Returning to sports after FAI surgery? What's the data really say?

Hip impingement surgery – can you return to sports and other activities?

A 2018 study in the American Journal of Sports Medicine claims that surgery for hip impingement is VERY successful. It says that arthroscopic hip surgery for femoroacetabular impingement reliably produces excellent results for patients. They claim it helps the overwhelming majority of hip pain patients return to sports quickly.

Other studies about FAI surgery don’t show these utopian results – like this one or this one. We’ve also seen a recent study on hip impingement surgery versus physical therapy. Surgery led to patient disappointment in that study too.

This new hip impingement study, Systematic Review and Meta-analysis of Outcomes After Hip Arthroscopy in Femoroacetabular Impingement, makes a bold claim.

It claims that 87.7% of patients return to sport activities after hip arthroscopy for FAI.

What makes this study so different? Let’s take a closer look.

What did they do in this hip impingement study?

This was a meta-analysis. It’s a review of studies on hip arthroscopy for femoroacetabular impingement.

In case you aren’t familiar with it, arthroscopy is where the surgeon inserts a small camera into the hip joint. The surgeon can perform his “fixes” with a small incision and small instruments. This is in contrast to open surgery, in which a much larger incision is made and the femur is totally pulled out of the socket.

The researchers gathered a total of 31 studies. This encompassed 1911 patients in total and 1981 hips. That’s a big sample size.

All the studies had to:

  • be about arthroscopic surgery for FAI and ONLY arthroscopic surgery.
  • be less than 12 years old.
  • include patient outcomes, with at least 6-months of follow-up.

A meta-analysis summarizes all the information in all the studies with statistics.

As we look at this study, it’s important to keep this German aphorism in mind (often incorrectly attributed to Winston Churchill): “Trust no statistics that you didn’t falsify yourself.”

Let’s take a look at why and how we should be suspicious about the findings of this hip impingement study.

Statistical charts

“Trust no statistics that you didn’t falsify yourself.”

This hip impingement study has an extremely high risk of bias

What does it mean to be biased? It means the authors behind the study may have incentives that predispose them to certain conclusions. In this case, that the study has a high risk of pro-surgery bias.

There are three major factors contributing to this high risk of bias.

  1. The authors are surgeons who make money performing hip arthroscopy.
  2. The authors are surgeons who receive money from companies that manufacture devices used in hip arthroscopy.
  3. The studies used in this review are all highly biased in favor of surgery (because the above two factors apply to the authors of those studies as well).

Here’s an example: if a cigarette company pays for a study, and the study concludes that smoking is good for your lungs, we might be suspicious that the authors were influenced by the money from the cigarette company.

They got their money from the cigarette company, and so it would be be more likely for them to come up with a conclusion that speaks positively about the cigarettes.

Cigarette


But could that be happening in the world of medicine?

Studies show that it happens regularly in orthopedic research.

So let’s take a close look here.

The first page of the study clearly states:

““The authors declared that they have no conflicts of interest in the authorship and publication of this contribution.”

We can double-check that claim on the official U.S. government website that tracks payments to American doctors.  This website ​​​​sees if anyone is paying the authors and creating hidden conflicts of interest. On that site, we have data from 2013 to 2017 (at the time of writing).

There are four lead authors in this hip impingement study.

One of them has no payment data.  

Three of them have payment data (here, here, and here). And all three receive regular payments from arthroscopic surgery device manufacturers.  

From 2013 to 2017, these three authors were paid a total of $203,078. In 2017, they earned a total of $99,017 in payments, gifts, and grants from arthroscopic surgery device manufacturers.

That 2017 number includes a $53,903 grant for research.

Let’s say you know someone who sells cigarettes. He earns several thousand dollars each month selling these cigarettes, and a cigarette company gives him a $50,000 grant to do research on the health benefits of cigarettes.

His study is published and claims that smoking cigarettes is good for your lungs. Would you trust it?

Probably not. He'll make more money if you believe cigarettes are good for you. He makes that money from the cigarette company and from people buying cigarettes directly from him.

He has a conflict of interest. There’s a very high risk of bias.

Conflict of Interest?

The lead authors received $203,078 from 2013-2017 from medical device manufacturers. One received over $50,000 as a research grant. 

The situation is no different with surgeons in this hip arthroscopy review.

Surgeons make money performing surgeries. These surgeons get extra money every year from arthroscopic surgery device manufacturers to publish research that says — unsurprisingly — surgery is good for you.

Is bias in the study likely?

Yes, and later in this article, you’ll see it very clearly.

