Does an alternative explanation for FAI make sense?

Does an alternative explanation for femoral acetabular impingement make sense?

A while back, I made this video to provide a preliminary outline of my ideas about hip pain and the recently created diagnosis of femoroacetabular impingement and the increasingly common surgical treatment.

I received a comment on that video from someone purporting to be a physician practicing in orthopedics that I thought would be very important to share.

Here is the comment.

Unedited as it appeared on February 3, 2016 (I have added line breaks for ease of reading, but no other edits have been made)

Your claims are completely ridiculous. The fact that I am even typing this is unlike me, but it’s people like you that put false ideas in the minds of people who go untreated for conditions related to FAI believing the same garbage you spout off. What really bothers me is when people get on here and trust you and follow your advice. For what it’s worth, I practice in orthopedics, specializing in hips.

For one… “Your story” of FAI holds no credibility. What imaging have you had that proves or disproves FAI? You said none, so right there your credibility is shot. You hardly understand the concept which I can tell by you fumbling your way through the description of FAI. Let me educate you. FAI is a clinical diagnosis that does not require intervention on its own. A majority of the population likely has FAI (be it CAM type or Pincer, or combined).

The only part of your statements that are true is that people can walk around with FAI (again, cam or pincer lesion) without pain. Great. Whether you believe this or not, orthopedic specialists are not screening patients for FAI if they have no pain. Glad we got that straightened out.

Saying that you have FAI would be like saying one of your thumbs is longer than the other, or one of your eyes is more green then the other. Do we do surgery to shorten your finger or take out your eye? Absolutely not. It’s a clinical diagnosis, not an indication for surgery. It is simply a diagnosis that we as clinicians can only make with imaging (Xray, MRI, CT). The fact that FAI leads to labral pathology and could lead to chondral (cartilage) defects is when the diagnosis of FAI becomes a focus of treatment, and surgery is indicated.

I think your confusing treating FAI on its own versus treating labral tears. FAI does not = pain. FAI with labral pathology does. Labral tears do not heal themselves. Reparing the labrum is the focus of surgery, but removing the lesions (cam and pincer) are also necessary as they are the likely cause of the labral tear in the first place… Which can clearly be proven by suggestive findings on MRI surrounding the area of cam and the adjacent labral pathology. Often times you can see evidence of degeneration around the cam lesion (whether it’s edema, cystic changes (Google Pitt pit), chondral fraying, etc). CT 3D reconstruction can further delineate this. On top of this… Patients history, and clinical suspicion (Physical exam findings of pain with FADIR testing along with Xray findings of FAI) help,point us in the right direction and MRA is obtained.

Classic labral pathology pain is groin pain which you have addressed in other videos.

Not all groin pain is due to labrum. This is where most of your theories come in to play. Yes, people can walk around with labral tears without pain. We don’t treat those because they never seek treatment.. Obviously… But just because some people do doesn’t mean that we can’t treat the ones that do develop pain.

Another item you fail to discuss and disproves your theories are another part of the diagnostic process… Diagnostic intra-articular (joint) injections. Since your so knowledgeable of the hip joint anatomy I hope you would agree that using a anesthetic agent and steroid agent to inject into the hip joint would sufficiently rule in or rule out the diagnosis of labral pathology or intra-articular pathology. Guess what? We do it all the time. How could it be that a patient with all the classic findings, along with MRI studies showing labral pathology who receives a diagnostic injection has full relief of pain after this injection simply hours after experiencing severe hip pain? I would love to hear you fumble your way through explaining that one, or use outdated and non-credible sources.

To sum it up… FAI-> labral/chondral pathology = pain. Enough said. Stop filling the minds of people with useless and uneducated content.

This youtube comment does raise some important points and illustrates some issues that are salient and extraordinarily prevalent in FAI discussions, so I decided to respond on YouTube to address the concerns raised as honestly and directly as possible.

Here is my response:

Sorry it took so long to get to your response. YouTube had it marked as possible spam.

First off, thanks for your input and opinion, and thanks for watching many of the other videos to get a fuller sense of where I’m coming from. You have excellent points, and I want to answers your concerns carefully.

Your explanation of what FAI is will probably be very interesting for some readers, as you have actually pointed out that FAI is a bone morphology that in and of itself does not lead to pain. On that we are definitely in agreement. One of the studies I’ve referenced also shows that there is little correlation in terms of pain as well as range of motion.

If I understand you correctly, you are proposing that if a person has FAI AND labral pathology, then the labral pathology is caused by the FAI, which then causes the pain. To establish that, we should look at some assumptions implicit in that line of thought. 1) Whether labral tears do, in fact lead to pain and 2) whether FAI is related to labral tear development.

Regarding the first point – labral pathology, as you point out, is not predictive of pain. This has been demonstrated in asymptomatic populations with both shoulder and hip labral pathology. A large segment of the population walks around without any symptoms at all despite having labral pathology as you point out. If the bones are not predictive of pain, and the labral pathology is not predictive of pain, how then do you establish that those two things together are predictive of pain? You mention that groin pain is a classic sign of labral pathology but how would one definitively establish that?

