An interesting study published last year by the Open Access Journal of Sports Medicine examined the prognosis of a woman with bilateral femoroacetabular impingement (FAI) who was treated with arthroscopic hip surgery on her right hip and conservative physical therapy on the left hip which included exercises for FAI. On paper, it would seem that this is another study promoting arthroscopic surgery over conservative rehabilitation. However, it’s what the study doesn’t mention that I believe provide the most important takeaways and is a perfect example of what I see with many of my clients.
Background & Treatment
A 31-year-old female physiotherapist was presented to an orthopedic surgeon in December 2009 with an 18-month history of right-sided hip and groin pain. The symptoms had started during a 100 km bicycle race and it was later discovered that she had FAI. The patient decided to receive arthroscopic surgery. About 3 years after surgery on her right hip, the patient started to develop pain in the left hip which was also diagnosed as FAI. The patient underwent non-surgical treatment for the left hip in the form of physiotherapy aimed mainly at strengthening and stabilizing the hip girdle in a pain-free range-of-motion. Physical therapy consisted of exercises for core, hip, and thigh strengthening to improve symptoms from the FAI diagnosis.
Result of Treatment
The right hip remained pain-free however there remained a noticeable reduction in strength. The left hip remained in the same state since the onset of symptoms with pain appearing during high-intensity activities. Internal rotation (moving the hip inwards) was significantly limited in both hips.
Reznik Health & Movement’s Observations
(1) Isn’t it possible that the surgical intervention on the right hip contributed to the pain in the left hip?
Segmenting the body into individualized parts with separate diagnoses along with separate protocols of treatment is a highly reductionist approach to healing. There is no area of health where this is truer than troubleshooting chronic joint pain. If there are underlying movement dysfunctions and muscle imbalances in the body that are creating pain signals in the right hip then these dysfunctions and imbalances must be corrected or the body will find another way to adapt and compensate.
In the study presented here, we see a common presentation; surgery is performed on one area of the body without addressing any underlying movement dysfunction and then pain develops in another area of the body shortly thereafter. Evaluating movement patterns certainly includes addressing dysfunction in the area of concern such as the right hip in this case but also the rest of the body such as the opposite hip, the gait cycle, the feet, the pelvis, the spine, etc.
The patient in this study followed a limited rehabilitative protocol which included “exercises for core, hip
(2) It was determined that the patient had limited internal rotation in hip flexion yet there was no indication that improving internal rotation was a goal during physiotherapy.
The study discusses how limited the patient’s internal rotation in hip flexion was during an assessment however there was no indication that there was any effort placed to improve internal rotation (especially in hip flexion) during physical therapy. Internal rotation during hip flexion in the left hip was nearly 0° yet conservative treatment for the left hip was focused on exercises to strengthen the core, hip and thigh. There is nothing inherently wrong with strengthening these areas of the body but when internal rotation of the hip is limited to such a degree then this must be the initial focus during rehabilitative training. In other words, strengthening the internal rotators of the hip and optimizing internal rotation should have been the primary focus during this individual’s rehabilitation.
(3) The patient in the study was engaging in high-intensity recreational activities without proper movement function, which is a recipe for disaster.
I can’t tell you how many individuals I see that run hundreds of miles a week, train for triathlons or take a cross-fit class every day without addressing their movement dysfunctions first and then wonder why they are in pain. If the ‘check engine’ light on your car lights up but you decide to ignore it and still take the ailing car on your cross-country road trip, chances are that car is not going to make it back without a costly trip to the mechanic.
The pain signals in your body are the same exact thing. It’s a ‘check movement function’ for your body and if you ignore it, more pain is inevitable. In this study, the individual started experiencing pain in both hips while participating in a high-intensity biking race. With an internal rotation of 0 degrees when in hip flexion, it is not surprising that she experienced this type of pain. Not many sports require as much hip flexion as biking and in a 100 km race, clearly, there will be some internal rotation that will be required from the hip as well.
I’m sure this individual, like many of my clients that I work with, was extremely eager to get back to her recreational pursuits. However, I always have a conversation where I ask my clients if running a certain race or participating in some event is more important than the health of their body. Sure, surgery might get you back to next year’s event but it won’t guarantee a future of healthy, pain-free movement.
If the ‘check movement function’ light is not addressed, pain, dysfunction, and poor movement will continue to get worse – with or without surgery.