Finally, this hip impingement study pulled from a pool of low quality research.  Of the 31 studies, 26 are of Level IV evidence. In case you aren’t familiar with the levels, Level IV is one step up from THE BOTTOM. Level I is considered the top.

That means 86% of the studies included are classified as having a high risk of bias (in favor of surgery) and are missing key information.  

So you have biased authors looking at biased studies.

Therefore, the fact that they play with statistics to paint an optimistic picture of surgery for FAI comes as no surprise.

What would a high quality study on hip arthroscopy for FAI look like?

A proper study of the efficacy of hip surgery for FAI would have a placebo treatment control group. Historically, orthopedic surgeons strongly resist calls for placebo-controlled studies. 


There is a long history of high quality studies debunking other cash-cow orthopedic surgeries. See: knee meniscus surgery, spine surgery, shoulder surgery for impingement.

How did they arrive at an 87% return to sport rate for hip arthroscopy for FAI?

This study claims 87.7% of patients returned to sports after hip arthroscopy for hip impingement.

In the abstract (the summary), the authors looked at 31 studies in total and over 1911 patients. This makes the 87.7% seem fantastic. It’s a huge patient population, so the conclusions must be trustworthy!

But the reality is different.

If you read the full paper, you’ll see the authors claim they calculated their 87.7% from only 10 studies and 554 patients. In Figure 3 of the study, they contradict that and actually show 11 studies and 631 patients. It’s a weird inconsistency that we can’t make heads or tails of.

Whether they used 10 or 11 studies isn’t that important. What is important is that the calculation is still not based on 1911 patients. At best, it’s only one-third of the entire sample.

So they did not have 87% of 1911 patients returning to sport. At most, they had 631 patients involved — AND it wasn’t 87% of them returning to sports. They used statistical tricks to make it SOUND that way.

In addition, all the studies they used to calculate their 87.7%  are highly biased Level IV studies. These were all studies published  by the surgeons who performed the surgeries. They had a strong interest in “proving” that their surgeries worked.

There was no oversight on how they collected data, no control groups, no placebo groups — nothing that would make for solid evidence. 

How did the authors make hip surgery for FAI for athletes look good?

They misused some statistical tools to create rosy numbers. The actual statistical tricks will make your eyes spin in your head, so we’re going to keep our discussion of math to a minimum.

When you study groups of people and try to apply what you find to the general population, you have to think about how representative your groups are of the general population.

Think about it this way: will a pro football player respond to surgery the same way a 70-year-old sedentary woman will? Probably not. This is a difficult thing to measure and quantify, but it’s something to respect when studying humans and medical treatments.  

It's something to pay close attention to when you combine numbers from multiple studies. You have to consider whether big differences in the populations in your studies may have an impact on the trustworthiness of your numbers. 

For example, one study has 153 patients. Their ages range from 50 to 70 years old, and the study doesn’t mention how many of those patients played sports.

Another study has 70 male baseball players. Their ages range from 14 to 35 years old.

The only thing both groups have in common is the hip impingement diagnosis.

If you were studying the effect of ibuprofen on the human digestive system, maybe the age and athletic abilities wouldn't be at the top of your concern list. But when you're talking about the musculoskeletal system and how someone recovers from surgery, there are obvious differences between how a young person and an older person recover. 

The outcomes of an otherwise healthy 20-year-old baseball pitcher may significantly differ from a 60-year-old female who is sedentary.  Their risk of re-operation and their risk of complications may be different, and their likelihood to “return to sports” will obviously be different. 

But you lose that perspective when you combine all these numbers. The differences in your populations are obliterated. That’s why this statistical trick is so sneaky.

Here's an example to make this more clear. We won't use the actual statistical math they used to keep it simple.

Let's say you're doing a super simplified calculation of the chance of winning two gambling games. One game is a coin toss. One game is rolling a six-sided die. A coin has two sides, the die has six.

When you flip the coin, heads is a win. When you roll the die, a six is a win.

For the coin toss, you have a 50% chance of a win on each turn.

For the die, you have a 16.6% chance of a win on each turn.

A red die

With a die, you have a 16.6% chance of a win on each turn.

These are clearly different situations. You have a higher chance of winning with the coin than with the die.

But what if we want to know the average chance of winning no matter which game I play? You might come up with up with a 33.3% chance of winning every time you play by averaging out the odds of winning for both games (again, this is not how you would do this statistically, but we’re keeping the math simple).

50 + 16.6 = 66.6.

66.6 / 2 = 33.3%

That lowers the perceived likelihood of winning with the coin and doubles the perceived likelihood of winning with the die.

Of course, this would be incorrect, and it would be silly. You wouldn't combine odds like this because your chance of winning depends entirely on whether you're flipping the coin or rolling the die.

