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The Therapists invoice

We have all heard the parable of the handyman’s invoice to explain the value of knowledge verses the value of work. The story ends with an invoice for £10,000. Broken down as £2 for hitting the broken engine with a hammer, and fixing it! £9,998 for knowing where to hit it.

Now we don’t use hammers ‘thank goodness’ but some therapy tools are looking increasingly similar. We have more therapy equipment, exercise equipment, medicines and surgical procedures available to us and our patients than ever before and as a result it can be tempting to take a scattergun approach to treatment and rehabilitation, especially when under patient pressure. Desperate patients make therapists desperate to deliver treatments. Our treatment approach also changes over our career, mostly from experience and education but perhaps also in response to popular views and treatment fashions made so much more viral on social media.

One such fashion is the focus on glutes in both the fitness and rehab circles and with this often comes the hip flexor stretches!

Now please don’t misinterpret me at this point. Glute exercises and hip flexor stretching is helpful for most people and probably very helpful for select patients. There are some patients who might find hip flexor stretches increase their problems and that holding your glutes tense might not be so good for your hips.

Do not do hip flexor stretches with patients with Femoroacetabular impingement (FAI).

What is FAI: FAI is defined as anterior hip pain with activities and upon hip flexion and internal rotation testing by a therapist plus identified structural changes (cam or pincer) on X-Ray. Surprisingly FAI is not diagnosed by X-Ray alone and requires a combination of imaging and clinical findings.

Symptoms: Anterior groin pain which is exacerbated by hip flexion activities such as deep squats, cycling or low chairs. On assessment hip flexion and internal rotation is often limited and painful.

Management: Patients with FAI do not necessarily need surgery and can respond well to exercise and activity modification.

What to avoid:

• Avoid deep squats and hip flexion activities, mountain biking is usually fine but trying to get down on the drops on a road bike can irritate the hips.
• Hip flexor stretches can actually irritate the anterior hip as the femoral head pushes forwards into the labrum.
• Glute stretches can also be difficult to perform due to the limited hip flexion or irritability of such movements. I always tell patients ‘Stretch is good, squash is bad’ as a general rule to stop them doing any unhelpful exercises in between appointments.

What should be done:

• Instead of stretching the glutes try teaching some gluteal SMR techniques with a ball as shown in the images.
• Advise excessive butt exercisers to literally ‘tone it down’ and relax their butt. Diane Lee (awesome Physio) referred to a patient group known as ‘butt grippers’ who for various reasons keep a constant tone in a muscle group designed for intermittent power and not constant tone.

Exercises should be functional and avoid excessive hip flexion or internal rotation. Banded abduction squats, step ups, 1 leg squats.


• For patients experiencing anterior groin pain remove all excessive hip flexion activities from their exercise programme.
• Advise they seek an XR from the GP to help inform the management plan.
• Hip flexor stretches and excessive glute training should be stopped.
• Glute massage, SMR, release techniques can be helpful.
• Glute exercise should be functional.

Got this far:- Want to know more? Daniel is the author of the Lower Limb Tendinopathy book  and the director of our education courses all of which are found here.