend working with one of the rehab coaches. As Austin mentioned above, it is almost impossible to go beyond general advice on the forum as each person tends to have:

  1. different entry points
  2. different beliefs about training and style in which they train
  3. different strategies that are best to address the issues.

While there are principles that we can follow and advise on, the specifics get a little muddy. That being said, from the modifications you have tried, even if we were to work under the premise of some “hip flexor irritation,” there has not been much stress/exposure applied to the front of the hip with those modifications. It sometimes it not about getting stronger per se as it is giving the area the adequate stress to adapt, and be able to calm down. If you had not had any real exposure to squatting in sometime, the novelty of the activity could be as much the contributor as anything else. It also would appear that most of the modifications were still primarily in the flexion/extension types of movements. While there is certainly a case to be made for some constrained movements, the hip has many directions in which is can move, and be trained. From a principles standpoint, I likely would start with some specific hip flexor work through tolerable range of motion with a slower tempo. Things like reverse nordics, hip flexor sit ups, or if your knee extension machine does not have a back on it, leaning back more for knee extensions. Then I would start working in different planes as much to get your hip moving in new directions as anything else. Sometimes when an area is irritated we need to work around to build up a base as much as modify the thing we want to do.