A Deeper Look into “Conservative Treatment” for FAI

Femoracetabular Impingement (“FAI”) is a near and dear topic for us at Upright Health. We have had countless clients at Upright Health who wanted conservative treatment for FAI (meaning NO surgery). 

Unfortunately, many people diagnosed with FAI get pushed toward unnecessary hip surgery every day. There is plenty of controversy around surgery for FAI. Recently, researchers started to publish studies comparing the effectiveness of surgery with conservative treatment for FAI.  

The usual conclusion is that surgery is more effective than the non-surgical option. These comparative studies usually use the best available surgical interventions. But the conservative treatments are not what we consider “the best.”

Personalised Hip Therapy (“PHT”) is the current non-surgical option used in some big FAI treatment studies. This article is going to examine what PHT is and why using it as conservative treatment for FAI results in a skewed view of surgery for hip impingement.

Who am I?

​I'm Maks Reznik. When I started to experience debilitating hip pain, doctors and physical therapists told me I needed surgery to fix my FAI.

I decided against it, and years later I'm happy I did.

You can see more of my story in this video

How Researchers Built the Personalized Hip Therapy using Ineffective Training Programs

PHT is a program of exercises that aim to improve hip function in those diagnosed with FAI.  A group of UK researchers created the PHT to establish the standard for conservative treatment for FAI. 

The purpose of PHT's creation was to compare it to hip surgery for FAI treatment. ​Since 2016, many medical journals published studies comparing the effectiveness of hip surgery to PHT in the treatment of FAI.

Researchers selected exercises based on a consensus from physiotherapists they interviewed. They then tested the protocol on patients with FAI. 

The researchers arrived at this consensus in two phases. In the first phase the researchers gathered evidence on published protocols and created a sort of “draft” exercise program. This program was then emailed to physiotherapists for suggestions on changes. Once 50% of the physiotherapists agreed upon a protocol, the researchers moved on to phase two. 

In phase two, researchers tested the draft protocol on a group of hip pain patients. Another group of patients received hip surgery for FAI. The physiotherapists completed case reports for each patient receiving the non-surgical FAI treatment. 

The physiotherapists then met at a conference to exchange ideas and make further changes to the protocol. At that point, the protocol became the Personalized Hip Therapy program.

The Personalized Hip Therapy protocol for FAI is built on a sandy foundation

The researchers did not interview hip pain sufferers that resolved FAI symptoms without surgery. Instead, they relied on published protocols on conservative treatmentf for FAI. But there were no published protocols that worked!

The researchers admitted this issue themselves: "[The PHT] was developed based on the experiences of clinicians treating patients . . . and not by targeting the deficiencies observed in patients with FAI syndrome.” 

It was impossible to create an effective non-surgical treatment method for FAI based on prior protocols. This is because no prior effective FAI protocols existed! The only way to approach non-surgical treatment for FAI is to alter the way we approach the issue.

They Did What!?

Researchers created the PHT by combining conservative treatments that already existed for FAI.  Only problem is that none of these existing protocols worked!

Conservative treatment for FAI with PHT does not Include Major Hip Movements

The PHT has turned out to be an underwhelming tool for hip pain at best. It overlooks a shocking number of muscles and movements for the hip joint. 

Let’s first focus on the movements and muscles that the PHT does explicitly target. 

The PHT targets the following hip muscles for strength: glutes, abs and the “lower limb in general.” 

Movements targeted with stretching include the following: hip external rotation and hip abduction. The protocol also mentions that stretching for the hip flexors may be necessary. 

And that’s it. 

It is impossible to list every muscle and movement pattern that may be responsible for hip pain. However, evaluation of a wide variety of muscles and movement patterns is a MUST. The PHT barely scratches the surface. 

The PHT ignores the following major muscles for strength: adductors, quadriceps, iliopsoas, hamstrings, obliques and TFL just to name a few.

Major movement patterns ignored include internal rotation, adduction, hip flexion, hip extension and combinations and different variations of these patterns (e.g. hip flexion with abduction, adduction with knee flexion, etc.).

In short, the PHT leaves out more than it includes! It's as if the consensus resulted in a short list of random muscles and movement patterns to improve. 

It Can't Be True!

Yes it's true.  The PHT leaves out more hip movements than it includes...a lot more!

Even more troubling is that the PHT recommends certain strategies without justification.

For example, the PHT directs the hip flexors to be stretched but there is no mention of strengthening this muscle group. We understand that hip flexor “tightness” is a popular bogeyman for hip pain. However, “tightness” does not always mean a muscle is strong and needs to be stretched. You can read more about this here.

One of the biggest issues I’ve seen with many people struggling with chronic hip pain is weak hip flexors. This alone can provide significant pain relief and the PHT doesn’t even mention it.

Personalized Hip Therapy is Structured to give Hip Pain Patients little Chance for Success 

The PHT provides for at least 6 and at most 10 sessions with a physiotherapist over the course of 12 weeks. This begs an important question: Is it possible for someone with chronic hip pain to see progress within this time frame? 

If they follow the PHT, which only focuses on 2 muscles groups and two movement patterns, it is unlikely.

How Long Does it Take to Get Out of Hip Pain?

