I recently watched Coach Kevin Neeld’s DVD set on mobility. He’s an intelligent coach and trainer with education in a great variety of perspectives who focuses on training hockey players. The DVD set covers mobility screens that he and his staff use to train a large population of pro and semi-pro ice hockey players who are trying to get the most out of their training without getting hurt. FAI (otherwise known as Femoroacetabular Impingement or Hip Impingement), unfortunately, seems to show up in a lot of hockey players.
What Neeld reports is that the longer hockey players play, the higher the likelihood of them “getting” FAI, and the higher the likelihood he needs to adapt his training and assessment protocols to account for their restricted range of motion.
Care to guess what sport I’ve played since I was twelve?
In my early and mid 20s, I couldn’t flex my hips. I couldn’t step over my hockey bag. I had trouble bending over to tie my skates. I had trouble driving because my hips would ache and my groin would snap every time I had to lift my foot/leg to shift from brake to gas or use the clutch (manual transmission is for real men). Sitting for 10 minutes would cause burning in my hips. Both hips would snap every time I had to step over the edge of the bathtub. Running wasn’t comfortable. Walking wasn’t comfortable.
Did I have FAI? Probably, but by the time all this was happening, I’d already given up asking doctors for help with my joint issues, so I never got the MRIs to get a firm diagnosis.
WHAT ARE THE SYMPTOMS OF FAI?
Have you ever found it difficult to lift your knee up to your chest? Like you couldn’t bring your knee up higher than the waistband on your undies? No matter what position you were in, trying to bring your knee to your chest seemed to just jam into something? This would be a restriction in hip flexion, and it would put you on a fast-track to being diagnosed with Femoral Acetabular Impingement once you saw the right doctor armed with an X-ray or MRI machine.
It’s not a fun thing. I just worked with a guy in his early thirties the other day who had been finding it increasingly difficult to flex his left hip. Every time he tried to bring his left knee up, he’d get sharp, burning pain in his groin on his left side. Sometimes the pain would even start heading down into his knee and ankle. After some doctor visits and some X-rays, it was suggested that he had some hip arthritis and a “congenital hip problem.”
In about 10 minutes, we figured out how to increase his ability to flex the hip without pain and without lumbar spine compensation.
After another 45 minutes, we had removed the pain almost completely during hip flexion. Now he’s gradually building up the strength and activation of his posterior and lateral hip musculature to keep his groin happy on a more regular basis.
WHAT IS FEMORAL ACETABULAR IMPINGEMENT, REALLY?
If you’ve read up on FAI, what I just said about the last guy and about myself sounds totally ridiculous. The standard line on FAI is that you can’t change it. You can’t really improve it. It’s a bony problem. The end. Get surgery and “fix” the bone and that’s how you improve the situation.
I think the standard line is almost completely wrong.
FAI is a classic orthopedic surgeon’s description of a problem. Essentially, the belief is that the problem is with the shape of the bones.
In one type, the shape of the head (the ball) of the femur is wrong and causes friction against the rim of the acetabulum (the socket). In another type of FAI, the shape of the rim of the acetabulum is supposedly wrong, causing friction against the head of the femur. In the third type, BOTH the rim of the acetabulum and the head of the femur are shaped incorrectly, causing friction (torn labrum, bone-on-bone action, etc.).
How do you determine if someone has FAI? Well, first, the person would have trouble flexing their affected hips. They might get clicking and popping with hip flexion. They will get groin pain when sitting or walking for long periods. They may have low back pain, trouble tying their shoes, trouble driving a car (hip flexion is heavily involved in driving!), and pain near the greater trochanter (the bony protrusion of your thigh bone). Then — and this is where you should start to get VERY suspicious — a doctor orders an X-ray and/or MRI to look for damage to the hip labrum and to the bony surfaces of the hip joint. If you find those things…
CONGRATULATIONS! You’ve found FAI!
THE PROBLEM WITH THE FAI DIAGNOSIS
You should be suspicious whenever an MRI or X-ray is used to make a diagnosis on a musculoskeletal problem.
MRIs and X-rays have definitively been shown over and over again to be UNRELIABLE diagnostic tools for pinpointing a cause of joint pain and musculoskeletal discomfort.
Let me repeat that. MRIs and X-rays are TERRIBLE tools for determining the root cause of pain in a joint. “Pathologies” that show up in MRIs and X-rays are shown time and time again to be coincidental and to have NO value in showing a cause of pain (Example #1: Baseball pitchers’ shoulders, Example #2: Back pain).
