Snapping hip syndrome (SHS) is a common injury in rowing. The most noticeable characteristic of SHS is a palpable or audible “snapping” sensation around the hip joint that may be painful or not painful. There is Internal SHS, felt more toward the groin and associated with the iliopsoas tendon, and External SHS, felt on the outside of the hip around the head of the femur and associated with IT band tendon or gluteus maximus tendon. Both forms of snapping hip syndrome in rowing are common, uncomfortable, often painful, and are usually a chronic injury, not a traumatic injury (Cheatham, Cain, Ernst, 2015). Snapping hip syndrome in rowing is common due to the seated and bilateral nature of the sport, which can result in chronically tight hip flexors, increasing risk of SHS. Prevention of snapping hip syndrome in rowing revolves around care of the hip flexors and muscles involved at the pelvis, as well as strengthening the antagonist muscle groups to prevent chronic hip flexor tightness and move through a full range of motion (Hannafin, 2011).
I personally dealt with external SHS after a particularly vigorous early winter season of rowing training. I have since learned a lot about the mechanism of injury and the anatomical causes. In my case, the main problem was adding too much training volume too quickly. In Part 1 of our rowing injury prevention series, Blake wrote about the 10% rule for increasing training volume. I did everything that I now advise against, ramping up volume quickly on my own, adding sessions of lifting and erging to my coach’s team program without her advice or input, and neglecting unilateral forms of training, and I ended up with an injury. Let’s learn, strategize, and move forward!
Snapping Hip Syndrome Causes
Restricted mobility of the hip flexors, or the muscles of the anterior thigh, is a common problem in rowing. In most other sports, practicing and playing is an opportunity to break from the daily seated lifestyle of sitting in the car, sitting in a desk at school, sitting at work, and sitting at home watching TV. For rowers, practicing your sport just means more sitting. In addition, rowing also emphasizes the muscles of the quadriceps and minimizes involvement of the glute muscles. The main muscle of the quadriceps, the rectus femoris, is also a primary hip flexor, while the glute muscles are the antagonist, or opposite-acting, hip extensor muscles. Furthermore, other hip flexors like the psoas, iliacus, and tensor fascia lata (TFL) are constantly engaged when rowing and erging to maintain upright posture, stay balanced in the boat, and maintain body angle on the recovery. It’s easy to see how rowers can develop chronically tight hip flexors that can lead to this condition.
To reduce risk of SHS, we focus on fixing any rowing technical issues, increasing hip flexor flexibility to alleviate the wrenching effect on the muscular structures in the hip, and strengthening the glute and other hip muscles to restore postural balance and prevent the hips from getting so tight in the first place.
First, if you feel the symptoms of SHS, you should consult a doctor or physical therapist rather than trying to self-diagnose. Most athletes wait until they feel pain associated with the snapping, but because this is a slow-developing, chronic, overuse injury, it’s vital to catch it early on (Garry, 2017). Certain styles of rowing can also aggravate hip flexors, such as those with a very deep lay-back position at the finish. We might try to treat the problem with mobility work, or strength training work, when we should really be addressing the rowing technique creating the problem.
If you don’t have SHS symptoms, you can use the Thomas Test to quickly assess for restricted hip flexors, and then take action to improve your hip flexor mobility. Restricted hip flexor mobility is such a common issue in rowing that I advise always including some preventative work in routine rowing training. For example, the three-way hip opener is a staple part of my rowing warmup.
Preventing Snapping Hip Syndrome
Unlike the multifactorial, more complex low back pain or rib stress injuries, the risk reduction plan for SHS is pretty straightforward. On the physical side, it revolves around stretching and manual therapy for the hip flexors and quadriceps, strength training for the glute muscles, and unilateral exercises to work the muscles of the hip and legs through a complete range of motion.
#1. Rowing Technique and Training
Make sure to clear up any issues in the athlete’s rowing technique before moving ahead to physical interventions. It creates a frustrating loop to chase possible physical causes of an injury when it turns out that the athlete is taking hundreds and thousands of strokes per week in a problematic movement pattern that contributes to injury. Athletes who have a poor hip hinge technique and achieve reach with the shoulders and back, instead of through the pelvis, or those who row with a very deep layback position, put excess stress on the hip flexor muscles. If the athlete struggles with this fix, try this “hands-behind-the-head” drill to teach good torso positioning and drive/recovery sequencing. Good technique can be good technique because it maximizes speed, and also because it minimizes risk of injury.
Training is the second piece of the puzzle. Athletes often develop SHS during especially heavy phases of training, especially when the training volume and/or load escalates quickly. In my case, this was due to my ignorant additions of extra training too much and too quickly. However, research indicates an increase injuries, particularly of the low back, during training after time away from structured training, for example, winter holiday and summer breaks. Coaches should plan a gradual progression of training load following more than one week away from regular training to reduce risk of all rowing injuries, including SHS.
