Sylvia was scheduled for hip replacement surgery due to worn cartilage, a labral tear, and bone spurs found on her MRI. A pattern called anterior femoral glide syndrome, and two simple corrections, changed her outcome.
Rick Olderman, MSPT is an orthopedic physical therapist with 30 years of clinical experience, former owner of an orthopedic PT clinic, and author of the Fixing You book series, including Fixing You: Hip & Knee Pain and the award-winning Pain Patterns (2025 NIEA Award winner). He created an APTA-approved continuing education course teaching other clinicians his systems-thinking approach to chronic pain.
If you’re weighing hip replacement surgery, you’re not alone
If hip pain has gotten bad enough that surgery has come up with your doctor, you already know the imaging can look alarming: worn cartilage, a labral tear, bone spurs, bone-on-bone contact. It’s natural to look at that and assume surgery is the only path forward.
Sylvia was in exactly that spot. Two surgeons recommended a hip replacement. She was walking with a cane and had given up kite surfing, tennis, gardening, and lifting weights.
She canceled the surgery soon after our session together. Here’s what she did instead.
Important: Always follow the guidance of your medical team. They know your case better than an article can. What follows isn’t a diagnosis. It’s an explanation of how your body actually works — something to think about before you decide anything about surgery.
In this article
One BIG Problem Causing Hip Pain (And How to Fix It!) — watch on YouTubeSylvia’s story: from scheduled surgery to pain-free
Sylvia had hip pain for about a decade before it got severe enough, last winter, that she could barely walk without a cane. Both surgeons showed her the same imaging: worn cartilage, a labral tear, bone spurs. A hip replacement was scheduled.
In my clinical experience with her, the underlying driver was anterior femoral glide syndrome (AFGS) — the pattern this article covers. Years at a desk job had left her glutes essentially asleep, and her thigh bone was sliding forward in the joint every time she stood or walked.
She worked through my hip pain home program: glute pump exercises, eventually with 15–20 lbs of ankle weight, and correcting a locked-knee walking pattern using the tiptoe cue described later in this article. She canceled the surgery because her pain disappeared. She’s back to gardening, weight training, and dancing, pain-free. It’s now been four years and she’s still doing great.
Watch the full conversation: How Sylvia Solved Her Hip Pain in Only Six Weeks
Do I need hip replacement surgery for hip pain?
Not necessarily — at least not before ruling out a mechanical pattern first. Always follow your medical team’s recommendation for your case, but structural findings on an X-ray or MRI don’t automatically explain your pain: labral tears and cartilage defects show up at similar rates in hips with and without pain.1 A movement pattern called anterior femoral glide syndrome — your thigh bone sliding too far forward in the hip socket, first described by researcher Shirley Sahrmann2 — can drive pain on its own, touching everything from the front of the hip to the low back and sciatic nerve. A published case series found patients with this pattern achieved complete symptom resolution with conservative treatment alone.4
The common thread underneath much of it is glute muscles that aren’t doing their job. Here’s exactly how that plays out.
A common movement pattern behind hip pain
Why this causes pain
“Anterior” means forward, “femoral” means thigh bone, “glide” means sliding. When the ball of your thigh bone habitually slides forward in the socket, it changes how force gets distributed around the joint every time you take a step. Weaker or poorly timed gluteal activity directly increases that forward-directed force.3
One of the jobs of the gluteus maximus is to create a pivot point for the femur head so the hip flexes and extends smoothly, especially while walking. Classic EMG research confirms this is meant to happen on every stride.8 When the gluteals don’t work well, that pivot becomes sloppy — like a washing machine that’s out of balance, careening around in the socket doing damage.
That slide creates problems in several places at once:
- In front: it pinches tissue, contributing to groin pain and labral irritation.