But that’s exactly how statistical tricks are misused in this study. The high-level athletes push the 'return to sport' numbers up (win!), and the bad outcomes (lose) don’t seem as frequent.

This study mixed six different outcome measurements, 18 studies, and 1462 patients. They mixed professional athletes with sedentary people, and they mixed patients with age ranges of 11 to 77 years old.

How pro athletes skew the data on return to sport after FAI surgery

This analysis looked at 11 studies on recovery from hip surgery and return to sport. You can take a closer look at all of them in the table below.

STUDY

OBJECTIVE

LEVEL OF EVIDENCE

SPORT

POPULATION

RESULTS

Study the return to sport in professional athletes operated arthroscopically for hip joint pathology.


IV

Football (Australian Football League).

26 males playing at professional level by the time of the surgery.

25 returned to play professionally for 2 to 8 years after surgery. 10 retired after an average of 2 years after surgery.


Describe the clinical presentation of labral pathology in rowers, the MRI and radiographic findings of labral pathology in rowers, and determine the likelihood that a rower with labral injury, treated arthroscopically, will return to sport.



IV


Rowers (prep school and collegiate).



18 rowers.

10 returned to rowing between 3 to 25 months after surgery (55%)


Authors don’t mention how long they practiced the sport after surgery. 6 patients never returned to rowing.


Analyze the participation in popular sports after arthroscopy for FAI.


IV


Mixed, recreational

53 (41 male, 12 female).

45 of those patients had “regular participation in popular sports” until their first FAI symptom.


31 (58.5%) patients returned to “their full accustomed level of activity”.





Assess the effectivity of arthroscopic management of symptomatic FAI in athletes.






IV






Mixed

200 athletes.


They mixed 23 professional, 56 intercollegiate, 24 high school, and 97 recreational athletes  from 30 different disciplines.


Their age ranged from 11 to 60 years old.

181 (90%) athletes returned to their previous level of competition.


95% (21 out of 23 pro athletes) returned at the professional level.


85% (47 out of 56 intercollegiate athletes) returned at the collegiate level.


Researchers don’t mention the time frame between surgery and returning to their previous level of competition.  


Review impingement patterns, return-to-play rates, and clinical outcomes following arthroscopic treatment of FAI among high-level baseball players.



IV


Competitive baseball players.

70 males, where:


27% professional athletes.


57.1% college athletes.

42 (60%) returned with the same or above pre-injury level.


Apparently, the athletes played from 4 months to a year after surgery.

Determine whether hip function improves after arthroscopic treatment of FAI in overhead athletes and the rate at which overhead athletes returned to preinjury level of play.



IV

Baseball and lacrosse (varsity high school, college, and pro).

34 athletes:


16 baseball,


18 lacrosse.



12 months after surgery, 33 of 34 athletes were able to return to their previous level of sport (97%).

Compare the time taken to return to the preinjury level of sport between professional and recreational athletes, the degree of improvement in time spent in training and competitive activities after arthroscopic surgery for FAI, and the difference in trend of improvement in hip scores.




IV



Mixed, pro and recreational.


80 athletes from 10 different disciplines. 50 males, 30 females.


Their ages ranged from 14 to 59 years.



After 1 year, 66 (82%) athletes returned to sports. Recreational athletes took 2 months longer to return to sports compared to professional athletes.



Review the clinical outcome after arthroscopic treatment of FAI in a mixed population of high-level athletes.




IV

Mixed competitive athletes (varsity high school, college, and pro)


47 patients from 11 different disciplines.


Their ages ranged from 17 to 56 years.


Only 55.3% are known to have returned to sports.

30% of the patients were not available for follow up.


Determine if an arthroscopic approach to treating FAI can allow professional athletes to return to high-level sport.



IV


Mixed, professional athletes

45 patients from 9 different disciplines. Their ages ranged from 17 to 61 years.

35 athletes remained active at the professional level at an average of 1.6 years follow up (78%).

3 athletes didn’t return at all.

5 athletes had reoperation (11%).

Investigate hip pathology found at hip arthroscopy in these athletes and describe treatments and outcomes.


IV

Football (Australian Football League)


24 males.

23 returned to top-level football. 95%

Athletes maintained their improvement from 1 year up to 4 years.



Report the short-term outcome of the arthroscopic treatment of cam-type FAI in skeletally immature adolescents.




IV




Mixed


34 athletes. 29 males, 5 females from 8 different disciplines.


2 patients didn’t practice sports.

All patients had a minimum follow-up of 1 year. At that time:

25 (78.1%) were about to return to full sporting activity, 4 (12.5%) were able to return to sport but at a lower level, while 3 (8.8%) were unable to return to sport.