#2. Warming Up
With rowing technique and training out of the way, we’ll now discuss some physical interventions for reducing risk of SHS. First, a thorough rowing-specific warmup is critical to reducing risk of many common rowing injuries. The warmup that we use before rowing, erging, and strength training includes exercises to stretch the hip flexors, activate the glutes, and move through a complete range of motion before getting into a seated position in the boat or transferring force in strength training. Warming up is good for reducing risk of injuries as well as for rowing performance, as warm and pliable muscles perform better than cold and tight muscles.
#3. Stretching and Self-Massage Therapy
Research suggests that massage and self-myofascial release, aka foam rolling, of the relevant hip structures is effective in SHS rehab and reduction (Cheatham, Cain, Ernst, 2015). Focus on hip flexors, quadriceps, and groin muscles. I recommend at least 10 minutes a day, and even better if you can do two separate bouts of 10 minutes. Consider all the time you spend sitting and using these muscles and the amount of time and consistency it will take to offset that. A warmup with some specific dynamic hip flexor stretches in the morning before training, and then an evening 10-minute bout of focused hip flexor rolling and stretching is a great way to fit it in.
#4. Strength Training
Strength training to reduce risk of SHS focuses on developing the muscles of the hip and lower body, which is conveniently similar to strength training to improve rowing performance. The squat, front squat, and deadlift or Romanian deadlift are important exercises because they develop the quadriceps, glutes, hamstrings, and other muscles of the pelvis in coordinated activity, not in isolation like leg extensions and leg curls. The basic idea here is that the hip flexors should not be doing a lot of work in the stroke. If they are, it most likely means rowing technique is faulty, or the athlete is too weak to correctly achieve stroke technique. If the athlete can’t get sufficient force from one muscle group in a stroke, they’ll get it from somewhere else to achieve higher rate or pressure, so strength of major muscle groups has a protective function by keeping excess pressure off of these smaller groups. This is similar to strength training prevention strategies for LBP and RSI.
However, bilateral exercises can also aggravate symptoms of SHS. The single-leg squat is an exercise I always include in my rowing strength training programs, so I was pleased to see it turn up in SHS rehab and prevention as well. I use the rear-foot-elevated split squat most, but a reverse lunge is also fine. Both of these exercises can be weighted once bodyweight is no longer challenging. Unilateral exercises are great for rowers for a few reasons. One is that they force development of opposite sides evenly. Sweep rowers often have strength imbalances between outside leg and inside leg and, if they aren’t very attentive to technique, can often shift balance to the stronger outside leg when doing a bilateral exercise. Another is that single leg exercises stretch the back leg (the one not doing the work) through each repetition for the front leg. This accomplishes two goals at once, as the front leg is getting stronger while the back leg is getting a good dynamic stretch for the hip flexors on every rep. Both the strengthening and the dynamic stretching effect of this exercise is great for rehab and reducing risk of SHS.
Additionally, some isolation exercises will be useful for fixing specific muscular imbalances. Researchers suggest that exercises such as single-and-double-leg hip thrusts, side-lying hip abduction, and side-lying hip rotation (“clamshells”) are effective ways to strengthen the hip muscles, while avoiding further aggravating the iliopsoas tendon for athletes experiencing symptoms of SHS (Cheatham, Cain, Ernst, 2015). Researchers found that eccentric hip abduction strength was 16% lower in patients with SHS symptoms compared to matched controls without SHS, suggesting that strengthening this movement pattern may reduce risk of SHS (Jacobsen et al., 2012). Side-lying hip abduction and X-band walks are my go-to exercises here. This is all work that can be included in a warmup or in the assistance exercise phase of a strength training program, and has benefits beyond just reducing risk of SHS.
Wrapping It Up
Restricted hip mobility and weak lower body muscles aren’t just bad for risk of SHS, they’re bad for rowing performance as well. Research and my own experience suggests that hamstring flexibility for rowers is overrated. I have found that hip flexor restriction is more often a limiting factor for reach, and also more problematic for low back pain. Hip flexor tightness may also be a contributing factor to self-diagnosed hamstring tightness. If the hip flexors are so tight that the pelvis is pulled into anterior tilt, the hamstrings will be over-stretched due to the pelvic positioning. In the stroke, the athlete will often be unable to maintain an upright posture, forcing them to round their back to reach rather than maintaining a braced torso. Clear up hip flexor tightness with targeted stretching and strength training to allow the athlete to sit upright and engage their core, and reach problems and supposed hamstring tightness often disappear.
In the short run, SHS caused me to take about three weeks off of training to ice, massage, stretch, and reduce the inflammation before I could start building again. Long-term, it took me almost a year before I didn’t have any symptoms after running or lifting. Any practice or water time missed is frustrating, but this injury in particular can cause a lot of missed time and frustrating sessions. We can do a lot as rowing coaches and strength coaches of rowers to reduce risk of this common injury, and keep athletes in the boat longer for more productive training sessions and better performance.
Last updated February 2019.