Progress with Physical Therapy

So it's been about three months of physical therapy, and although I have been making progress, the progress has been slow going.  Part of that reason is that the source of all of my hip immobility is a mystery. For some reason, none of the exercises I have done sets up my hips to pass an Ober test right away in the morning, and I have yet to pass the test with my left (never-been-in-pain) hip.  This has been the sticking point for like two months now.  Once the PT can get my hips to pass that test we can start doing more real-world type of exercises (read, exercises done standing up).  Until then, we need to figure out what is going on, what is making my hips immobile.

Well, they seemed to make a bit of a breakthrough last week. Having two PT's work on me at the same time last week (because I'm oh so special), the idea came up that maybe my upper body is driving the show.  Mike had previously noticed that my shoulder internal rotation was atrocious, so they decided to work on that.

The odd thing is, after each exercise done to mobilize my shoulder, my hips became more mobile.

Even odder, the first three days after PT my hip was pretty much pain free. Sometimes I would experience some pain, but it was definitely in the minority of time and was less severe.  So I really think this is the answer.

I have also started seeing a chiropractor again, thinking the two different therapies will help out each other, so perhaps that is working as well.

This is all very interesting because this could mean that the huge knot next to my left shoulder blade is part of the reason my left hip isn't moving correctly.  I've almost always had the two issues, it wouldn't be that unreasonable to think they are intertwined.

In order to try to fix my back they've given me some exercises that stretch my back.  It's kind of like doing a plank but instead of trying to pinch your shoulder blades together you do the exact opposite, you try to extend your shoulders forward as far as possible, spreading your back.  This stretches out the muscle some.

...When I was training for the Oly competition, I was front squatting all the time.  Two or three times, when I was squatting, I felt this brief, very sudden, stab of pain where my knot is.  The pain felt like I was being stabbed by a hot poker, but just for a split second.  Right after the sensation I felt completely normal.  I was asking Bobby what this could mean and he said it was an adhesion tearing.  In front squatting I have my shoulders shifted forward in the same manner as this plank exercise, but when squatting they are also being flexed at the same time for stability sake.  That summer was also the most normal my left back/shoulder area has ever felt.  So I think we're really on to something here, at least to treat my back/shoulder pain.

Unfortunately, I did have a bit of a setback later in the week.  I was at the gym with a friend, and I was helping him out with his deadlift form.  I was demonstrating how he should approach the bar, and when I lowered my hips to the proper depth, while holding my spine in what I think is a straight posture, I felt my groin get tweaked.  It feels like it's the pectineus/psoas.  So at least that other pain that I've been experiencing, the one that seemed to be from the rectus femoris, has still disappeared and has not resurfaced its ugly head.

Still, now I'm experiencing some slight groin pain during some different times throughout the day.

...That is one thing that is absolutely maddening for me about this hip pain: I can not figure out what causes it and what helps it go away.  Sometimes I wake up with it, sometimes not.  Sometimes doing my PT exercises helps, sometimes not.  Sometimes working on it with a softball helps, sometimes not.  All this does is confuse me and irritates me.  I pride myself on listening to my body and figuring out what is making it respond the way that it does.  This groin pain, however, never seems to go away.  When I saw the chiro he noticed my pubic bone was out of place, but I can't remember if putting it back in helped or not.

Speaking of groins, I feel like my left adductors, previously completely turned off/hard to use, have gotten significantly stronger.  Once I actually thought I tweaked my left groin pushing off of my left foot to go around a corner.  I feel like I've gotten much, much stronger in that area, hopefully it means that it is no longer an issue.

I will be seeing three physical therapists tomorrow.  Feel a bit like a lab rat but hey the more brains the better.  Last week it seems like we've reached a turning point, and barring any stupidity on my part (won't even think about deadlifts) this week might be the first week I've been pain free in a long, long time.

You’ve been diagnosed with FAI, now what?

So you’ve had hip pain for a while, finally caved and saw an Orthopedic doctor, and duh-DUH-duh, you’re told that you have FAI and need surgery. You’ve been told no more squatting and your world has been turned upside down.  Well in this blog post I’ve created a protocol of things to try before surgery.