The two patients who did not participate in sports returned to “full activity.”


There are two athlete studies on professional Australian football players (Singh 2010 and Amenabar 2013).  Notice how high their return to sports rates are? Compare that to the numbers in the Brunner 2009 study with recreational athletes. The pro football players returned to sport at a rate of about 95%. But the rec athletes? 58.5%.

Here’s the thing to keep in mind. Pro and competitive athletes have a lot of things going for them that make it more likely they’ll return to sports after surgery. 

They are generally younger and have more muscle to begin with. They will also likely have training staff, likely have access to better rehab staff after surgery, and likely have better overall body awareness and control. In addition, serious athletes have enough time and money to dedicate to proper rehab training post-surgery. All those things have significant effects on outcomes.

Pro football athlete

Pro athletes are more likely to return to sports after surgery. They are motivated by their teammates, fans, and their paychecks.

As Tjong 2016 puts it:

“Higher-level athletes may have access to increased support from their coaches, athletic trainers, and teammates. Furthermore, professional athletes have been found to display a heightened level of self-efficacy as their motivation to return to play is also influenced by financial gains.” 

In addition, there’s a factor that’s easily observable but not easy to quantify: Elite athletes are often elite because they are able to play through pain and discomfort. We’ve seen this with elite athletes time and again (and we’ll talk about it more later). 

Returning to a sport as a high level athlete doesn’t necessarily mean that the athlete is “cured” of all hip pain.

But with these athletes included, the authors have a very optimistic "average". And that’s how they come up with their 87.7% number.

They came up with a high average routine to sport for a small subset of the patients, and then they extrapolated that out to all the other patients. 

This is like saying, “I have 10 marbles. Five of them are red. I don’t know the colors of the other five. Of the five reds, two have cracks in them (40%) . Therefore, 40% of all my marbles have cracks in them.”

This is not sound reasoning for marbles, and it’s not sound reasoning for hip surgery for FAI.

How long can you play sports after hip arthroscopy?

When surgeons talk about “return to sport” after hip arthroscopy, they don’t talk about whether the effect of the surgery is long-lasting. That’s a crucial question.

Patients often think, “I just want to get back to my sport, and the surgeon promises arthroscopy will help me do that.” What people don’t realize is that there is little-to-no data on how well hip surgery works for athletes diagnosed with FAI in the long run.

In this review, there were five studies that looked at specific athletes and return to their specific sports after hip arthroscopy.

STUDY

LEVEL OF EVIDENCE

SPORT

POPULATION

HOW MANY RETURNED TO SPORTS?


IV


Competitive baseball players.

70 males:

27% professional athletes.

57.1% college athletes.

42 (60%) returned with the same or above pre-injury level.

Apparently, the athletes played from 4 months to a year after surgery.



IV


Football (Australian Football League).

26 males playing at a  professional level by the time of the surgery.


The age at the time of the surgery ranged from 16 to 30 years old.

25 (96.15%) returned to play professionally after surgery. They played for 2 to 8 years after surgery.

10 (40%) retired after an average of 2 years after surgery.



IV



Rowers.

15 females and 3 males of prep school and college age


Their age ranged from 14 to 23 years old.

10 (55.55%)  returned to rowing between 3 to 25 months.

They don’t mention how long they practiced the sport after surgery.

6 (33.33%) never returned.


IV


Baseball, lacrosse.


34 (16 baseball, 18 lacrosse).

33 (97%) reported returning in the 1-year follow-up. There’s no further information.

IV

Football (Australian Football League).

24 males.

23 (95.8%) returned to top-level football. They don’t mention for how long.


There are some key things to notice in the table above.

First is that these are all Level IV studies again (low quality, high pro-surgery bias).

Second is that only one study bothered to look at longevity in sport after hip arthroscopy — and that was for those pro Australian football players. So nobody has any idea how well hip arthroscopy works in the long run — not even for pros.

Third is that the outcomes are different for the various kinds of athletes.

Two out of these five studies looked at players in the Australian Football League. This is not like American football. This a helmet-free game that resembles rugby (but has a number of different rules).

As we saw earlier, pro athletes have a tendency to do better in returning to their sports in the short term. Ask yourself, are pro athletes who make a living sprinting, running, and tackling others representative of your life? Are they representative of the average adult female’s, average adult male’s, or the average teenager’s life? Hardly.

We’ve worked with a few pro or former pro American football players, Army Rangers, and Navy SEALs over the years. These are top level athletes.

When you talk with top level athletes, you notice something: they are exceptionally good at playing with and through pain.

