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WHAT ACTUALLY CAUSES FAI AND HIP LABRAL TEARS?
If you conduct a google search for FAI, the first hit is an article from Orthoinfo.com, a website managed by the American Academy of Orthopaedic Surgeons (“AAOS”). According to the AAOS, FAI is caused by bone spurs which “develop around the femoral head and/or along the acetabulum.” They go on to explain that this extra bone causes abnormal contact between the hip bones which ultimately results in tears of the labrum and osteoarthritis.
The problem with this explanation is that it is a gross over-simplification of a very complex condition. Someone with FAI knows that they have hip pain but is that hip pain occurring because of this “abnormal contact” between the hip bones or because of some other movement dysfunction or muscle imbalance. Our bodies are smart enough to send us pain signals when something is wrong but not smart enough to tell us what is wrong. Pain in the hip does not mean there is something wrong in the hip. Rather, it is very possible and more likely that there is dysfunction in the muscles around the hip that is causing the pain. In those who have been diagnosed with FAI and suffer from chronic hip pain, we usually see weakness and dysfunction in muscles like the adductors, quadriceps, hip flexors and extreme weakness in opposing muscles like the glutes, hamstrings, and abdominals.
So the orthopedic view of this condition is a skeletal problem when in reality it’s a muscle imbalance problem. This is a difficult reality to digest because it does feel like the bones are rubbing against each other. This is exactly what I thought when I was figuring out whether I needed to get surgery for FAI back in 2014. The key is to change our label of this issue from “FAI” to what it actually is – hip pain.
WHAT ABOUT THE MRI THAT SHOWED ME I HAVE A HIP LABRAL TEAR?
Time and time again, studies have consistently shown that there is no correlation between joint pain and some type of perceived abnormality on an X-Ray or MRI. The most important study for our purposes comes from the American Journal of Sports Medicine in 2012 when forty-five volunteers with no history of hip pain underwent an MRI scan. 69% of these participants with no history of hip pain had labral tears!
In other words, someone can have absolutely no hip pain but have a labral tear on an MRI. In fact, according to the study above, it is likely (69%) that most people with or without pain have a labral tear in the hip. Given these statistics, how much weight can truly be given to these MRI scans?
If you got an MRI on your pain-free shoulder and discovered you had a labral tear, would you let someone shave off some bone to eliminate the “abnormal contact”? This doesn’t seem prudent but neither does having surgery based on tests that simply have no merit.
WHY CONVENTIONAL TREATMENTS DON’T WORK
In respect to nonsurgical treatments, the first conventional option usually offered is to avoid activities that cause symptoms. There is nothing more defeatist than allowing a condition to dictate how you live your life. This was a never an option for me and I truly hope it isn’t for most people who suffer from hip pain. This is a setback, yes, but not a death sentence. Instead of avoiding activities, there should be a focus on modifying activities to promote healing and function.
The next nonsurgical treatment option is non-steroidal anti-inflammatory medications (“NSAIDs”). Multiple studies have shown links between chronic NSAID use and Irritable Bowel Syndrome, Leaky Gut and a disrupted Gut Microbiome. Beside these unpleasantries, in my experience, NSAIDs just don’t seem to work even for short-term use – especially when attempting an activity that is known to exacerbate symptoms.
Then there is the ultimate band-aid solution: cortisone injections. During my search for pain relief, I received two injections – and they provided no short-term or long-term relief. In fact, a study from Mayo Clinic showed no clinical benefit from cortisone injections for patients with FAI and labral tears.  It’s not a pleasant process getting a needle shoved into your hip and if it doesn’t work, is it really worth it?
The last non-surgical treatment method is physical therapy. This must work, right? Physical therapists are trained in correcting muscle imbalances and optimizing movement dysfunction, right? Unfortunately, from personal experience and from many individuals I’ve worked with, most physical therapists just don’t have the capacity to really help individuals with chronic hip pain. This can be for multiple reasons (i.e. insurance limitations, not viewing the body holistically, etc.) but usually, physical therapists are not trained in treating complicated difficult to manage chronic pain issues such as FAI. During my recovery, I visited three different physical therapist offices, and each left me more frustrated than the last.
STILL CONSIDERING SURGERY?
If you’re still not convinced that surgery is not the answer, consider a study from January of 2013 that measured the fulfillment of patient-related expectations from FAI surgeries. Before surgery, individuals were asked what their main reasons for receiving surgery were. These included pain reduction, fear of worsening and improvement in performance of everyday activities. The results of the study showed that 56% of individuals who received FAI surgery did not have their expectations met in respect to hip pain, 45% did not have their expectations met in respect to walking capacity and another 61% did not have their expectations met in respect to sport. The bottom line is that there is simply not enough evidence to support surgery for an FAI diagnosis.
I’ve met many individuals who got out of pain without surgery and met even more individuals who got out of pain only after surgery didn’t provide any relief. The best part about this alternative approach is that you’ll always have surgery in your back pocket if necessary. Approached properly however, restoring proper movement function usually alleviates the hip pain.
 Check out Upright Health’s article on this study at https://uprighthealth.com/real-success-rates-surgery-femoroacetabular-impingement/.
HOW DO I GET OUT OF PAIN THEN?
If movement dysfunction or muscle imbalance is causing the symptoms, then of course, these must be corrected and maintained to eliminate the painful symptoms. These dysfunctions and imbalances will be different for every person but there is some common patterns that are seen in those diagnosed with FAI: overactive adductors, overactive quadriceps, weak hamstrings, weak glutes, weak core, poor hip hinge mechanics, etc.
What’s important to understand is that your hip pain is a product of deeply rooted faulty movement patterns. The pain comes from years of conditioning and there is no overnight fix. Treating this dysfunction requires reversing this conditioning and although it is not easy, with proper guidance and determination, it will happen. Sometimes the biggest challenges in life are the ones that help us grow the most. I’ll leave you with a quote from the great Stoic Roman Emperor Marcus Aurelius: “The impediment to action advances action. What stands in the way becomes the way.”
If you haven’t already, check out part I, part II, and part III of my personal story recovering from FAI without surgery. There, I give specific tips and strategies that can be used to troubleshoot your hips. I’ve overcome FAI without surgery and I’m passionate about helping others do the same. Contact me today to start your FAI recovery – in-person and online training available!