Would you say that there could be no other causes of groin pain besides labral pathology? Would muscles come into play at any point? The statement that you don’t treat the people who don’t need treatment is circular in logic. It seems you are claiming that anyone who does come in for hip pain problems who does have a labral tear is having hip pain from the labral tear. But if we are being evidence based, the fact that labral pathology is not predictive of pain means you cannot come to the conclusion that the pain is generated by the labrum just because they came in for treatment without further investigation.

Here, I think you may think the FADIR and FABER tests qualify as thorough investigation and that description of onset is helpful. There have been no good studies yet to determine how effective and specific FADIR and FABER tests are (a recent study pointed out how little research has been done on ROM tests and FAI). As someone who has spent years fixing his own body, I do not think quick range of motion tests are at all thorough in sussing out muscular issues. As for the onset of issues, we have heard people who had sudden onset of hip symptoms after an acute injury as well as people who had the hip pain slowly progress over time. If acute injury and slow progression are both possibilities that do not rule anything out in the face of an X-ray and MRI, it seems that the history is largely irrelevant. Is there something in history that would provide a contradictory force to the X-ray and MRIs in your practice? If not, then again the X-ray and MRI appear to be the biggest players in the equation.

Typical physical therapy (oft aimed at strengthening the quads and abs) is often not particularly helpful for various reasons. For example, quick stretches for short periods of time are most definitely not thorough enough.

You make an excellent point about diagnostic injections. This is exactly where I’m lacking enough information to satisfy you (and myself). I have tried to look into the specificity of those injections and tried to better understand how they are currently used to bolster this idea that the labral pathology is the pain generator. As I have no direct experience with the injections and don’t know what chemicals are used or how the anesthetic affects all the tissues and nerves around the joint, I can only speculate that the injections affect far more than just signals from the labrum and in doing so create a false sense of certainty of the labrum being the pain generator. I do wish to learn more about this, but I’ve reached road blocks in time and general direction.

However, that point does not weaken my belief that X-ray and MRI evidence and symptoms do not add up to a properly thought out diagnosis and treatment direction for the following reason:

If your position is true – that the bones cause the labral tears which cause pain, then we should not be able to find cases of people with the FAI morphology, labral tears, and NO pain. Further, we should not be able to see an improvement in symptoms for people with FAI morphology and labral tears.

People with those bone and labral pathologies should simply be unable to get better without surgical intervention. But people do.

Shane – my partner on the FAI Fix project – has been diagnosed via X-ray and MRI investigations with FAI, paralabral cysts, and a labral tear. Years ago, he had very intense hip pain and severely reduced range of motion. He has never had surgery to repair any of those issues. Over the years, he has gradually relieved all his pain and trained his body to have range of motion 99% of adult males do not have (full splits side to side and front to back). He STILL has FAI and the labral tear but has zero hip pain as long as he continues to train his body right.

Our program was released nearly a year ago, and we have been accumulating stories from many individuals around the world who have the FAI diagnosis, labral tears, and are achieving pain relief and improving range of motion (as long as they continue to train smartly) without surgery. If, in fact, labral tears caused by FAI are the generators of pain and disability, Shane’s case should not be possible. The improvement others are getting should also not be possible. What would your interpretation of this situation be?

If there are other pain generators possible (as it seems), then how should that affect the diagnostic process and the entire concept of FAI? Given that we are establishing improvement as a real, repeatable possibility, it seems reasonable and not dangerous to strongly suggest that 1) the bones are not a big concern (you and many studies support this) and 2) the labral tears are not a limiting or determining factor (studies also support this).

As for the development of arthritis, which often comes up in these discussions, large scale, long range studies are demonstrating no connection between FAI morphology and the development of arthritis, so I do not feel we are endangering anyone in that regard either.

A short analogy of the situation as I see it: if we were involved in helping people with headaches, and we all believed black hair was predictive of headaches, we would do studies on black hair and headaches. If we found in preliminary studies with short time horizons with no control groups that a lot of people with black hair have headaches, we might start to suspect black hair as an indicator. When we then looked at asymptomatic groups and discovered that black hair had no predictive value for the development of headaches over long periods of time, we would have to re examine things. We could not say: “Black hair does not have predictive value for headaches, but if someone comes in with black hair and headaches, we should treat the black hair.” No, that’s a clearly a bad conclusion. But this is essentially what has happened historically with the FAI diagnosis, the treatment studies, and the current way the whole “disease” is viewed.

I hope that this response addressed your concerns and more clearly explains where I’m coming from. If I had any belief that what I was talking about was endangering others, I would most certainly take this video and all other videos on this topic down.

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About the Author

Matt Hsu is a trainer and orthopedic massage therapist. He fought a long battle with chronic pain all over his body and won. He blends the principles he learned in his journey, empirical observations with clients, and relevant research to help others get their lives back.

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