Medical Disclaimer: I don’t have a medical degree, nor do I know your medical history. I’m posting this in order to let people out there know about options other than surgery. So please put all of these ideas into your own context. Be smart, and consult your doctor(s) before trying any of these things.

“Why should I trust you?” 

You shouldn’t, I’m just some random guy on the internet without a medical degree. However, I’m not telling you what you should do, I’m just trying to let you what is out there, that there are alternatives to surgery. I also think you should listen to what I have to say; I’m a guy who has dealt with hip pain for almost seven years now, and has seen it all. I have seen multiple physical therapists, massage therapists, chiropractors, orthopedic surgeons, even multiple prolotherapists, and throughout these years I kept asking questions and did my own research.  And in that time I’ve learned that you shouldn’t trust ANYONE. I’ve encountered many a Doctor who felt free to give advice on subjects they were ignorant on, so I took everything they said with a grain of salt.  That’s one reason why I have avoided surgery like the plague; I just don’t feel comfortable putting the fate of my body’s health into the hands of another person. I mean, once you go the route of surgery, there’s no coming back.  So while I am only self-educated, I have learned a lot and have dedicated quite a significant portion of my life to helping people trying to prevent them from going under the knife.

 “Ok I have FAI, how did I get it?”

So how did this excessive both growth occur?  Why does this question even matter? FAI doesn’t just randomly happen, FAI is the body’s response to the concussive force of the femur bashing into the acetabular joint. I should point out that it is a response; it is an effect, not a cause.  That is one reason why I didn’t believe I needed surgery, because if I only address the symptom (remove excess bone growth) but not the underlying cause (femur hitting hip socket), my body will just respond with more bone growth.  A physical therapist by the name of Dan Pope wrote this excellent article about FAI (and squatting) part one here, part two here, part 3 here, and part 4 here. All this begs the question...

“Why is my femur bashing into the acetabular joint, causing the concussive force?”  

It seems that most people I’ve talked to have had at least somewhat unstable joints. It seems that the femur head can move around a little in the hip socket, there’s a little leeway for the femur to move around.  However, if the femur isn’t nestled in the right part of the hip socket it can rattle around and cause those concussive forces that result in the extra bone growth. From what I’ve seen most people with FAI have excessive anterior hip capsule laxity, I know I did.  So what causes anterior hip capsule laxity? This is not an exhaustive list, but these are the factors that I am aware of that can cause unstable hip joints.

• Poor hip mobility. If your hips aren’t working properly, you’re probably going to cause issues when you use them (like squatting and being active, pretty much doing anything).  Find yourself sleeping on your side with one leg thrown over the other? That’s because you have tight hip flexors (and I recommend sleeping on your back to help straighten that out).  That is one reason why I highly recommend doing these ten exercises for hip mobility for a while to see if it helps.
• Anterior Pelvic tilt (APT).  This is my own little devil I’ve been fighting with.  When you have weak abs you get APT, and when you start working out with APT you shut off the glutes and start using your hip flexors. This will tighten up the hip flexors and pull your femur to the anterior part of the hip socket, allowing the femur to bang around and cause the FAI.  The physical therapist Lisa Bartels wrote up a beautiful article about APT here. If you have APT I highly recommend you go and read it. Go on, read it.  It’s ok, I’ll still be here when you’re done.
• Tight hip capsules aka tight hip flexors. You might simply have tight hip flexors without APT. In today’s world of desk jobs and never sinking down into a full squat (“ass to grass” as it’s nicknamed) there are multiple opportunities for a person to shorten all kinds of muscles in the hips.  Sitting a whole lot? Work a desk job? Used to sit a whole lot with school and studying? Sitting shortens up all kinds of muscles in the hips, this one Harvard article even calls sitting the new smoking.
• Developmental Hip dysplasia. This I am the least knowledgeable about because I don’t have it, but basically it is malformed hip sockets.  From what I’ve read it’s genetic.  I have also read that if you have hip dysplasia then you are not a good candidate for the typical FAI surgery; you would have to get some other operation performed.

“Alright Adam now I know how I got FAI, but what is causing this pain I’m feeling?”

