As many of you know, this past May I had arthroscopic surgery to repair a labral tear in my left hip. Femoroacetabular Impingement (FAI) with or without a labral tear is kind of “the new thing” in orthopedic and sports medicine and rehab; it’s being diagnosed much more often than it was ten or even five years ago, and no one is really certain as to why. Is the prevalence actually increasing? Or are we just getting better at imaging?
We’re also not sure what to do about it. As Dr. Mike Reiman pointed out in a recent editorial in JOSPT (June 2016), surgery has become the “gold-standard” treatment for FAI; but how effective is it really? And wait, to back up….what are we even fixing in the first place? With FAI, are we confusing MORPHOLOGY with PATHOLOGY? Studies have shown that it’s certainly possible to have FAI and be asymptomatic. Would you operate on such a person? And if someone is having pain, has FAI and/or a labral tear….if not surgery, then what? there is no “gold standard” physical therapy protocol for relieving symptoms of FAI without surgery.
So….there’s a lot of grey here. Research doesn’t really support surgery, and it also doesn’t support conservative care; not least because what even IS “conservative care?” It’s hard to draw conclusions from the literature when every study does something different with their patients. Here at Duke, I’m very lucky to be part of a research team (led by Dr Reiman and Dr. Chad Cook) that is running a clinical trial of the effectiveness of a rehabilitation protocol on preventing surgery in patients with symptomatic FAI. I’m excited to see what the results are, but until then, treatment really comes down to a personal decision. I’ll share with you the factors that allowed me to make my own decision to have surgery; Hopefully, if you are faced with the same dilemma, or you have a patient who is faced with this decision, you’ll have an outline of factors to consider.
Background: I first started having hip pain in March 2012; I was training for my first marathon, and unfortunately was also dealing with an eating disorder and some related obsessive exercise tendencies. I would run 5-8 miles in the morning and spend an hour crosstraining on the elliptical or the bike in the evenings. Seven days a week. Not much in the way of lifting, and also not much in the way of food. So, one evening, I was on the elliptical and felt a sharp, stabbing pain in my right hip. The rest is history.
Sort of – I tried physical therapy until August, moved to Colorado for work, and then around November of that year I’d had enough. I saw a hip specialist, was diagnosed with a labral tear, and had surgery to repair it in January 2013. I don’t really have issues with my right hip anymore.
Fast forward to May 2015 – I began having pain in my left hip. Still dealing with disordered eating, still doing 14 hours a week of cardio and mayyyybe “lifting” 2 days per week. (it is safe to say I’ve learned my lesson now HAH!) Symptoms were as follows:
-Sharp, “pinching” sensation in the front of the hip
-Knot-like feeling in the piriformis region
-Occasional tightness over the greater trochanter
-Occasional low back tightness (unsure if this is due to the labral tear or due to grad school problems hah)
At this point, I was pretttttyyyy sure I knew my diagnosis, but I opted for physical therapy first. I’d read some of the literature and thought it was worth a shot, maybe it wasn’t too late, and I was also in my first year of PT school and did not want to disrupt my busy life with a surgery.
On the whole, physical therapy did a LOT for me. I was doing strength work four days per week, had cut my cardio down to three hours per week, and (what I’m most proud of), I was eating like a normal human again for the first time in ten years. I had even started running again for the first time since my 2013 surgery, without pain. However, I still had pretty intense pain while sitting. Some days, it was so bad that I could not focus on school. I consulted with my physical therapist, and with a Duke surgeon who specializes in hip arthroscopy. and ultimately (obviously) decided to have the surgery. Here were my deciding factors:
-Labral tear = possible increased risk for OA down the road
-You can train running and lifting and hiking…you cannot train sitting and that’s where I had most of my pain
-Can I run three miles pain free with a labral tear? Yes. Can I train for and run 26.2 with a labral tear? Most likely not, and that’s my goal.
-Surgeon is one of the best in the country….If I’m gonna do it, this is the best place
-Timing worked out well. Summer semester at Duke was super light, surgery and rehab would not interfere with anything (this ended up 100% true, could not have asked for better timing)
-Had already had the same operation on my other hip and tolerated it extremely well
-The tear was small, with no other cartilage damage – an easy fix (the actual surgery only took about 75 minutes)
Ultimately, it depends on who you are and what your goals are! I am a super active person and I want to continue to be active and be FIT for the rest of my life! I want to be fitter than I was before my injury, and I would like the opportunity to train for and compete in races again. Conservative care decreased a lot of my pain, but after a full year of it, it just wasn’t quite enough to get me to my goals.
I am currently (at the time of writing) 12 weeks post-op and doing AWESOME. Next week, I’ll continue the story and share the rehab process with you!