- On the side: the greater trochanter rubs more than it should against the IT band and the bursa on top of it — a common driver of bursitis, linked to hip abductor (gluteus medius) weakness5 and shown to improve with targeted gluteal-loading exercise in a randomized trial.6
- In back: the piriformis has to fire constantly trying to control the thigh bone to make up for the poor job the gluteus maximus is doing — leading to overuse, not tightness. This is usually what’s behind piriformis-related pain, a mechanism also described in the literature as gluteal weakness shifting load onto the piriformis.7
It doesn’t stop at the hip. Many practitioners assume hip pain is caused by the back, or that sciatica causes hip pain. In my experience it’s often the reverse: AFGS feeds a compensation pattern first, which then refers pain down the leg in the case of sciatica. I cover a dramatic example of this in this video, where a man’s eight years of sciatica — including a failed back surgery — resolved once we addressed his hip instead of his spine.
The real cause: glutes that aren’t firing
Figure 2. The gluteal muscles and their actions.
The self-test
Step 1
Place your fingertips on the center of each butt cheek.
Step 2
Pinch your cheeks together, feel the contraction, then relax completely.
Step 3
Keeping your fingertips there, walk normally for 10 steps.
Step 4
Notice whether you feel any contraction at all while walking.
Figure 3. Walking Test.
Most people with chronic hip pain feel little or nothing happening in their glutes when walking. That gap is the problem. Sylvia had the same experience.
The fix: butt pumps
Figure 4. Correct butt pump form: starting position, leg raised, small pump range.
The exercise
Step 1
Get on your elbows and knees (or stand and lean on a countertop).
Step 2
Lift one leg to the height where you feel your glute turn on. It doesn’t need to be very high.
Step 3
Small pumps, up and down a half inch to an inch, 20–30 reps.
Step 4
Don’t let the leg drop too low between pumps, or the glute shuts back off.
Step 5
Switch legs. Two sets per leg.
Form note: Don’t arch your back to get the leg higher. Go only as high as it takes to feel the glute working. Not feeling the butt turn on? Slightly rotate that knee outward to help it.
The habit that’s keeping your glutes turned off
Figure 5a, b. Gait pattern with the glutes inactive versus active.
Why this causes pain
Most people walk with a strong heel strike that locks the knee. Locking the knee also pushes the hip into more extension than it needs, and walking with greater hip extension has been shown to increase the forward-directed force on the hip joint.9 In my clinical observation, that locked-knee pattern is also what shuts the glutes off.
The habit change
Step 1
Anytime you get up from a chair to walk, walk on your tiptoes for 5–10 steps.
Step 2
Notice your glutes turning on by checking with your fingertips.
Step 3
Slowly lower your heels and notice the contraction holding for a few more steps.
Tiptoe walking works because you can’t lock your knees while on your toes, and your body can’t lag behind your advancing foot. Repeat this cue throughout the day, every time you stand up from a chair. It’s often enough to retrain your gait pattern within days.
But I have FAI — can this still help?
Yes. Pain from FAI, or femoral acetabular impingement, typically occurs in the front of the hip in the groin area. FAI involves a buildup of bone on the femoral head (cam-type), the rim of the acetabulum (pincer-type), or both (mixed-type).12 Hip muscle weakness, including reduced glute strength, is well documented in people with symptomatic FAI.11 Instability — excessive movement of the femoral head within the socket — is also increasingly recognized as a contributing factor in FAI-related hip pain.13
Having AFGS means those surfaces come into more contact, causing pain. Improving gluteal performance helps restore the pivot point further back in the hip socket, reducing or removing that contact.
Putting it together
Groin pain, bursitis, piriformis pain, low back pain, even sciatica: in my clinical experience, these frequently trace back to the same starting point — glutes that have stopped stabilizing the hip during standing and walking, letting the thigh bone glide forward (AFGS) or leading to poor pelvic control.
- The self-test tells you whether this is happening in your body.
- The butt pump exercise rebuilds the strength piece.
- The tiptoe-walking habit retrains the movement pattern that turned the glutes off in the first place.