The answer depends on what you're doing to improve your hip functioning. If you follow the PHT protocol and focus on only two movement patterns of the hip, you might never reclaim proper hip function. If you troubleshoot each movement pattern of the hip and identify your weaknesses then you're heading in the right direction. It can take months or years to be at your version of 100%. But after each workout, your hips will feel stronger, more mobile and more capable.

If comprehensive training focuses on improving specific weaknesses, then it is much more likely.

A lifetime of poor movement habits takes more than three months to reverse. Giving people with hip pain realistic expectations is important.

From our experience, three months is a reasonable time frame to start seeing improvement. It’s reasonable in that time to see how a comprehensive movement practice can improve hip comfort.

But ALL hip pain will NOT be “cured” in such a short period.

And most people will not learn enough in only six or ten sessions. Certainly not if those sessions are only thirty minutes long. And with a physiotherapist who already believes that FAI can only be treated surgically.

Personalized Hip Therapy does not improve hip range of motion

PHT prohibits painful hard end stretches. This is a good idea. The nervous system will not adopt a greater range of motion in a position when it senses extreme pain.

However, obtaining larger ranges of motion in essential hip movements is critical when regaining function in the hips.

The PHT advises against “vigorous stretching” and “painful hard end stretches.” This likely causes therapists to avoid improving ranges of motion in certain positions. This, in effect, paralyzes the patient from ever making significant progress.

Pain in the end range of a stretch means the body does not like this position. But that does not mean it is not capable of becoming more resilient in that position. It is crucial that people with hip pain explore these painful positions to determine how they can overcome the restriction.

If you avoid every position that triggers discomfort, then what’s the point of the therapy in the first place? Avoidance is a guaranteed method of making zero progress.

If one stretch is difficult, may be a less intense stretch will help to progress into it. Maybe strengthening the main muscles involved will make the stretch easier.

Maybe working on another movement pattern will open the stretch more.  The fact that a stretch or a position is painful is actually a great opportunity to use it as an assessment. Finding ways to perform the movement in a pain-free way brings you one step closer to being pain-free in your daily life. 

There are nuances to stretching that everyone must become aware of to gain hip mobility. The PHT throws proper flexibility training for the hips into the trash, and leaves hip pain sufferers with nothing useful!

The Ideal Conservative Treatment for FAI

The ideal conservative treatment for FAI would include all three of the following elements:

• (1) Assessments that identify individual movement dysfunctions; 
• (2) A reference guide of exercises to improve each basic movement pattern, including progressions; and
• (3) Guidance from an experienced trainer that is familiar with common difficulties.

The first task in any movement protocol is to test the functioning of basic movements. For the hip joint itself, assessments can include: flexion, extension, external rotation, internal rotation, abduction, adduction, and combinations of all those motions. Other assessments can include full body movements such as hip hinging and squatting to test the ability of the muscles to handle loading. 

Then, the protocol must identify techniques and exercises to improve restricted movement patterns. There would also be progressions for each exercise. This way,  there is continuous improvement in key movement patterns. 

Unfortunately, creating a fool-proof protocol without human error is impossible. The human body is not a perfectly predictable machine. People with hip pain often need modifications and unique strategies to work around challenges. 

The FAI Fix, for example, includes over 80 different exercises. It also includes assessments and guidance on how to deal with various challenges. It works for many people, but we know that it’s not 100% foolproof. Sometimes more specific coaching and coaxing is necessary to make positive changes.

We’ve had users of the FAI Fix work with us when they want more guidance, and we’ve seen how many variables can go wrong. Sometimes the problem is poor form. Sometimes it’s fear of a certain position. Other times it's the upper body that is causing compensations in the lower body. The possibilities are endless.

There are many possible obstacles in healing your own hips. But they are surmountable if you put time, attention, and intention into solving your own issues.

It can be a time-consuming and frustrating process. That’s why it can be helpful to work with an experienced trainer or physical therapist. It is important to find someone with the right mindset and who is familiar with the various hurdles of movement training.

Conclusion

An adaptive protocol is in a much better position to compete with hip surgery than PHT for improving hip pain. Focusing on the root cause of the hip pain - improper movement patterns - should be the basis of conservative treatment.

Unfortunately in the medical literature, that approach doesn’t exist. The best option right now is PHT, and that is a woefully inadequate protocol for solving hip pain.

FAI patients deserve a more comprehensive, nuanced non-surgical treatment. Otherwise, studies comparing hip surgery and conservative treatment for FAI are not helpful. The results between the two treatment methods will be minimal at best.

To become better at hip movement, you need to practice . . . hip movement! This is a process that is individualized. It's a process that requires time and customization and does not fit well into the mold of modern medical studies.

If you’re weak in hip flexion, you need to practice hip flexion. If you have limited hip internal rotation, you need to practice becoming better at hip internal rotation. The PHT misses this basic concept and so many more.

I hope this article gives you the information you may need when deciding on whether surgery for FAI is right for you. I encourage you to continue troubleshooting your hips through movement. Leave hip surgery and Personalized Hip Therapy on the shelf to gather dust in the meantime.

Interested in working with an experienced trainer? Check out our hip program!