- In one study directly related to hips, scientists took 39 hockey players with NO symptoms of hip pain and discomfort. 77% of them showed signs of hip/groin pathology. And yet no symptoms.
- In another study, 200 people with no history of hip problems were examined for FAI. Guess how many people had FAI? A whopping 14 percent. How many were asymptomatic? All of them. So did the imaging correlate enough to even lightly suggest that FAI in an image was indicative of hip problems? No.
- And you can even have a labral tear and have exactly ZERO symptoms (see this study on asymptomatic hockey players ALL with labral tears)!
So how good is the MRI then if there is no correlation between the symptoms and the image? Did I say terrible? I meant HORRIBLE.
So let’s look at the whole diagnostic process again.
You have pain in your groin and you can’t flex your hip fully. You see a doctor. He says to rest it. It doesn’t improve (may even get worse since sitting is known to actually makes things worse). You go back to the doctor. He gives you NSAIDs. You rest more. It still doesn’t improve. You go back and the doctor (the same one or possibly a new specialist) does an X-ray or MRI and sees a labral tear and possibly some wear and tear on the joint surfaces.
You have pain and range of motion restriction, and you want an answer. The doctor needs to give you some kind of diagnosis! Abracadabra!
YOU HAVE FAI! There you go! Now go sand off part of your hip joint.
THE PROBLEM WITH SURGERY FOR FAI
If the surgery to treat FAI were foolproof, that’d be one thing. But the surgery ISN’T 100% successful. There are some studies that are “promising” (you can read about ALL of it here), but promising evidence for a surgery isn’t something to bank on. Arthroscopic knee surgeries have long been thought to be GREAT for fixing up knees…but studies over the last few years that compare surgery to fake surgery have sadly turned out very well — for FAKE surgeries.
There isn’t enough data yet or good enough studies yet to really confirm anything as being great or terrible in either direction, but I wouldn’t bank on things turning out well for FAI surgery over the next 10 to 15 years of rigorous study. Back surgery was around for literally decades before rigorous studies determined that the risks associated with back surgery and the poor outcomes made them pretty much not worth doing. Read this post for more info on FAI surgery success rates.
As a guy I met once said about surgery: “never cut into your Earth suit.” Words I plan to live by for a long, long time.
WHAT SHOULD YOU DO IF YOU HAVE FAI?
I’m working with more and more clients with FAI or FAI-like symptoms, and it has become painfully (literally) clear that for most people, there are strength deficits as well as motor control issues. If I had to sum it up, I’d say “your butt is off and your adductors are on.”
It’s as if the nervous system keeps recruiting the wrong muscles in every possible motion, making the hip joint grind itself into oblivion, causing popping and snapping, and just plain annoying you. The process of reprogramming the body, retraining the right muscle patterns, and retaking control over your hips can be long and frustrating, but I’ve done it, I’ve seen others do it, and with the right mindset, you can do it too.
You must start carefully in retraining the butt, recognize the daily habits that switch your butt back off, and stubbornly work on fundamental exercises that gradually restore your proprioceptive sense to your backside and build your ability to recruit those muscles instead of your inner thighs for joint mobility and stability.
The whole time, remember that this is a process that can be grueling, irritating, and slow, and the fact that many of us sit all day doesn’t help at all!
The problem is like the classic algebra question: you have a pool that holds 500 gallons of water. You’re trying to fill it with water with a hose that pours 50 gallons of water per hour. The drain is open, and it drains at 23 gallons per hour. How long will it take to fill the pool? Only the pool is your butt/hips, and you’re trying to get enough exercise to counteract all the draining (sitting a lot and moving with poor intermuscular coordination) that you’re doing. Be patient, keep moving, and you’ll get there.
More videos on the topic can be found on our YouTube channel.
Do any doctors think this way about hip impingement?
A lot of people are often skeptical about my opinion on hip impingement because I am not a medical physician. Many people get downright angry that someone who isn’t a doctor has an opinion on this topic. From time to time I’ll get angry YouTube comments, emails, and messages about what an idiot I am.
Recently, more written pieces are showing up with medical practitioners publicly questioning the rationale for surgery for hip impingement. Below you’ll find three pieces that all echo the perspective I’ve presented and address the very same concerns I’ve raised over the years. One was published by a surgical center, one by a physical therapist, and one by a radiologist.
If your major gripe with this perspective is that it’s not being put forth by a doctor, you may find these physicians’ well-reasoned arguments helpful.
Sports Surgery Clinic – Dublin, Ireland – The growth of hip surgery in Ireland
David Rubin, Radiologist – Femoroacetabular impingement: fact, fiction, or fantasy?