It would not be hard to believe a pro football player returned to play even if he still had pain following surgery.  A pro Australian football player returning to play after surgery is influenced by far more than the surgery alone.

But even so, Amenabar 2013 showed that 40% retired at an average of two years post-surgery. Was it because of their hips? Other injuries? It’s impossible to know because the study wasn’t detailed enough to find out.

When you look at the rowers and baseball players in the other studies, you can’t find any information on longevity in the sport. But you can see that the return to sport rate is not good.

At least 33% of the rowers never got back to their sport, and two of the patients never reported back.  Forty percent of the baseball players were unable to return to their same levels after surgery.

Those numbers much more closely align with the satisfaction rates found in this FAI surgery satisfaction study and this study on satisfaction with open and arthroscopic hip surgeries for FAI.

If you take out the studies with pro football players, you see that returning to specific sports after arthroscopic surgery for FAI is not a sure thing.

The authors of this study, however, hid this behind a wall of statistics.

The authors also based their “success” conclusions on some metrics that are highly questionable. We go more in depth on the success metrics surgeons use for hip surgery in another article.

Question mark

The metrics surgeons use for "successful" hip surgeries are highly questionable. 

Are we biased in our assessment of this hip arthroscopy study?

Yes.

We’ve seen a lot of people come into our studio whose surgeons told them they definitely needed surgery, and we’ve seen people come in AFTER surgery failed to provide any relief.

And we’ve seen those same people get better without surgery (or more surgery). Careful exercises chosen specifically with the needs of the individual in mind solves hip pain.

We have already witnessed this countless times.

Here's the thing: if the surgeons’ perspective on hip pain and FAI bone shapes is right, we should NEVER see people get better with exercise. Never.

But we see it often.

Surgeons and other proponents of surgery often say “well, then the people were misdiagnosed.”

If that’s the case, then hip pain sufferers everywhere should be afraid. This means people are frequently “misdiagnosed” and mistreated with surgery when, in fact, the problem could have been solved with exercise.

Some critics claim that how we read these studies is biased because we ourselves are motivated by money (because we help people with hip pain with personal coaching and online programs).

This could certainly be at play. But there are two things to keep in mind.

First, we never make money anywhere near the scale of surgeons. Our in-person coaching for one hour is often just a fraction of what a surgeon charges for a consultation. What we make in one year from one client is still often less than what a surgeon makes for ONE procedure.

Second, our online DIY programs come with money-back guarantees. That means if a program of ours doesn’t help someone, we actually DON’T make money. We know learning how to troubleshoot your own body can be difficult and frustrating. Learning the process online just doesn't work for some people. And some people have so much going on they need personalized help and attention. Nothing is a fit for 100% of people, so giving people their money back is a simple way to help others and know we aren't leaving anyone feeling cheated. 

Contrast that with surgeons who make thousands of dollars per procedure whether or not hip surgery cures someone's hip pain or not.

Contrast that with surgeons who author pro-surgery studies but do not disclose that they earn millions of dollars per year in royalties from device manufacturers for popularizing surgery.

Can muscles change? Can pain caused by muscular problems be addressed naturally and non-invasively? Yes. There is ample evidence for this that any person can experience themselves.

Human body

Muscles CAN change.


This perspective means that you, the individual, can solve your own hip problems with time, patience, and education.

You can retrain your muscles to control your hips comfortably and with confidence. You need to learn to train and treat your body well. If you don’t succeed at first, then you need to experiment with new exercises and other lifestyle modifications.

The surgical perspective means that you are hopelessly broken and in need of high tech and expensive repairs. It means you are at the mercy of “experts” who make lots of money per procedure and per device used. You are at the mercy of medical device manufacturers who have an interest in selling more expensive widgets to put in your body. And if a first surgery doesn’t succeed, surgeons will sell you a second more invasive surgery.

Trusting these studies is like putting the health of your lungs in the hands of a cigarette salesman.

You are free to choose which perspective makes the most sense to you. One gives you power and control. The other makes you helpless and hopeless.

So does hip arthroscopy for FAI work for athletes?

The authors of this study have a vested interest in your believing that surgery works for FAI. They’ve massaged the numbers to make it seem like return to sport rates for hip arthroscopy for FAI are great. They want it to seem like hip surgery is a great idea for athletes and for everyone with hip pain and FAI bone shapes.

But now you’ve seen exactly how those statistics have been massaged. And you can arm yourself with facts that will help you make smart decisions in the long run.

You should also know that these authors ignored and omitted key information that other orthopedic surgeons are honest about.

 

Learn more about our DIY program to help you train out of hip pain.

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