That’s an excellent question and I’m glad you asked it.  In two words: muscle tightness. I am aware of two types of muscle tightness that can cause pain: adhesions and muscles being stretched from joints being out of alignment   I found a great description of adhesions (scar tissue, gristle, trigger points, it has many names, like the devil) from this website here.  To quote from the site:

Fascia is a connective tissue within the body. Think of your entire body wrapped in fishnet hose both internally and externally including each individual bone, nerve, and muscle. Over time, fishnet hose get entangled and require adjustment. If not, you develop an impingement. Fascia works in the same manner. Once fascia becomes entangled, impingement occurs. It may impinge blood circulation, muscle movement, or nerves within the body. Over time, myofascial adhesions occur as a result of unattended impingements. You may feel tingling or cold extremities due to poor blood circulation and/or nerve impingements. You may feel extreme tightness or lack flexibility in certain muscles while having extreme pain or pulling sensations in counteracting muscles. Knots develop over time known as Trigger Points. And then there is the ultimate myofascial adhesion, scar tissue. Yes, all of the above mentioned forms of chronic pain can be a result of myofascial adhesions. Myofascial adhesions occur for many reasons. Injury, illness, inactivity, lifestyle, job type, nutrition, dehydration, and the aging process all play a contributing role in the development of myofascial adhesions.

From pretty much every person that I’ve talked to, the pain comes from a combination of muscles being too tight and inflamed (usually from a twisted pelvis) as well as having all kinds of adhesions in the hip flexors.  One source of hip pain can be SI joint dysfunction, something I'm starting to see as something that is really common with FAI.  Try out these short, quick exercises here and if they help then your SI joint might also be an issue.

If your pain is constant and doesn’t change no matter what you do then it might be pain from joint damage, but if your pain worsens throughout the day or gets worse after squats, then that is probably muscular pain. Also, if you seek any of these treatments and it alleviates the pain then FAI is not what is causing the pain and so the surgery will not help with the pain, it might even make it worse.

The good thing about muscular pain is that it is typically treatable without surgery (various treatments are listed below). Yay for hope!

Concerning hip pain/fai, I’ve seen three main reasons for muscles to become tight and inflamed. 

1. The most popular is you always keep your hip muscles short, by sitting for example.  Do you always sleep on your side, with one leg thrown over the other? That’s another sign of tight hips, and that needs to be addressed ASAP.  I now have a standing desk and things are much, much better.
2. Another, less common experience is your hip muscles are stretched because your pelvis is twisted.  When I first started my journey towards health I discovered that my psoas was causing my pain. The reason why it felt like it was on fire was because my pelvis was twisted, stretching my psoas to the point of becoming “piano wire tight”.  If this is the case stretching will only make things worse. So if you’ve tried yoga/pilates/stretching to relieve your muscle pain and it’s only made worse, this is probably what is happening to you. 
3. Last but certainly not least is your hip muscles could be tight in order to try to protect your hip joint.  Even after I got my pelvis untwisted I still had a really tight psoas. After releasing it through massage it would tighten back up fairly quickly, and I realized it was because the psoas was trying to make up for the fact that I had a really unstable hip joint (I had a torn labrum).  If you’re in that particular situation (damaged labrum or some other part of the hip) then you’re probably going to have to get more aggressive in your treatment. This may mean surgery but it may not, I was able to address my torn labrum through PRP injections (see below).

Here are things you can try that in order of aggressiveness, starting from least aggressive to most aggressive.

Mobility work

Here are my top ten hip mobility exercises.  Though they may be my personal favorite, there are even more stretches/exercises out there, just use google and search Kstar's website.  If any of exercise hurts in a bad way, then stop.  What I mean by hurt in a bad way is that there are two types of pain: pain like stretching a recently pulled muscle (bad), and the kind of pain of feeling adhesions tearing (this is what causes the discomfort in myofacial release massage). After a while you learn to tell them apart.

Massage

Massage is great for breaking up scar tissue/adhesions. I highly, highly recommend massage if you're experiencing hip pain. 

