Femoral Acetabular Impingement question

[jhartman]

Hi Mark & Starting Strength coaches,

I'm asking for your advice on surgery for femoral acetabular impingement since you've given some advice from the perspective of a strength coach on surgery before in your Ask Rip videos.

Background: I've hurt my left hip twice squatting in the mid 200s. I now have some pain in the hip doing things like climbing stairs, biking, and sometimes sitting on the toilet. There's a crunching sensation in the hip when I lift my knee (it was there before but has gotten worse). I've stopped squatting and have been doing deadlift-only training, making very slow progress. The right hip can bother me from time to time but there hasn't been any serious pain yet and mobility work seems to help.

Surgeon/PT: I was X-ray'd and diagnosed with FAI in both hips. You can see the X-Ray here if you like. The surgeon describes it as a mild case. I did physical therapy, which focused on stretching the joint capsule to make room and stretching hip flexors and adductors. Pain is still there, but at a lower level. Something showed up on the MRI, but there wasn't enough contrast to distinguish between myxoid degeneration and labral tear.

My question: I'm going to see my surgeon again today, and I intend to proceed with surgery on that hip. Do you think it's likely that I will eventually need it in the right hip too to continue squatting and if so, should I just ask to have both femurs shaved down a bit while I'm under? I ask because you mentioned having both shoulders fixed in an Ask-Rip and the same thing for a hernia and the rehab is supposed to take a long time, so if I'm going to be unable to train I'd rather it just happen once.

Thanks for your advice & time.

[Mark Rippetoe]

If there is not enough damage to actually diagnose the injury on MRI, and the pain is mild, why are we doing this surgery?

[Will Morris]

Hi Mark & Starting Strength coaches,

I'm asking for your advice on surgery for femoral acetabular impingement since you've given some advice from the perspective of a strength coach on surgery before in your Ask Rip videos.

Background: I've hurt my left hip twice squatting in the mid 200s. I now have some pain in the hip doing things like climbing stairs, biking, and sometimes sitting on the toilet. There's a crunching sensation in the hip when I lift my knee (it was there before but has gotten worse). I've stopped squatting and have been doing deadlift-only training, making very slow progress. The right hip can bother me from time to time but there hasn't been any serious pain yet and mobility work seems to help.

Surgeon/PT: I was X-ray'd and diagnosed with FAI in both hips. You can see the X-Ray here if you like. The surgeon describes it as a mild case. I did physical therapy, which focused on stretching the joint capsule to make room and stretching hip flexors and adductors. Pain is still there, but at a lower level. Something showed up on the MRI, but there wasn't enough contrast to distinguish between myxoid degeneration and labral tear.

My question: I'm going to see my surgeon again today, and I intend to proceed with surgery on that hip. Do you think it's likely that I will eventually need it in the right hip too to continue squatting and if so, should I just ask to have both femurs shaved down a bit while I'm under? I ask because you mentioned having both shoulders fixed in an Ask-Rip and the same thing for a hernia and the rehab is supposed to take a long time, so if I'm going to be unable to train I'd rather it just happen once.

Thanks for your advice & time.

Look up the rate of good outcomes with FAI and / or hip labral repair surgeries. It might change your mind.

[jhartman]

Sorry Rip if I was not clear. The pain on the left isn't mild (I've had it hit 8/10 after squatting and walked with a limp for the next couple of weeks), but pain on the right is mild and happens rarely. The radiologist said he had trouble getting enough die in the hip. Regardless of the labral damage, the left hip hurts even when doing lighter activities like hiking or even driving a car for more than an hour so I don't see a good option other than have the bone shaved down. I was asking if you had any perspective on how likely the right was to get worse over time if I continue squatting, based on your many years as a coach. If that number is 80+% I might as well have it addressed too while I'm under. Of course I'd prefer to have as little surgery done as possible, these things have risks. If you've had trainees who have successfully worked around FAI then I definitely would only want the left done.