It’s what changed the outcome for Sylvia.
Sylvia’s story has a happy ending. She caught this pattern early enough that it never cost her anything beyond the hip itself. Not everyone catches it that early. One of the most common recommendations from surgeons is to say, “Come back when the pain is bad enough and we’ll do the surgery.” However, what they are unaware of are the critical secondary changes that happen when people gradually begin compensating for their hip pain.
Next in this series, we’ll dive into how the body adjusts to offload that hip, and what it means for the rest of your joints and muscles. After that, a critical piece hiding underneath all of it: the actual shape of your thigh bone — something almost no clinician considers, yet it has a profound impact on the lower body system.
Did you find a glute activation gap on the self-test? Did the tiptoe-walking cue change anything for you right away? Please leave your results in the comments section below, and let me know if this article helped. Thanks.
See it for yourself
- Watch the hip pain self-test, exercise, and gait fix on YouTube, along with the femoral torsion follow-up and other hip and knee conditions on my channel.
- 7 Days to Better Hips. My home program that walks you through the tests to understand and solve the larger problems feeding your hip pain. Built on the same approach I used with Sylvia, and even more complete now.
- Fixing You: Hip & Knee Pain. My full book on self-treating various types of hip and knee pain, with the anatomy and reasoning behind this approach laid out in detail.
Read my book: Pain Patterns: Why You Are in Pain and How to Stop It
Try the program: 7 Days to Better Hips
Watch: my YouTube channel for guided exercises.
FAQ
Always follow your medical team’s guidance. They know the specifics of your case. That said, structural findings don’t automatically tell you what’s causing your pain,1 and in my experience it’s often worth spending a few weeks correcting the mechanical drivers first. I go much further into this decision, including what waiting can cost the rest of your body, in the next article in this series.
In many cases, yes — at least in terms of pain and function. Sylvia had worn cartilage and bone spurs and avoided surgery entirely. Improvement doesn’t mean the arthritis itself reverses. It means the mechanical stress driving the pain gets addressed, which is often enough to change the outcome.
It’s not a diagnosis you’ll typically hear from a doctor. It’s a movement pattern I use clinically, and which is described in Dr. Sahrmann’s textbook, Diagnosis and Treatment of Movement Impairment Syndromes, to explain and treat a range of hip-related pain, based on decades of practice.
In my clinical experience, yes. The hip instability alters pelvic and low back mechanics, which can then impinge nerves, creating sciatica down the leg. I’ve seen this resolve sciatica that had already failed back surgery — watch that video here.
It varies by person, but many people notice the gait-pattern habit change (the tiptoe-walking cue) making a difference within 1–3 days, while strength changes from the exercise itself typically build over a few weeks of consistent practice.
That’s common and usually just means the pattern has been present for a while. Keep practicing the fingertip check and the tiptoe cue, and activation typically starts to return with consistency. Don’t forget the butt pump exercise.
No. It’s done on the floor or table using just your elbows and knees — no equipment required. As you get stronger, adding ankle weight, the way Sylvia did, can help.
No, though they’re related. Anterior femoral glide syndrome is about how the thigh bone moves during activity; femoral anteversion and retroversion describe the actual twisted shape of the thigh bone itself, which I cover in the third article in this series.
It can affect one or both hips, depending on your individual movement pattern, strength, and history.
Have a question this article didn’t answer?
Send it below. I read every question, and use the most common ones to shape future articles, videos, and my monthly email — sometimes by featuring them (never with identifying details) in a public answer. I ask for your email in case I need more detail, or want to let you know when I’ve covered it.
Footnotes
- Heerey JJ, Kemp JL, Mosler AB, et al. What Is the Prevalence of Hip Intra-Articular Pathologies and Osteoarthritis in Active Athletes with Hip and Groin Pain Compared with Those Without? A Systematic Review and Meta-Analysis. Sports Medicine. 2019. Found labral tears and cartilage defects at similar rates in people with hip/groin pain and pain-free controls, undermining the assumption that a structural finding alone explains pain.