Self-massage. I am a huge fan of self massage, mostly because it's free and you're on your own clock.  Get a foam roller, a softball, a tennis ball, and at least a lacrosse ball. These are your tools to get your muscles to release.  Find a way to apply pressure to what is bothering you and keep that pressure constant until the muscle releases. It may take five minutes, may take fifteen minutes. But just camp out and wait.  Fair warning, muscles tend to hurt the worst right before they release, trust me, the feeling of relief is worth the couple seconds of pain.

You can be excellent at self-massage, but you will still probably need to supplement with a professional's massage.  Find a massage therapist. Make that a great massage therapist.  The problem with massage is that it is only as good as the therapist you see.  So here are some ways to try to find a good massage therapist:

1. Word of mouth from people who work out. I message my local crossfit gyms asking them if they have any massage therapist they could recommend. Crossfitters need massage therapists who know what they are doing so they tend to find solid massage therapists
2. Try to find a Rolfer. Rolfing is a type of deep tissue massage. It’s a much safer bet that a Rolfer will be able to help you than a random massage therapist.
3. All else fails, try to find a massage therapist that specializes in deep tissue work. Ask if they are comfortable/ familiar with releasing your psoas. If the answer is no, walk away before you waste your hard earned money.

Dry needling is also a popular option that is supposed to have good results. As of the time of this writing I have yet to experience it but my physical therapist believes I'm a good candidate for the treatment.  Once that happens I will update this post accordingly.

Chiropractor or Doctor of Osteopath

This could be more of a temporary Band-Aid, but it can be a very helpful diagnostic tool. Through them you can find out which muscle might be causing your pain.  There are also a lot of Chiros out there that also do trigger point massage, which can also be helpful.

The reason why this could be only a temporary Band-Aid is because although they address the symptoms (e.g. a twisted pelvis) they most likely will not address whatever it is that you are doing to pull everything out of alignment.  However, doing exercises that work on your core (like squats, deadlifts, pilates) WITH PERFECT FORM will make your body more responsive to the treatment.  I responded really well to my D.O.’s treatment because I was doing such exercises at the time.

Physical therapist

This one is tricky. A great physical therapist will be able to figure out what is off with your mechanics and figure out exercises to retrain your body so that your femur sits in your hip socket correctly and will render you asymptomatic. A so-so PT will tell you they can’t help you. A really bad PT will tell you they think they can help you but end up doing nothing.  Again, you’re left with word of mouth, but do your best to find the best PT in your area. Trust me, it’s worth that extra 20 minutes of driving.

Prolotherapist

This was the option I took to treat my laberal tear.  Again, this is all depends on who is doing your prolotherapy. Four years ago I saw “the best” in the Mid-Atlantic area and he told me I had FAI with no laberal tear and there was nothing that could be done except surgery.  Then I saw one of the best in the world, Dr. Hauser in Chicago, and he was able to pretty much fix 95% of my hip.  Of what I know, there are two different styles of prolotherapy, both of which I talk about here with video examples.  I can only attest to Dr. Hauser’s method, but on an intuitive level it makes much more sense to me.

"Ok I’ve tried everything and everyone says the only way to fix this is surgery, now what?"

Like with the above treatments, try to see the best Dr. you can. That doesn’t mean some surgeon who has performed arthroscopic surgery before, I mean someone who dedicates their practice to helping people with FAI. You wouldn’t want some random Orthopedic surgeon doing a total hip replacement on you, would you? No, you would want someone who does that day in, day out.  It’s no different with treating FAI.

Takeaway points

• Don’t rush into surgery, try other approaches first.  I would try every other approach before going under the knife.
• Ask all kinds of questions. “What is causing the pain?” “Why will your treatment help?” “How will your treatment help?” When you see a specialist they will rush through things as quickly as they can if you don’t stop them by asking questions. Make a list on your phone, be ready, and after the meeting send out an email confirming what you took away from the conversation.
• Be your own advocate, your health is your own responsibility. If I had listened to the first doctor I would still be crippled and inactive right now.
• Be Patient!  It took years of bad posture/mechanics to get you into this mess, it's going to take some time to get you out of it as well.
• Try to see the best Dr./therapist you can. Usually that means someone who has seen your type of situation multiple times and has had many, many success stories.