Will, that's a great point. Everything I've read suggests pretty high improvement rates. According to this meta-study Current concepts in management of femoroacetabular impingement it is 70+%. I would do arthroscopic surgery. Do you have any link or experiences to share? I have read that people who continue to live with FAI slowly wear down the cartilage until they need a hip replacement. Some surgeons seem to think it's better to treat the FAI to prevent this, others seem to disagree.

Thanks again to everyone for their time.

[Will Morris]

Sorry Rip if I was not clear. The pain on the left isn't mild (I've had it hit 8/10 after squatting and walked with a limp for the next couple of weeks), but pain on the right is mild and happens rarely. The radiologist said he had trouble getting enough die in the hip. Regardless of the labral damage, the left hip hurts even when doing lighter activities like hiking or even driving a car for more than an hour so I don't see a good option other than have the bone shaved down. I was asking if you had any perspective on how likely the right was to get worse over time if I continue squatting, based on your many years as a coach. If that number is 80+% I might as well have it addressed too while I'm under. Of course I'd prefer to have as little surgery done as possible, these things have risks. If you've had trainees who have successfully worked around FAI then I definitely would only want the left done.

Will, that's a great point. Everything I've read suggests pretty high improvement rates. According to this meta-study Current concepts in management of femoroacetabular impingement it is 70+%. I would do arthroscopic surgery. Do you have any link or experiences to share? I have read that people who continue to live with FAI slowly wear down the cartilage until they need a hip replacement. Some surgeons seem to think it's better to treat the FAI to prevent this, others seem to disagree.

Thanks again to everyone for their time.

From the summary on surgical intervention for FAI from the Cochrane Review: "1. No research studies have been completed that are of sufficient quality to accurately determine the benefit and safety of surgery for femoroacetabular impingement."

In real life, I have only seen one FAI surgery that resulted in complete resolution of symptoms and full return to function. I have seen a dozen or so that resulted in permanent disability. The vast majority end up being no better, no worse...other than the 6-9 months of rehab that occurred. For what it is worth, our orthopedics department (a very, very good orthopedics department at a major medical center) will not perform a hip labral repair or FAI surgery, and only on very rare circumstances will they refer a patient to a surgeon that will perform them.

I'd like to see Matt Reynolds hop on here and talk about this, because, as best as I remember, he has some pretty shoddy hips and still manages to train.

[Matt Reynolds]

Posting from my phone, so apologies for typos....

I have lived with and trained with pretty severe FAI, and now pretty serious osteoarthritis in both hips for over ten years. 9 years ago I was told by an ortho surgeon that my hips were clearly bad enough for a bi lateral replacement but that he would not do one on a 28 year old unless o was basically unable to walk. Part of the issue, is that having a hip replacement done at 28 pretty much guarantees that you are going to need it at least THREE times before you die, since these things wear out.

I have since continued to train with the hips, deadlifting over 700lbs many many times on them, and I have continued to squat with them, albeit I have to take a stance with my heels approx 12" apart to reduce the amount of FAI, osteo-arthritis grinding, and the resulting inflammatory response. It's been fine. I have squatted 600+ on the hips 3x in competition over the past 6 years. Yes, it hurts. Sometimes it's an 8/10 on the pain scale. Putting on underwear, pants, and socks/shoes is a chore. Sex is debilitating if I do the work. (Luckily I have an ambitious wife who will do the majority of the work).

When it's particularly inflamed it hurts all the time. When it's good it only hurts in during the above activities or after sitting in a chair for longer than an hour or so. (Plane trips are tough).

My advice would be to train around it as best as you can until you REALLY need the hip replacement. Hip replacements have a high success rate. Ed Coan just squatted 700 raw on his, I believe.