- Sahrmann SA. Diagnosis and Treatment of Movement Impairment Syndromes. St. Louis, MO: Mosby; 2002. The original clinical description of anterior femoral glide syndrome as a movement-impairment pattern.
- Lewis CL, Sahrmann SA, Moran DW. Anterior Hip Joint Force Increases with Hip Extension, Decreased Gluteal Force, or Decreased Iliopsoas Force. Journal of Biomechanics. 2007;40(16):3725–3731. Biomechanical modeling showing that weaker gluteal force directly increases the forward-directed (anterior) force on the hip joint.
- Grant C, Pajaczkowski J. Conservative Management of Femoral Anterior Glide Syndrome: A Case Series. Journal of the Canadian Chiropractic Association. 2018;62(3):182–192. Patients with this exact pattern achieved complete symptom resolution using conservative treatment alone.
- Grimaldi A, Fearon A. Gluteal Tendinopathy: Integrating Pathomechanics and Clinical Features in Its Management. Journal of Orthopaedic & Sports Physical Therapy. 2015;45(11):910–922. Reviews the link between hip abductor (glute) weakness and gluteal tendinopathy/bursitis.
- Ganderton C, Semciw A, Cook J, Moreira E, Pizzari T. Gluteal Loading Versus Sham Exercises to Improve Pain and Dysfunction in Postmenopausal Women with Greater Trochanteric Pain Syndrome: A Randomized Controlled Trial. Journal of Women’s Health. 2018;27(6):815–829. Gluteal-loading exercise outperformed sham exercise for reducing bursitis pain and dysfunction.
- Tonley JC, et al. Treatment of an Individual with Piriformis Syndrome Focusing on Hip Muscle Strengthening and Movement Reeducation: A Case Report. Journal of Orthopaedic & Sports Physical Therapy. 2010;40(2):103–111. Describes gluteal weakness shifting excess load onto the piriformis, resolved through hip strengthening.
- Lyons K, Perry J, Gronley JK, Barnes L, Antonelli D. Timing and Relative Intensity of Hip Extensor and Abductor Muscle Action During Level and Stair Ambulation: An EMG Study. Physical Therapy. 1983;63(10):1597–1605. Classic EMG confirmation that the glutes are meant to activate during the weight-bearing phase of every stride.
- Lewis CL, Sahrmann SA, Moran DW. Effect of Hip Angle on Anterior Hip Joint Force during Gait. Gait & Posture. 2010;32(4):603–607. Walking with greater hip extension increases the forward-directed force on the hip joint.
- Lewis CL, Sahrmann SA. Muscle Activation and Movement Patterns During Prone Hip Extension Exercise in Women. Journal of Athletic Training. 2009;44(3):238–248. EMG measurement of glute activation during the exact prone hip-extension exercise position used in the butt pump.
- Casartelli NC, Maffiuletti NA, Item-Glatthorn JF, et al. Hip Muscle Weakness in Patients with Symptomatic Femoroacetabular Impingement. Osteoarthritis and Cartilage. 2011;19(7):816–821. Found FAI patients had significantly weaker hip abduction, external rotation, and flexion strength than healthy controls, with reduced EMG activity in these muscle groups.
- Gómez-Verdejo F, Alvarado-Solorio E, Suarez-Ahedo C. Review of Femoroacetabular Impingement Syndrome. Journal of Hip Preservation Surgery. 2024. Defines and describes cam, pincer, and mixed-type bone morphology, the underlying variants of FAI.
- Wong SE, Cogan CJ, Zhang AL. Physical Examination of the Hip: Assessment of Femoroacetabular Impingement, Labral Pathology, and Microinstability. Current Reviews in Musculoskeletal Medicine. 2022;15(2):38–52. Reviews hip microinstability — excessive femoral head movement within the joint — as an increasingly recognized contributor to FAI-related hip pain.