Deadlifts don't bother it much at all (especially with the high-hip pull we teach), and there are probably ways to squat to work around the majority of FAI (narrow stance, high bar or front squat if needed to keep hips more open and knees more closed), you'll almost certainly have to squat with less frequency (probably once a week, maybe twice if things are going well but 3x is prob out of the question). Do what you can to work around things, then get the replacements in a decade when you really need them.

[John Petrizzo]

From the summary on surgical intervention for FAI from the Cochrane Review: "1. No research studies have been completed that are of sufficient quality to accurately determine the benefit and safety of surgery for femoroacetabular impingement."

In real life, I have only seen one FAI surgery that resulted in complete resolution of symptoms and full return to function. I have seen a dozen or so that resulted in permanent disability. The vast majority end up being no better, no worse...other than the 6-9 months of rehab that occurred. For what it is worth, our orthopedics department (a very, very good orthopedics department at a major medical center) will not perform a hip labral repair or FAI surgery, and only on very rare circumstances will they refer a patient to a surgeon that will perform them.

I'd like to see Matt Reynolds hop on here and talk about this, because, as best as I remember, he has some pretty shoddy hips and still manages to train.

I just wanted to reiterate Will's point. I have worked with approximately a dozen patients (if not more) who have had corrective surgery for FAI and/or acatabular labral repairs and I can tell you that the results can vary wildly from patient to patient. It is a long recovery and given the uncertainty of the outcomes, not a surgery I would recommend lightly. If your pain has had a significant negative impact on your daily life for a prolonged period of time and you want to give the surgery a shot, go ahead, just realize going into it that there are no guarantees that you end up any better than you are now. I hope that is not the case for you, but it is a very real possibility with this type of procedure.

[Bekah Cygan]

I have had some of these same issues and still sometimes experience symptoms. Maybe not as severe as yours...I saw an orthopedic surgeon who told me to only box squat, and that the method of squat we use in Starting Strength would continue to stimulate bone growth and I would get worse. This is of course bullshit.
I squat with a little exaggerated external rotation and it makes my symptoms tolerable...

[jhartman]

Thanks folks. What an awesome community. I really appreciate the advice and expertise. I've been disabused of any notion that I should do anything about that right hip.

I saw the surgeon, turns out I do have a partial labral tear. Here's what I think is the right MRI photo if anyone is ever interested in seeing what these look like: Imgur: The most awesome images on the Internet . We'll try a cortizone shot but I get the sense he's following a script and isn't too optimistic about it.

I can live with the hip as-is but I just don't see any way I can squat for anything more than a month. Every time it gets tweaked squatting it seems to get permanently worse, and yeah putting on shoes was god-awful for the month after. I'm betting it's getting torn just a little each time. Matt, I have also noticed no pain whatsoever from deadlifting.

John, is the 6 month estimate of rehab accurate in your experience? How many months before someone is able to do things like bodyweight squats? Have you seen anyone get significantly worse as a result of fixing a labral tear?

Thanks again to everyone for being so awesome.

[jamiet]

Thanks folks. What an awesome community. I really appreciate the advice and expertise. I've been disabused of any notion that I should do anything about that right hip.

I saw the surgeon, turns out I do have a partial labral tear. Here's what I think is the right MRI photo if anyone is ever interested in seeing what these look like: Imgur: The most awesome images on the Internet . We'll try a cortizone shot but I get the sense he's following a script and isn't too optimistic about it.

I can live with the hip as-is but I just don't see any way I can squat for anything more than a month. Every time it gets tweaked squatting it seems to get permanently worse, and yeah putting on shoes was god-awful for the month after. I'm betting it's getting torn just a little each time. Matt, I have also noticed no pain whatsoever from deadlifting.

John, is the 6 month estimate of rehab accurate in your experience? How many months before someone is able to do things like bodyweight squats? Have you seen anyone get significantly worse as a result of fixing a labral tear?

Thanks again to everyone for being so awesome.

Not sure if rip will approve this link but it's relevant and starting strength related. It may shed some light on your situation.

Instagram